Help is on the way for seniors on Medicare. The Inflation Reduction Act, once signed, will cap the cost of out-of-pocket expenses for seniors to $2,000 a year. NewsdayTV’s Shari Einhorn reports. Credit: Howard Schnapp; Jennifer Altman

Linda Weekes said three drugs dramatically improved her life after she began taking them in the spring for her lung disease. Last month, though, Weekes could no longer afford two of the medications and stopped using them. Her symptoms worsened.

“I started having difficulty breathing, with my chest being tight, with coughing — not being able to do too much without having to stop and sit down,” said Weekes, of Hempstead.

'A savings of $500 a year — that’s great for me.'

-Linda Weekes, 76, of Hempstead

Credit: Jennifer S. Altman

Weekes, 76, said she hopes health-related provisions in the $740 billion Inflation Reduction Act, which on Friday passed the House and now awaits President Joe Biden's signature, will ease some of her concerns about prescription drug costs. The bill sets an annual limit of $2,000 for out-of-pocket prescription drug expenses for Medicare beneficiaries and would save Weekes at least $520 a year — or more, if the cost of the medications goes up.

“A savings of $500 a year — that’s great for me,” she said. “It would be wonderful. Any little bit is a help for me to save money.”

WHAT TO KNOW

  • The Inflation Reduction Act now will limit prescription costs for Medicare recipients in several ways, including with a $2,000 cap in annual out-of-pocket expenditures.
  • The bill also will allow the federal government to negotiate the prices of some drugs, penalize drug companies that increase prices beyond the rate of inflation, and cap monthly insulin out-of-pocket costs at $35.
  • Some Long Island seniors say the bill will save them money. But some say it doesn’t go far enough, and that it should do more to help those on private insurance.

$2,000 The yearly cap on out-of-pocket expenses for Medicare Part D beneficiaries starting in 2025.

The $2,000 cap is one of several measures in the Inflation Reduction Act aimed at reducing how much Medicare recipients pay for prescription drugs, some of which have skyrocketed in price in recent years. Experts say some of those measures may reduce the cost of medications for people on private insurance as well.

“After years of discussions and negotiations, Congress is finally on the cusp of delivering real prescription drug price relief for millions of older Americans, which is huge,” Joseph Stelling, associate state director of advocacy for AARP New York, said before the bill's final passage.

Yet parts of the bill will require several years to take full effect, offering seniors little relief in the short term. And while congressional Republicans were unanimous in opposing the bill, with many saying it went too far in regulating costs, some Long Islanders said the bill doesn't go far enough.

The Senate passed the bill on Aug. 7. Biden is expected to sign the legislation within the next few days.

The $2,000 annual cap on out-of-pocket medication expenses, which takes effect in 2025, would be for the 49 million Medicare beneficiaries who have Part D prescription drug coverage. Total Medicare enrollment is nearly 64 million — mostly people 65 and older, along with some people with disabilities. In addition, the bill would, according to analyses by AARP and the Kaiser Family Foundation:

  • Cap the monthly cost for insulin for Medicare recipients at $35. About 8.4 million Americans depend on insulin, according to the American Diabetes Association.
  • Allow the federal government to negotiate the prices of 60 high-cost prescription drugs by 2029. New prices for the first 10 would go into effect for Part D in 2026.
  • Expand eligibility for Part D low-income subsidies in 2024.
  • Extend federal subsidies through the end of 2025 for millions who receive coverage under the Affordable Care Act.
  • Penalize drug companies when they raise Part D medication costs beyond the rate of inflation, beginning in October. AARP last year said the average retail price for 143 widely used drugs increased more than 300% in the past 15 years, compared with a 32% rise in inflation.
  • Make most vaccines free for Medicare recipients, beginning next year.

Seniors going into debt

Christine Rice, executive director of the Glen Cove Senior Center, said seniors frequently talk to her and center social workers about struggling to pay for prescription drugs.

'It’s a constant worry for them.'

- Christine Rice, executive director of the Glen Cove Senior Center

Credit: Jennifer S. Altman

“It’s a constant worry for them,” she said.

Basic Medicare does not cover most prescription drugs. Seniors must pay for Part D prescription coverage.

Rona Tubon, 65, of Glen Cove, said after eating lunch at the senior center that she is going into debt paying for prescription medications each month. Tubon takes medications for diabetes, hypertension, hypothyroidism and high cholesterol.

The bill could save the retired nurse educator about $400 a year in out-of-pocket drug costs. “I would rather have that [the savings], so I don’t have to deprive myself of other activities, like seeing a doctor,” she said.

Tubon said she sometimes cancels doctor appointments because of the $30 copay, which would be unaffected by the bill. Cutting down prescription drug costs “would help me a lot to focus more on my health,” she said.

Cutting down prescription drug costs 'would help me a lot to focus more on my health.'

-Rona Tubon, 65, of Glen Cove

Credit: Jennifer S. Altman

Like Tubon, Weekes, a retired medical assistant, sees multiple specialists. Her copay for each visit is $40. Weekes said her doctor prescribed three drugs in April for chronic obstructive pulmonary disease.

She initially only took two, because her Part D insurance company at first refused to cover a $1,000-a-month medication. The two helped, but since she finally got approval for the third, in May, “I’m breathing a whole lot better. I can do more. I have more energy.”

She couldn’t afford the initial copay costs for any of the three. Her pharmacy helped obtain lower prices, she said.

Even after the discounts, “It’s $210 a month out of pocket I pay for these meds, and I live on a fixed income,” about $1,257 a month in Social Security, Weekes said. “It’s really a strain.”

Last month, she paid $150 for the medication that helps her the most, but “I just couldn’t afford the ones for $60. I didn’t have it.”

More than 300% The increase in the average retail price of 143 commonly used drugs in the past 15 years.

Weekes' sister paid for the other two this month.

“The coughing was so bad, she was concerned and gave me the money to get these two,” she said.

David Kilmnick, president of the Hauppauge-based LGBT Network, has heard similar stories. He said seniors his organization works with sometimes “have to make the decision between getting the medicine that they need or paying their rent and getting food. … No one should have to make that decision.”

Ann Marie Martinez, 68, a retired civil-service clerk and typist from Glen Cove, estimates she pays about $1,000 a year out of pocket on medications. Martinez said while sitting at the Glen Cove Senior Center that she believes the $2,000 ceiling is too high “when you’re a senior citizen and you’re living on a fixed income.”

José Pagán, chair of the Department of Public Health Policy and Management at the NYU School of Global Public Health in Manhattan, said the bill helps shield Medicare recipients from the effects of future drug price increases. Currently, price increases can lead to higher out-of-pocket expenses.

'If the price decreases are substantial, then there will be pressure to increase the number of drugs that go through that process.'

-José Pagán, chair of Public Health Policy and Management, NYU School of Global Public Health

Credit: NYU School of Global Public Health

But, he said, “If your out-of-pocket is capped, then it stops at that point.”

Pagán said allowing the government to begin to negotiate drug costs likely will lower prices for those medications.

“If the price decreases are substantial, then there will be pressure to increase the number of drugs that go through that process,” he said.

Only people on Medicare would directly benefit. But, said Stelling, of AARP, it could help people on private insurance.

“Insurance companies are going to see that and want to get the same deal that Medicare is making,” he said. “So there is a spillover effect.”

'Mixed feelings' about lower costs

Mary Ann Romano, 80, a retired sociology professor from Huntington Station, said she has “mixed feelings” about the lower drug costs.

Romano said it may benefit her, because “some medications are going to be less money.” But she worries that if pharmaceutical companies’ profits decline, “research is going to suffer. They are not going to spend money on research.”

Some congressional Republicans have made similar arguments in opposing efforts to rein in drug prices. But a July estimate from the nonpartisan Congressional Budget Office estimated that the bill would lead to a drop of only 1.2% in the number of drugs introduced over the next 30 years — 15 fewer out of 1,300 new medications.

Democrats had wanted the parts of the bill penalizing drug companies for price increases beyond inflation, and imposing a $35 monthly cap on insulin costs, to apply to private insurance. A ruling from the nonpartisan Senate parliamentarian and opposition from Republicans killed those measures.

'I work 10 hours a day, paying taxes ... Why can’t I get a break?'

-James Adams, 65, of Glen Cove

Credit: Jennifer S. Altman

James Adams, 65, of Glen Cove, who works on the tarmac at Kennedy Airport, said he spends $10,000 a year on private insurance for him, his wife and son. People 65 and older with group health plan coverage through their jobs can sign up for Medicare without penalty after they retire. He believes the bill should apply to people like him.

“I work 10 hours a day, paying taxes,” he said. “I have to work. I have to pay insurance. Why can’t I get a break?”

Adams said he pays $100 a month for insulin alone, despite his hefty insurance premiums.

Nearly 1,500%  How much the price of one vial of the insulin drug Humalog rose between 1999 and 2019, from $21 to $332.

Helen Mendes, 70, a retired teacher from East Hampton on Medicare, is battling breast and colorectal cancer. She was initially quoted $7,000 in out-of-pocket expenses for one chemotherapy drug, a cost she was able to get down to $600 with the help of an employee of a cancer center. That’s still a challenge because “I already have a box full of bills I can’t pay,” she said.

Mendes said the bill is a good first step and hopes it leads to more price drops for potentially lifesaving medications.

“The American health care system,” she said, “is your money or your life.”

Correction: The amount listed for monthly out-of-pocket prescription drug expenses for Rona Tubon in a previous version of this story was incorrect. It is about $200 a month. 

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