13M people delayed or didn't fill prescription drugs pre-pandemic

An estimated 13 million adults delayed getting or didn't fill prescription drugs prior to the COVID-19 pandemic due to cost, according to a new survey.

More than one-quarter of Medicare beneficiaries and 5.3% of privately insured adults spent more than 1% of their household income on their out-of-pocket prescription drug costs, according to the Urban Institute's estimated annual averages of 2018 and 2019 Medicare Expenditure Panel Survey data from nearly 30,000 Americans. More than 3% of Medicare beneficiaries—and nearly 7% of beneficiaries with unmet prescription drug needs—spent more than 10% of their household income on prescription drugs.

Medication adherence continued to decline while cost-sharing rose during the pandemic, which will likely lead to more hospitalizations, researchers said.

"So much of the mortality in the U.S. is preventable," said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, adding that much of it stems from unmanaged chronic conditions. "When you are not able to take your medications, it invalidates so much of healthcare. It shortens peoples' lives and leads to more expensive treatment down the road."

Taking prescribed medication is crucial to better health outcomes. But rising out-of-pocket costs continue to dent adherence.

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Around 10% of uninsured adults reported unmet prescription drug needs, compared with 4.9% of Medicare beneficiaries, 3% of privately insured adults and 5.6% of nonelderly adults with Medicaid, according to the Urban Institute's research brief.

Women, people with low incomes and those with multiple chronic health conditions were most likely to forgo medication.

"This again shows us that as tough as healthcare can be, it can be even tougher for communities of color and low-income people. As you look at cost-sharing as a percentage of income, it starts to get significant really quickly," said Dr. Harry Greenspun, chief medical officer at the consultancy Guidehouse. "Unless we start to address health equity issues on a systemic level, we will keep running into these kinds of problems."

Rising out-of-pocket costs for prescription drugs can prove fatal, other research shows. A $10.40 increase in out-of-pocket costs per prescription was associated with a 22.6% drop in consumption and a 32.7% increase in monthly mortality rates, a recent analysis of more than 358,000 relatively healthy 65-year-old Medicare beneficiaries found.

The House recently passed President Joe Biden's Build Back Better Act, which would cap out-of-pocket spending for Medicare beneficiaries at $2,000 and limit cost-sharing for insulin products to $35. The bill would force drug manufactures to pay rebates to the federal government if their price increases exceed inflation. It would also give HHS the authority to negotiate prices with drug companies for a small number of high-cost drugs without generic or biosimilar competitors.

The negotiation provisions would save the federal government about $76 billion between 2022 and 2031, and the inflation rebates would cut about $84 billion in spending over that time, the Congressional Budget Office estimated.

"The drug pricing provisions in BBB are targeted at some serious unmet needs—it is an important first step," said Hempstead, who is optimistic that the $2,000 spending cap will stick. "This is a really significant part of peoples' health, especially for seniors who are already spending a ton of their income on health insurance, premiums and cost-sharing. Not being able to afford the thing that will make them feel better is a status quo that we should not accept."

The Build Back Better Act is less ambitious than the Lower Drug Costs Now Act, which was written by the late Democratic congressman from Maryland, Elijah Cummings. The legislation, which stalled in the Senate, would have allowed the federal government to negotiate the prices of at least 50 drugs from a list of up to 250 brand-name drugs per year, and these prices would have been available to both Medicare and commercial plans.

But pricing is just one element, Greenspun said. People may not take their medication if it has too many side effects, it's less effective or inconvenient. The convoluted pharmaceutical supply chain is a product of misaligned incentives, experts noted.

Having an open discussion about cost-sharing, side effects and other barriers when drugs are prescribed would improve adherence, Greenspun said.

"If we look at this as just an absolute issue of price without the context of how it impacts each patient differently, that is not going to move the needle," he said.