Feeding a Need


A caller this morning on The Stephanie Miller Show wanted to talk  about the donut hole and Medicaid – explaining (incorrectly) the term referred to the people being stranded by Republican lawmakers refusing to expand health care coverage for the poor. We ran out of time to get into the issues on the air, but her confusion reminded me that people genuinely are baffled by most general health care-related terminology.

So for starters, let’s address Medicare v. Medicaid and that pesky donut hole.

Medicare is the federal government-sponsored health insurance program for people over 65. Some younger people with disabilities and some people with  permanent kidney failure also can get Medicare. But the majority of the time, when we’re talking about people on Medicare, we’re talking about seniors.

Medicare has 4 parts (A, B, C, and D) and the official Medicare website has a very simple explanation of those 4 different parts. It’s worth a read.

Medicaid – without mincing words – is a government-sponsored health insurance program for the poor. Both the federal and state governments fund Medicaid, but the states are in charge of deciding who gets help. Each state is different, and while no state is required to provide Medicaid, all do.

Before we passed health care reform, low-income adults with dependent children and people with certain disabilities were able to get Medicaid. The Affordable Care Act expanded the pool to include all adults making less than 138% of the poverty level – whether or not those adults had dependent kids. Under the law, the federal government would pay for 100% of the cost of expanding Medicaid coverage for the first three years and then at least 90% of the cost after that. But the Supreme Court ruled in 2012 that states had the right to choose whether or not they wanted to participate in the Medicaid expansion plan, and if they opted out, they could not lose their current levels of federal funding.

Sadly, many Republican governors and state legislatures decided against expanding Medicaid, leaving many of their neediest residents uninsured and unable to access affordable health care.

The Healthcare.gov website has a good tool for finding out whether or not your state has expanded Medicaid and whether or not you may qualify.

Now to that donut hole thing…

Most Medicare Part D plans (the plans that seniors buy to help them afford prescription drugs) have a significant gap in coverage. It’s called the donut hole, and it’s nothing like the pastry. It’s neither adorable nor delicious.

Again, the official Medicare website is a good resource for more detail, and it’s an easy read. But the gist is that if you have a Medicare prescription drug plan, it gives you a discount until you (or you and your insurance company) spend $2800. Then you pay everything until you reach an out-of-pocket limit of $4550. At that point, aid kicks in again.

I should say the gist was because health care reform is closing the donut hole, and by 2020, it won’t exist anymore. One more thanks to Medicare.gov for this chart showing how the donut hole is shrinking gradually over the next 6 years.

I hope this is helpful. Next week, I’ll be joining Stephanie on Monday morning from 8-9am PT because I’ll be traveling the second half of the week. But for regular health care chat, you can tune in every Thursday morning from 11-12pm EST/8-9am PT or watch online at FreeSpeech.org.