On July 31, Mike West fell into the infamous doughnut hole of Medicare prescription coverage.
Instead of paying $40 a month for his prescription medication, his out-of-pocket costs suddenly ballooned to $400 a month. To get by, he did what Medicare recipients all over the country report doing: He cut back on his medication.
"I just take less," he said. "I'm only taking half what I was."
His doctor doesn't endorse the dosage change. His doctor doesn't even know.
West's experience in the doughnut hole is just one of the reasons AARP has endorsed the U.S. House health care reform bill, passed Nov. 7. In addition to various other reforms, the bill moves to close the doughnut hole by 2018.
"Closing the doughnut hole is one of AARP's biggest priorities," state AARP director Sarah Jennings said.
Jennings said AARP also supports the Senate health care reform bill now being debated in Congress but sees the House bill as doing the most to help seniors, especially when it comes to the doughnut hole.
To understand West's dilemma, it's critical to understand the doughnut hole itself.
In January 2006, the new Medicare prescription drug program, commonly called Plan D, went into effect. Under Plan D, Medicare participants can enroll in either a private prescription drug plan, which offers drug-only coverage, or in Medicare Advantage, which combines prescription and health care coverage.
Under Plan D, when a Medicare client's prescription costs reach $2,700, their drug coverage ends until they pay a total of $4,350 out of pocket for the year, Jennings said. That window, between $2,700 and $4,350, is the so-called "doughnut hole," or coverage gap, Jennings said. It's "devastating to seniors," she said.
Jennings said a third of the 135,000 South Dakotans on Medicare fall into the doughnut hole each year.
When seniors make their prescription enrollment decisions, they can choose from a variety of plans, some of which provide coverage in the doughnut hole for a higher premium. The problem arises when people choose their plans based on income and current health situation and then experience health issues that drastically change medication needs.
That's what happened to West.
A former high school teacher in Philip, West has congestive heart failure and has undergone knee surgery. He picked his prescription program for 2009, late in 2008, based on his health care needs during the enrollment period. This year, a new health crisis increased his medication needs. He now takes four medicines in the morning and three each night.
"I had complications that came up that I did not expect whatsoever," he said.
West said he always chooses his plans carefully, trying to reach the end of the year before the $2,700 maximum. But illnesses don't care about plans.
"They're unexpected, of course," he said of his health issues. "If I expected them, I would have planned for it."
While protecting Medicare in general and closing the doughnut hole are top priorities for AARP, Jennings said insurance premiums based on age alone are another focus for the organization and another reason it endorses the House bill.
"You could have a 55-year-old man who runs a marathon who is getting charged five or six times more than a 23-year-old who doesn't exercise at all, ... maybe is a smoker," Jennings said.
Under the House bill, that discrepancy would be restricted to a two-to-one ratio. The proposal in the Senate bill is three to one, Jennings said.
The House bill also addresses people ages 50 to 64 who can't afford health coverage. This is especially relevant in South Dakota, where farmers and ranchers often find themselves unable to afford coverage on the open market, Jennings said. There are 22,000 people in the state in that age range who must get insurance without the benefit of an employer, Jennings said.
Too often, that segment of the population goes without, Jennings said. By the time they reach 65 and enroll in Medicare, their health conditions are often at crisis level.
"It really benefits us as a country to take care of everybody," Jennings said, "not to have them show up with a crisis and be on Medicare's dime."
West and his wife, Marcia, have cut back on travel and Christmas gifts this year because of added medical expenses, but they will be OK. He knows, however, that others in his situation aren't as lucky. Even some of his children who own small businesses can't afford health insurance for their families.
For that reason, he and Marcia watch the health bill reform debates in Washington closely and hope for some reasonable change soon.