A Simple Solution to Control Costs and Protect Our Nation’s Seniors

No senior should go hungry at the expense of being able to afford the lifesaving medication needed to stay healthy. But many of America’s low-income seniors are having to make that very decision because there is no limit on out-of-pocket costs in Medicare Part D. 

Unless lawmakers in Washington do something about it, only more seniors will struggle to access the care they need and deserve.

First introduced in 2006, the Medicare Part D prescription drug program has benefited millions of America’s seniors. But the lack of a cap on out-of-pocket costs in Part D has left many low-income seniors to fend for themselves while trying to manage chronic and complex conditions and rising costs.

The Medicare Part D coverage cap, also known as the “donut hole,” has decreased significantly thanks in part to the Affordable Care Act. But a change in how Medicare calculates the out-of-pocket threshold before catastrophic coverage begins will increase that amount by $1,250 in 2020. That amount may not seem like much over the course of the year, but for seniors who depend on their Social Security check or savings to manage their monthly expenses, this increase could put at risk other important necessities, including the food they put on the table.

For senior patients who require specialty medications to manage rheumatoid arthritis, cancer, multiple sclerosis or a heart condition, their out-of-pocket costs could be drastically higher, anywhere from $2,600 to $16,500. The bottom line is, if you’re 65 or older and have a chronic illness, rising out-of-pocket costs jeopardize your ability to pay for preventative care and basic necessities.

When a senior — or any patient — has to make the decision to split a pill in half or stop taking their medication altogether just to make ends meet, it can lead to more serious issues. Patients who are managing complex conditions who don’t adhere to treatments can experience side effects and require more visits to the doctor, which increase overall medical costs.

Putting a cap or limit on out-of-pocket costs in the Medicare Part D program makes sense because it would protect access to care for millions of seniors, and most people would agree. More than 3 out of 4 polled voters (76 percent) said they would support legislation that would cap or limit what seniors pay out of pocket for their prescription drugs.

It’s up to our nation’s lawmakers to pursue legislation that would cap rising costs in Part D and fight to protect some of our most vulnerable seniors: our neighbors, friends and loved ones. In a climate where Washington is racing to find ways to control the cost of care, this is a commonsense solution that can make an immediate difference. Simple changes to Medicare can have broad impacts throughout the entire health care system.

Forty-four million low-income seniors rely on Medicare Part D to access their prescription medications. That number is only going to grow as 10,000 baby boomers turn 65 every day for the next 19 years.

If Washington doesn’t act now, even more seniors will face tough health care decisions. We need Congress to stand up for seniors and cap out-of-pocket costs in Medicare Part D.


Andrea Baer, MS, BCPA, is the executive director of Mended Hearts, a national, community-based nonprofit organization that supports patients with heart disease.

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