Medicare Prescription Coverage and Congressional Gridlock: Time for Compromise

摘要: Few would argue that millions of elderly and disabled Americans with chronic illness have improved quality life, reduced risk acute hospitalization, lower mortality rates because access to new effective pharmaceutical agents.1–4 Ironically, however, while the United States is world leader in research development, it “world loser” among industrialized nations its failure provide insurance coverage for outpatient prescription drugs senior citizens. Such not included Medicare. Over a third U.S. Medicare enrollees no drug coverage; remaining two thirds, almost half discontinuous or limited coverage.5 The costs supplemental private are so high only small minority elders can afford premiums coinsurance.6 Certainly, some medications over-promoted inappropriately prescribed by physicians. But anecdotal scientific evidence mounting lack economic pharmaceuticals having serious adverse impacts on health life our nation's citizens.7,8 Many commentators point rapidly rising expenditures as culprit declining access. Between 1993 1999, increased from $51 billion $100 billion.9 Yet, 9.4% total personal 1999 were drugs.9 From societal perspective, this seems price pay given represent most technologies controlling illness. For 5.7% elderly, exceeded $2,000 1995, representing over 17.0% typical (median) citizen's income $14,42510,11 all discretionary income.12 Drug protects against distributed equally Americans. Despite existence Medicaid, poor who need least it; about those incomes less than $10,000 compared 70% above $50,000.13 Disparities extend status well: likely excellent health.13 What clinical consequences elderly? In issue Journal General Internal Medicine, Steinman et al.14 demonstrate strong link between underuse due costs. Using 2 years data (1995–1996) large sample participants Survey Asset Health Dynamics Among Oldest Old, researchers important disconcerting go beyond cost-related non-adherence. Further, using self-reports cause use (i.e., cost), study weakens argument without could be lesser medication rather coverage. Another notable contribution al. attention high-risk groups coverage. authors find people coverage, minorities 4 times more report cost whites; low <$10,000) 3 reason; very good health. While cross-sectional relies adherence, findings consistent previous studies showing association medication. recent review literature population, strongest indicated considerable unmet needs population.16 Importantly, was associated clinically essential drugs.15–17 beneficiaries hypertension, we found public (e.g., state-supported pharmacy benefit programs) twice rate antihypertensives fee-for-service after socioeconomic ($302 vs $191; P < .05).16 addition, well-controlled demonstrated limiting frail low-income resulted in: dramatic reduction (35%) such insulin, particularly mental problems pain; exacerbation (both somatic psychiatric); 200% increase expensive services nursing homes emergency services) outweighed drugs.6,7,18,19 Previous also identified vulnerable populations African-American race, low-income) coverage.15,16 variations existing evidence, preponderance supports al.'s finding cost, preventable condition results needless widespread suffering. Despite bipartisan agreement regarding seriousness national issue, continuing influence special interests Congressional gridlock led several missed opportunities address problem: demise Catastrophic Coverage Act 1988 Clinton Security Act, well act during last when numerous front-page articles describing citizens rationing food medicine8,20 helped galvanize support solution. Clearly, details proposed legislation highly controversial. Democrats generally preferred universal within Medicare, Republican proposals tend emphasize private-sector solutions targeting uncovered individuals. providing adequate estimated $15 per year,21 difficult proposition suddenly vanished surplus. Unfortunately, current legislative proposals22 do protect many vulnerable, (<200% poverty), sick elders. Most incorporate cost-sharing (about 50% costs), cost-containment feature has been reduce medications, hospitalization home admissions, study.23 Furthermore, catastrophic does kick until expend $4,000 $6,000 out-of-pocket costs.22 Rather pass inadequate pales comparison employer plans, recommend an approach recognizes urgent unlimited copayments.20 We estimate substantial portion group, whose utilization undertreatment illnesses, offset institutional services.24 one should become impoverished medications. second priority protection $3,000 costs). will larger impact thin everyone, including currently any assistance. The passage recognized votes future presidential candidates may depend whether promises program kept broken. Unfortunately, deteriorating economy urgency response terrorism make inaction provision too plausible. urge affordable compromise allow immediate comprehensive high-risk, beneficiaries. Our yet again inexcusable.