![]() ![]() 15 – 17 In a study of Medicare beneficiaries with hypertension, we found public drug coverage (e.g., state-supported pharmacy benefit programs) to be associated with almost twice the rate of use of antihypertensives compared with Medicare beneficiaries having only fee-for-service coverage after controlling for health and socioeconomic status ($302 vs $191 P <. 16 Importantly, lack of coverage for prescription drugs was associated with lower use of clinically essential drugs. In our recent review of the literature on prescription drug coverage and drug use in the Medicare population, the strongest evidence indicated considerable unmet needs for prescription drug coverage in this population. study is cross-sectional and relies on self-reports of medication adherence, its findings are consistent with previous studies showing a strong association between drug coverage and use of effective medication. The authors find that among people without drug coverage, minorities are 4 times more likely to report underuse due to cost compared to whites people with low incomes (i.e., income <$10,000) are 3 times more likely to report underuse for this reason and those in poor health are 3 times more likely to report underuse due to cost compared to those in very good or excellent health. study is its attention to underuse among high-risk groups without drug coverage. Further, by using self-reports of the cause of reduced drug use (i.e., cost), this study weakens the argument that lower rates of drug use among those without coverage could be due to a lesser need for medication rather than a lack of coverage.Īnother notable contribution of the Steinman et al. Using 2 years of data (1995–1996) and a large sample of elderly participants in the Survey of Asset and Health Dynamics Among the Oldest Old, the researchers provide important and disconcerting data that go beyond anecdotal evidence of cost-related non-adherence. ![]() 14 demonstrate a strong link between lack of prescription drug coverage and underuse of prescribed medications due to costs. What are the clinical consequences of this failure to provide economic access to medications among the elderly? In this issue of the Journal of General Internal Medicine, Steinman et al. 13 Disparities in coverage extend to those with poor health status as well: those in poor health are almost half as likely to have drug coverage as those in excellent health. Despite the existence of Medicaid, poor elders who need coverage the most have the least access to it about a third of those with incomes less than $10,000 have coverage as compared to over 70% of those with incomes above $50,000. 12 Drug coverage that protects against the high costs of medications is not distributed equally to all elderly Americans. For 5.7% of elderly, however, the costs of prescribed medications exceeded $2,000 in 1995, representing over 17.0% of the typical (median) senior citizen's income of $14,425 10, 11 or almost all of discretionary income. ![]() 9 From a societal perspective, this seems a small price to pay given that medications represent the most effective technologies for controlling the rapidly rising costs of chronic illness. 9 Yet, only 9.4% of total personal health expenditures in 1999 were for outpatient drugs. Between 19, outpatient drug expenditures in the United States increased from $51 billion to $100 billion. Many commentators point to rapidly rising drug expenditures as the culprit in declining access. But anecdotal and scientific evidence is mounting that the lack of economic access to new and effective pharmaceuticals is having serious adverse impacts on the health and quality of life of our nation's senior citizens. 6 Certainly, some new medications are over-promoted or inappropriately prescribed by physicians. 5 The costs of supplemental private drug coverage are so high that only a small minority of elders can afford the high premiums and coinsurance. Medicare enrollees have no outpatient drug coverage among the remaining two thirds, almost half have discontinuous or limited coverage. Such coverage is not included in Medicare. 1 – 4 Ironically, however, while the United States is the world leader in pharmaceutical research and development, it is the “world loser” among industrialized nations in its failure to provide insurance coverage for outpatient prescription drugs for disabled and senior citizens. Few would argue that millions of elderly and disabled Americans with chronic illness have improved quality of life, reduced risk of acute illness and hospitalization, and lower mortality rates because of access to new and effective pharmaceutical agents.
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