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The Medicine Cabinet is Shrinking

Medication costs without insurance coverage are astronomical-- and my uninsured patients are struggling to pay for all their needed prescriptions. By 2019 many of my patients could be dead simply because they're not taking their medications--even when they know they should.
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Earlier this year in February, the Congressional Budget Office predicted that without changes in federal policy, the number of Americans without health insurance would grow from about 45 million this year to about 54 million in 2019 . But 2019 is years away and I wonder in the more immediate future what my patients will do if they need medication for diabetes, hypertension or high cholesterol and can't afford it. Medication costs without insurance coverage are astronomical-- and my uninsured patients are struggling to pay for all their needed prescriptions. By 2019 many of my patients could be dead simply because they're not taking their medications--even when they know they should.

A report issued by the US Public Interest Research Group in 2006 documented that uninsured Americans were paying 65% more than what drug companies charged the federal government for prescriptive medications. This survey evaluated ten of the most commonly prescribed medication in 35 cities including D.C.. Customers purchasing medications online from Canadian pharmacies were paying half the price for the same medications. Not only that, the average price between 2004- 2006 rose 11% annually. At the time this study was conducted Premarin®, a commonly prescribed estrogen medication, was 550% higher in the U.S. versus the listed price in a Canadian pharmacy.

Surveys released by the Center for Studying Health System Change (HSC) taken between the years 2001-2007 revealed that the proportion of Americans under the age of 65 having problems affording prescription medications grew from 10.3 % in 2003 to 13.9 % --an 11.7 million increase of people from 2003 which initially recorded 36.1 million working age adults and children experiencing medication cost concerns Not surprisingly, the report noted that the most vulnerable were the uninsured, those with low incomes and those with chronic conditions . Having at least one chronic condition more than doubled the likelihood of reporting unmet prescription drug needs.

The health insurance safety net under the Consolidated Omnibus Budget Reconciliation Act (COBRA), for those recently losing their jobs is not necessarily preserving health coverage like it was in the past. When a person becomes unemployed COBRA extends insurance benefits under a previous employer's plan. An employer's health care plan is typically much lower in cost to the individual because it is a plan negotiated by the employer as a group plan. Its benefits are good for 18 months. Despite the fact that 2 out of 3 working adults are eligible for COBRA, nine out of ten unemployed workers opt out of COBRA coverage because it is too expensive. Those opting out with medical conditions represent another growing group of people at risk for developing unmet prescription medication needs.

Today there are people among the insured who are struggling to keep up with the ever increasing price of prescription medication co-payments. A HSC report released in 2007 indicated that tiered prescriptive medicine plans which use generic medicines to reduce overall healthcare costs are now offered by roughly 95% of employers. Generic drugs are substituted in most medication categories and are offered as the first line full coverage medication to the patient over the more expensive name brands. Those who wish to use name brands can still purchase these medications as an out-of-pocket expense.

During the initiation of copayments for prescriptive medications early reports suggested little or no negative effect on patient compliance or health outcomes. However, an HSC tracking report released in January 2009 revealed that with a rise in prescriptive drug copayments higher than 20% many people began to have trouble paying for needed medications. In fact, the percentage of unmet medication needs among U.S. working age adults with higher incomes and chronic conditions was almost as high as those with unmet prescription drug needs without chronic conditions and low incomes ( 21% versus 23% respectively). Low income was defined as those families with incomes below the federal poverty line and high income was defined as those families whose incomes were two times above the federal poverty level.

In addition, I have seen many patients attempt medical management of some of their medical problems by using dietary supplements, additionally availing themselves to indigenous medical practices such as acupuncture and chiropractic. The current prevalence of use of these practices and modalities often referred to as complementary and alternative medicine (CAM) or modalities is approximately 40-60 % depending on the survey and definition of CAM. However, it is unclear what proportion of activity is due to philosophical preferences versus attempts toward cost containment by the patient--especially in this last year when so many have lost their jobs. Yet, what is consistent among reports of patients incorporating these practices is the lack of disclosure to their healthcare providers; typically this represents 60-70% of patients in primary care. What has always been troublesome about this fact is the potential for medical mismanagement. I wonder if we will see additional complications as more people use CAM as an alternative to conventional or integrative medicine primary care purposefully leaving behind any discussion from medical practitioners.

For whatever the reason, the growing proportion of patients with unmet prescription drug needs is disturbing. The fact that those suffering financially the most are those with chronic diseases certainly is a signal that in a time when health care cost containment is critical to our nation we need to change course. It is imperative that what ever system we choose medications for the management of chronic diseases should be accessible to all regardless of income. Prevention and proper management of disease saves money, but more importantly, it saves lives and improves quality of life for patients and their families.