Costs Block Prescription Access for Millions: Study
Dec. 3, 2021 — As Senate Democrats debate the Build Back Better Act, which includes measures that would lower prescription drug costs for consumers, a new Urban Institute study finds that 12.8 million adults delayed getting or didn’t get needed prescription drugs because of cost.
The people who deferred or went without these prescription drugs included 2.3 million elderly Medicare beneficiaries, 3.8 million nonelderly adults with private insurance, 1.1 million Medicaid recipients, and 4.1 million adults who were uninsured at any point in the prior year.
The nationally representative data came from 2018-2019, before the beginning of the COVID-19 pandemic. The Urban Institute’s researchers used information from the Medical Expenditure Panel Survey done by the Agency for Healthcare Research and Quality.
According to the study, around 1 in 10 adults uninsured all year (9.5%) or part of the year (11.6%) had unmet prescription drug needs, compared with 4.9% of Medicare enrolees, 3% of nonelderly privately insured adults, and 5.6% of nonelderly adults with Medicaid.
Among Medicare beneficiaries and privately insured adults, unmet prescription drug needs were most common among women, people with low incomes, and people with multiple chronic conditions. More than 6 million adults with Medicare or private insurance delayed getting or went without needed medications because of the cost.
Nearly all Medicare members and 82% of privately insured nonelderly adults with unmet drug needs had one or more chronic conditions such as high blood pressure, high cholesterol, stroke, diabetes, arthritis, and respiratory illnesses. The study points out that when people are diagnosed with such conditions and can’t get the drugs they need, they’re likely to have poor outcomes.
A larger portion of Medicare members with multiple chronic conditions (5.6%) had trouble paying for their prescription drugs than those with no conditions (1.5%) or just one condition (1.7%), the study found. Of nonelderly adults with private insurance, 5.4% with multiple conditions reported not being able to afford their drugs, versus 1.5% who had no conditions and 2.3% who had one condition.
Drug Costs and Ability to Pay
Overall, prescription drugs accounted for up to 14% of national health spending in the study period, the study said. By contrast, medications accounted for nearly 22% of out-of-pocket costs for Medicare members and about 17% of costs for privately insured people.
Like spending on other types of health care, out-of-pocket spending on prescription drugs is highly concentrated among certain groups of people. Of privately insured nonelderly adults, 5.3% spent above 1% of their family income on prescription drugs; 6.1% reported out-of-pocket spending above $500; 2.3%, more than $1,000; and 0.8%, more than $2,000.
Out-of-pocket spending on prescription drugs exceeded 1% of household income among 25.4% of Medicare beneficiaries, and 3.4% spent more than 10% of their household income on drugs. Personal spending on drugs exceeded $500 for 21.5% of this cohort; 8.9% of Medicare members spent over $1,000; and 2.7%, over $2,000.
More than 7% of Medicare beneficiaries with unmet prescription drug needs reported spending over $2,000. Just 2.3% of privately insured nonelderly adults with unmet drug needs reported the same.
The Build Back Better Act Would Have Major Impact
The 1.3 million Medicare beneficiaries who spent the most on prescription drugs would be directly impacted by the Build Back Better Act, which caps prescription drug spending for Medicare members at $2,000.
Among other things, the report said, the act would:
- Allow Medicare to negotiate prices for certain high-priced drugs covered by Parts B and D
- Limit beneficiary cost sharing for insulin to $35 per month for people with Medicare and commercial plans.
- Lower coinsurance in Part D’s initial phase from 25% to 23%
- Establish mandatory rebates for drugs covered by Medicare with prices that increase faster than inflation
- Increase incentives for Part D to negotiate lower prices with manufacturers
What’s more, passage of the Build Back Better Act would make health insurance affordable for more of the uninsured, including people who live in states that chose not to expand Medicaid under the Affordable Care Act, the study notes. The coverage expansion would make it easier for currently uninsured people to afford the prescription drugs they need.