Of doughnuts and holes


At least one more iceberg awaits for the election-year shakedown cruise of Medicare's prescription drug program.

Over the next few weeks, millions of elderly voters, including tens of thousands in Maryland, are likely to discover that their drug coverage has suddenly gone missing - forcing a huge rise in cost for medicine even though they are still paying premiums to their Medicare prescription plans.

Based on the experiences of the first few folks in Baltimore to hit the so-called "dough-nut hole" in coverage, John P. Stewart, director of the city's Commission on Aging, is predicting a public health disaster.

Which could also mean a political disaster - perhaps the only trigger powerful enough for Congress to get serious about fixing a problem deliberately and needlessly created.

Back in 2003, when President Bush and Republican congressional leaders were pressuring their fiscally conservative colleagues to approve a long overdue drug benefit for Medicare, they performed some creative surgery to trim the cost. The private drug plans that would compete for Medicare customers were permitted to lower their premiums by stopping coverage once annual costs reached $2,250, but resuming it once the yearly bill exceeded $3,600.

During the initial sign-up period, which ended May 15, savvy shoppers with high drug costs could have chosen drug plans with higher premiums to avoid this doughnut hole. Low income folks could qualify for extra help from the government.

But the program is so confusing that, despite lots of coaching from public and private organizations, an estimated 3.4 million Medicare beneficiaries signed up for plans with a break in coverage that apparently many have no idea is coming.

Among the more practical short-term remedies being proposed in Congress is one that would allow doughnut-holers to sign up for more comprehensive coverage immediately under a different plan without waiting for open enrollment to make changes that wouldn't apply until next year.

The obvious long-term solution, though, is to finally allow Medicare to use its huge buying power to negotiate with drug companies for lower prices, as the Veterans Administration does. By some estimates, that step alone would fill the doughnut hole.

Mr. Bush and GOP leaders have stoutly resisted such dickering. But the drug plans are now reporting double digit profits thanks to their Medicare business. They have more to gain by making Medicare Part D financially sustainable then letting it capsize in red ink.

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