By PAULA SPAN
August 21, 2014
In 2003, when President George W. Bush signed the major Medicare expansion that would establish prescription drug coverage, he called it “a promise, a solemn promise, to America’s seniors.”
Medicare Part D, which took effect in 2006, initially made plenty of people angry. Some Congressional Democrats had argued that it would “privatize Medicare” by relying on insurance companies, while a number of Republicans insisted that the nation couldn’t afford the new program. Ordinary older adults learned to fear falling into the infamous “doughnut hole” coverage gap.
But in its first few years, national data shows, Part D did help elderly Medicare beneficiaries make modest progress. Out-of-pocket costs decreased. Better able to afford their medications, seniors were less likely to stop taking them for financial reasons. And they were less likely to do without other basic needs — like food and heat — in order to pay for drugs.
“I expected that to keep going,” said Jeanne Madden, a health policy analyst at Harvard Medical School. Instead, as she and a team researchers from Harvard and the University of Massachusetts report in the most recent issue of Health Affairs, those downward trends took a U-turn in 2009. “Things improved after Part D, continued to improve for a few years, and then reversed,” she said in an interview.
Moreover, having tracked a representative national sample of 16,000 beneficiaries, Dr. Madden said, the researchers determined that “the people who are more ill and need more medications have particular problems.”
A few numbers: In 2005, the year before Part D, nearly 15 percent of elderly beneficiaries acknowledged what the researchers (with scientists’ usual flair for language) called “cost-related non-adherence,” meaning people stopped taking prescribed medications, skipped or reduced doses to make drugs last longer, or delayed refills. It’s a medically risky strategy, and the proportion practicing it dropped to 11.3 percent in 2007, then to 10.2 percent in 2009. But in 2011, it rose again to 10.8 percent.
The same pattern shows up for forgoing basic needs to pay for drugs. Close to 9 percent of beneficiaries reported doing that in 2005; by 2009, only 4 percent did. But in 2011, the proportion climbed back to 5.3 percent — a statistically significant change.
Compounding the problem is that affordability has eroded the most for people with the greatest needs. The study looked at beneficiaries with four or more chronic conditions, including cardiac disease, hypertension, diabetes, stroke, cancer, pulmonary diseases and others. In this group, non-adherence fell from 23.4 percent in 2004 to 14.4 percent in 2009; by 2011 it had rebounded to 17 percent. Similarly, forgoing basic needs to afford medication decreased from 12.2 percent in 2004 to 6.8 percent in 2009 before climbing again to 10.2 percent.
It’s not surprising that people with multiple health problems are taking the hit. “They require more medications and with every one, even with small co-pays, the total adds up,” Dr. Madden said. “People are on fixed incomes and may struggle to pay their bills. And they’re more likely to hit that doughnut hole, which is still there,” though Obamacare will close it by 2020.
The Medicare Current Beneficiary Survey, from which the researchers drew the data, doesn’t ask people why they can’t afford their prescribed drugs, but the Great Recession likely contributed, Dr. Madden said. Seniors, too, faced foreclosures and shrunken I.R.A.’s and other nest eggs, and Social Security paid no cost of living increases in 2010 and 2011.
But Part D plans have been changing, too. “They appear to be covering fewer medications,” Dr. Madden said. “They’re using more tiering strategies, putting some drugs in very high-priced tiers. They may require pre-authorization from a doctor — another hurdle. People may be facing more restrictions.”
Possibly, data from 2012 and 2013 will bring better news; it will take a couple of years for more recent data to become available for analysis. In the meantime, the researchers suggest working to increase the number of low-income seniors receiving Medicare’s Extra Help subsidy (many who are eligible don’t enroll). Assisting beneficiaries in choosing the best Part D plan — often a bewildering process, as Jane Gross has recounted here — might also make drugs more affordable.
Rep. Jan Schakowsky, the Illinois Democrat who introduced legislation requiring nursing homes to have registered nurses on duty around the clock, has tackled this problem, too. Her bill would authorize Medicare itself to operate a national prescription drug plan that negotiates with pharmaceutical companies for lower-priced medications.
For several years, drugs did become more affordable for Medicare recipients — at a lower than projected cost to taxpayers — so this recent reversal of the trend looks like a fixable problem.
Otherwise, if sick old people must choose between refilling prescriptions and turning up the thermostat, and if they skip doses to save money, the solemn promise President Bush made has been broken.