Why the "Doughnut Hole" Metaphor is Inside Out

The recent passage of health care legislation in the U.S. Congress has got linguist Neal Whitman ruminating over a reform-related metaphor that doesn't make much sense when you stop to think about it.

With President Obama's signing of the health care reform bill, we move a step closer to finding out whether it will solve the problems it is intended to solve: the out-of-control increases in insurance premiums, the maddening denial or dropping of coverage due to preexisting conditions, the tasty-sounding "doughnut hole" of Medicare prescription drug coverage.

For those who have gotten lost in the talk of public options, death spirals, and Cadillac policies during the past year of debate on health care reform, the doughnut hole is a metaphor for a coverage gap in Part D of Medicare — the part established in 2006 to cover prescription drugs. The basic idea is that prescription drug costs up to some dollar amount X are at least partially covered by Medicare. (There's a deductible you have to meet, and after that the coverage is 75%.) Above X, coverage stops, but it kicks back in at some larger dollar amount Y. The values of X and Y have varied between 2006 and now; currently, they stand at $2830 and $4550. In his Political Dictionary, William Safire credited Rep. Willie Tauzin (R-La) with creating the metaphor in 2001, and a union known as the Alliance for Retired Americans with popularizing it in 2002.

The doughnut-hole metaphor has us picture the dollar amounts as corresponding to areas of concentric circles, as shown in Figure 1 (not to scale): 

Viewed this way, the gap in coverage does indeed look like a doughnut.

But reading about the doughnut hole in the newspaper or hearing about it on the radio, I kept having a feeling I wasn't understanding something. It was when I called upon my real-world knowledge of doughnut structure that I finally realized it wasn't the issue itself that was troubling me, but the choice of metaphor. Figure 2 shows a typical donut. We can observe that it is a glazed, cake doughnut, without sprinkles. We can also see that the gap in coverage from Figure 1 corresponds not to the doughnut hole, but to the sweet, cakey goodness of the doughnut itself.

In other words, when we're talking about Medicare prescription drug coverage, doughnut hole doesn't mean "hole in a doughnut" the way housework means "work in the house." That's the ordinary meaning of doughnut hole. With that meaning, doughnut hole is what linguists call a determinative compound, in which one noun has something or other to do with the other one. In this case, the noun doughnut restricts the meaning of the noun hole to just those holes that are located in doughnuts. But in Medicare jargon, doughnut hole means "hole that is (metaphorically) a doughnut," the way houseboat means "boat that is a house." Linguists call this kind of compound a descriptive compound, in which one noun tells what the other one is, or at least what the other one is like. In this case, the noun doughnut says that we're talking about holes that are (like) doughnuts.

In employing the doughnut metaphor, we're trying to use two ideas associated with doughnuts: the idea of a ring, and the idea of a hole. The trouble is that those two ideas are manifested in fundamentally different parts of a doughnut.

A better metaphor for the gap in prescription drug coverage would be a castle moat. First of all, it's both a ring and a hole: a ring-shaped, water-filled ditch separating two areas of dry land. Second, the area of dry land inside the moat — the castle — is an area of safety, corresponding to the covered prescription-drug costs. Third, moats are often associated with danger — if not from crocodiles or poisonous snakes, then from arrows raining down from the castle. This corresponds well with the fear-inducing, in-between area of prescription-drug costs not covered by Medicare. Beyond the moat is more dry land, corresponding to the resumed prescription-drug coverage. The metaphor starts to break down here, since the land outside the moat is not safe like the land inside it. It might be overrun with invading armies deploying catapults or other siege weapons. Even so, this metaphor doesn't suffer from the topological confusion of the doughnut-hole metaphor.

The doughnut actually is a pretty good metaphor for one aspect of modern health care, just not Medicare prescription drug coverage. It could stand for your own medical insurance policy. The doughnut hole is the annual deductible for your plan — the uncovered costs that fall below a certain minimum. The doughnut itself is the medical expenses that your insurance company covers once you've met your deductible. And beyond the doughnut lie the medical expenses incurred after you've reached your annual coverage limit.

Of course, transferring the doughnut metaphor to a different health care-related situation would just create confusion, so we're stuck with it as it is. However, when the doughnut hole is filled, don't think of Medicare Part D as now being like a jelly doughnut, with no hole. What's being filled is a doughnut-shaped hole, so a metaphor for the resulting situation would be something like one of those small, spherical doughnuts that are playfully called doughnut holes, surrounded by a traditional, toroidal doughnut, surrounded by ... some more doughnut material that just forms a flat sheet, I guess. At that point, with neither a ring nor a hole having any significance, I think the doughnut-hole metaphor will be done.