Full Coverage of Vaccines Under Medicare Would Help Reduce Preventable Diseases in Older Adults

What if you knew you had a one in three chance of developing a painful, blistering rash and that the risk would only increase as you got older? And what if you knew you could prevent the condition known as shingles by getting vaccinated? The answer seems obvious: you’d get the vaccine.

While you might think so, millions of adults in the US don’t get vaccinated, mainly because they’re deterred by out-of-pocket costs.

Despite the fact that one in three adults will get shingles during their lifetime and there are more than one million new cases each year, in 2015, only 34 percent of US adults age 65 years and older had ever gotten a shot to prevent shingles, according to the Centers for Disease Control and Prevention (CDC).

While vaccination rates for all adult vaccines are below public health targets, the rates for shingles and tetanus, diphtheria, and pertussis (Tdap) are the lowest. The risk of shingles increases with age and a recent study found that medical costs for treatment of shingles will soar to $4.7 billion annually by 2030 when 70 million US adults, or 20 percent of the population, will be over age 65.

One thing standing in the way of boosting vaccination rates is that most seniors on Medicare must pay out-of-pocket costs for certain vaccines. That’s not the case if you’re under age 65. The Affordable Care Act guarantees that most working adults age 64 years and younger can get vaccines without having to pay a dime while seniors with Medicare Part D—many of whom are retired and living on a fixed income—must reach into their own pockets to pay a portion of the cost. And millions of seniors on Medicare opt not to buy the optional Part D prescription drug program, further deterring them from getting the shots by making vaccines even more expensive.

Yet, there is a way to increase immunization rates: eliminate out-of-pocket costs.

Researchers at CDC found that immunization rates for the pneumococcal pneumonia and influenza vaccines, which require zero cost-sharing under Medicare Part B, are significantly higher than immunization rates for the shingles and Tdap vaccines, which require a co-pay under Part D—a 60 percent vaccination rate for pneumococcal vs. only 30 percent for shingles in 2014-2015.

Research published in 2016 in the American Journal of Pharmacy Benefits showed that higher out-of-pocket costs for vaccines lead to a lower chance of vaccination. Another study published in the Journal of Managed Care & Specialty Pharmacy found that Part D beneficiaries facing a co-pay of $75 or more for the shingles vaccine were more than twice as likely to skip their vaccinations than those with no out-of-pocket costs. The same study also looked at Tdap vaccination rates and found a similar result: those with co-pays of less than $50 skipped vaccinations 37 percent of the time; for those with higher out-of-pocket costs, the rate of those skipping vaccination jumped to 48 percent.

To its credit, since 2012, the Centers for Medicare & Medicaid Services (CMS) has urged Part D plans to create a tier for vaccines that would require no out-of-pocket costs. However, as of 2015, no enrollees in Medicare prescription drug plans and only 12 percent of seniors in Medicare Advantage Part D plans had access to zero-cost vaccines, so there is still much work to be done.

CMS should not give up the fight. It should continue to urge insurers to eliminate cost-sharing for shingles and other covered vaccines.

While not the only barrier to immunization, out-of-pocket costs represent a financial burden that not only discourages older adults from getting vaccinated, but also increases the incidence of vaccine-preventable diseases and adds billions of dollars in avoidable expense to the nation’s healthcare budget.

Eliminating these costs would help consumers, increase vaccination rates, and go a long way toward protecting the health of our rapidly aging population.

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