Prescription Drug Affordability among Medicare Beneficiaries

January 2022

DATA POINT

HP-2022-03

Prescription Drug Affordability among Medicare

Beneficiaries

More than 5 million Medicare beneficiaries struggle to afford prescription

medications. Among adults 65 and older, Black and Latino beneficiaries are most

likely to experience affordability problems. Medicare beneficiaries with lower

incomes and those under age 65 also had above-average rates of not taking needed

medications due to cost.

Wafa Tarazi, Kenneth Finegold, Steven Sheingold, Nancy De Lew, and Benjamin D. Sommers

KEY POINTS

• Using the National Health Interview Survey (NHIS), we estimate that 3.5 million adults 65 and

older and 1.8 million Medicare beneficiaries under 65 had difficulty affording their medications in

2019.

• Black and Latino adults over age 65 reported difficulty affording prescription medications at rates

roughly 1.5 to 2 times higher than White adults.

• Medicare beneficiaries below age 65 – who generally qualify for Medicare on the basis of a

disability or end-stage renal disease – had much higher rates of affordability problems with

prescriptions than did adults over 65.

• Women, people with lower incomes, and beneficiaries diagnosed with chronic conditions such as

diabetes had higher rates of having affordability problems with prescriptions than other groups.

• Several potential policies, including changes to the Medicare Part D drug benefit and proposals to

lower the price of prescription drugs in Medicare, would likely improve equitable access to

needed medications.

BACKGROUND

High drug prices in the U.S. are harmful to patients and the country as a whole. U.S. drug prices, for example,

are nearly twice as high as prices in other comparable countries, even after rebates.

The high cost and out-of-

pocket expenses of drugs cause many Americans – particularly those with chronic conditions such as diabetes

– to delay or skip taking needed treatments.

2,3

The Biden-Harris Administration has renewed policy attention to the cost of prescription drugs in an effort to

protect consumers and enhance health equity.

Policymakers have proposed redesigning the Medicare Part D

program by creating a maximum out-of-pocket cost for beneficiaries, ensuring that Part D plans are

January 19, 2022

January 2022

DATA POINT

incentivized to promote drugs with the most value at the lowest cost, and requiring drug manufacturers to

provide cost discounts.

The Build Back Better Act being considered by Congress proposes steps to reduce

drug prices and lower costs for Medicare beneficiaries, including allowing Medicare to negotiate drug prices;

addressing price increases above inflation; restructuring the Part D benefit to cap beneficiary out-of-pocket

costs at $2,000 a year; and limiting insulin cost-sharing to $35 per month.

The Biden-Harris administration is also pursuing regulatory changes to improve prescription drug affordability

for Medicare enrollees, which do not require congressional approval. For example, applying Part D pharmacy

price concessions at the point of sale, as in the Notice of Proposed Rulemaking issued January 6, 2022, is

projected to reduce beneficiary costs by more than $2 billion per year.

Medicare beneficiaries who are

prescribed more costly drugs or require multiple drugs to treat chronic conditions would be particularly likely

to benefit from this proposal.

Approximately 48.7 million out of 62.2 million Medicare beneficiaries depend on Part D for prescription drug

coverage.

†

While most beneficiaries qualify for Medicare coverage when they turn 65, younger individuals

may be eligible based on having a disability or end-stage renal disease (ESRD).

The objective of this Data Point was to examine the affordability of needed prescription drugs among

Medicare beneficiaries, using recent data from the National Health Interview Survey (NHIS). Specifically, we

examined whether adults 65 and older and Medicare beneficiaries younger than 65 reported affordability

problems of skipping medication doses, taking less medication, delaying filling a prescription to save money, or

not getting needed prescriptions because of cost in the past 12 months.

METHODS

We use the 2019 NHIS, a cross-sectional household interview survey that is considered one of the important

sources of information on the health of the civilian noninstitutionalized population of the U.S.

A major

strength of the NHIS is its ability to categorize information on health by several demographic and

socioeconomic characteristics. The NHIS can be used to examine characteristics of individuals with various

health problems, identify barriers to accessing and using appropriate health care, and evaluate Federal health

programs. We use 2019 NHIS data rather than 2020 data because of concerns that the COVID-19 pandemic

may have affected both drug utilization and patterns of survey responses.

We analyzed two outcomes:

• The first outcome combined several NHIS questions related to problems affording prescription

medications. For those who reported taking prescription medications in the past 12 months, the

questions were, “During the past 12 months, were any of the following true for you?

(a) skipped medication doses to save money?

(b) took less medication to save money?

and

_______________________

The Notice of Proposed Rulemaking proposes to define price concession in a broad manner to include all forms of discounts and direct

or indirect subsidies or rebates that serve to reduce the costs incurred under Part D plans by Part D sponsors. The effect of the

proposal would be to include pharmacy price concessions to Part D sponsors in calculating the negotiated price of a drug, lowering the

amount used to determine cost-sharing for Part D beneficiaries subject to coinsurance or in the annual deductible phase of their

benefit. https://public-inspection.federalregister.gov/2022-00117.pdf

†

In 2021, 12 percent of Medicare beneficiaries were not enrolled in Part D or other creditable drug coverage

(https://www.medpac.gov/wp-content/uploads/2021/10/July2021_MedPAC_DataBook_Sec10_SEC.pdf, p. 14). This share is

equivalent to 7-8 million individuals (ASPE estimate based on above and https://www.cms.gov/files/document/2021-medicare-

trustees-report.pdf, p. 14).

January 2022

DATA POINT

(d) “During the past 12 months, was there any time when you needed prescription medication, but

did not get it because of the cost?”

• We also examined item (d) above as a standalone measure, medications not taken due to cost.

The first outcome is broader and reflects multiple potential negative impacts of expensive medications. The

second outcome is narrower and reflects the most severe consequence of medication costs – a patient not

taking a needed medication at all.

We examined these two measures of medication affordability separately for adults aged 65 and older, and for

those adults under age 65 who reported having Medicare coverage. We examined medication affordability by

race/ethnicity, sex, family income (above vs. below 200 percent of the Federal Poverty Level [FPL]), urban vs.

rural counties, and the presence of selected chronic conditions (diabetes, hypertension, and asthma or chronic

obstructive pulmonary disease [COPD]).

‡

We applied survey weights to estimate the total population size that

experienced these affordability difficulties.

FINDINGS

Table 1 presents characteristics of individuals who reported any medication affordability problems and those

who needed prescription drugs but did not get it because of cost in the past 12 months. The table presents the

characteristics separately for adults 65 and older and for Medicare

beneficiaries below 65.

Overall, 3.5 million adults 65 and older (6.6 percent) and 1.8 million

Medicare beneficiaries younger than 65 (22.7 percent) reported

affordability problems with prescriptions in 2019. The numbers for those

who did not get needed prescriptions due to cost were 2.3 million adults 65

and older and 1.4 million Medicare beneficiaries under age 65.

Among adults 65 and older, Latino and Black adults were roughly 1.5 times

more likely to have affordability problems than were Non-Latino White

adults and 2 times as likely not to get needed prescriptions due to cost.

In the Medicare group under age 65, the pattern was somewhat different,

with the rates of not getting needed prescriptions due to cost being lower

among Black and Asian beneficiaries than White beneficiaries, while American Indian and Alaska Native

beneficiaries had the highest rate.

In both age groups and outcome measures, women and those with lower incomes were more likely to

experience affordability problems than men and those with higher incomes, respectively. Rates were fairly

similar for urban and rural residents.

Individuals with chronic conditions had higher rates of overall affordability problems and higher-than-average

rates of not getting needed prescriptions due to cost. For example, among adults with diabetes, 9.9 percent of

adults 65 and older and 26.2 percent of Medicare beneficiaries younger than 65 experienced affordability

problems (compared to 6.6 percent and 22.7 percent, respectively, for the age groups as a whole). Rates of

affordability problems were even higher for adults with asthma or COPD.

_______________________

‡

We combined the NHIS question on asthma and “COPD, emphysema, or chronic bronchitis” for a single composite group.

Overall, 3.5 million

adults 65 and older

and 1.8 million

Medicare

beneficiaries younger

than 65 reported

affordability problems

with prescriptions in

2019

January 2022

DATA POINT

Table 1. Share of Adults Who Reported Affordability Problems or Did Not Get Needed Prescription Drugs

Due to Cost in the Past 12 Months, by Beneficiary Characteristic (2019)

% Who Reported Any

Affordability Problems

% Who Did Not Get

Needed Prescriptions due

to Cost

Characteristic

All Adults

65 and

Older

Medicare

Beneficiaries

Under Age 65

All Adults

65 and

Older

Medicare

Beneficiaries

Under Age 65

Race and Ethnicity

Latino

9.8%

18.1%

7.6%

12.9%

White (Non-Latino)

6.2%

25.3%

3.8%

20.3%

Black (Non-Latino)

9.5%

17.0%

7.3%

11.6%

Asian-American (Non-Latino)

2.7%

15.7%

1.9%

14.2%

American Indian / Alaska Native

3.8%

23.2%

2.8%

23.2%

Sex

Male

5.2%

18.1%

3.6%

13.0%

Female

7.8%

27.2%

5.0%

22.4%

Family Income

Less Than 200% Federal Poverty Level

11.1%

26.0%

7.7%

20.3%

Above 200% Federal Poverty Level

4.7%

16.7%

2.9%

13.2%

Urban/Rural Counties

Urban (Metro)

6.7%

22.5%

4.4%

17.0%

Rural (Non-metro)

6.3%

23.2%

4.0%

20.3%

Chronic conditions

Ever had diabetes

9.9%

26.2%

7.2%

22.0%

Ever had hypertension

7.3%

26.1%

4.9%

21.2%

Ever had asthma or COPD

11.0%

28.4%

7.8%

22.1%

FULL SAMPLE

6.6%

22.7%

4.4%

17.8%

Number of “yes” respondents (weighted)

3.5M

1.8M

2.3M

1.4M

Total number of respondents (weighted)

52.8M

7.8M

52.8M

7.8M

Notes: Analysis of the 2019 National Health Interview Survey (NHIS) data. The first outcome was the percentage of respondents in each

subgroup who answered “yes” to any of the questions on whether they saved money by skipping medication doses, taking less

medication, or delaying filling a prescription during the past 12 months. These questions are only administered to respondents who

reported utilizing prescription drugs in the previous 12 months. In addition to these questions, the first outcome included respondents

who reported not getting needed prescriptions due to cost but were not asked the additional questions because they did not report

prescription drug utilization in the previous 12 months. The second narrower outcome was the percentage of respondents who

answered “yes” to the question, “During the past 12 months, was there any time when you needed prescription medication, but did

not get it because of the cost?” The table does not report results for multiple races in combination, or Native Hawaiian and Pacific

Islanders due to limitations on definitions of these groups from NHIS and sample sizes. Urban/rural counties in the data were based on

the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties. In this analysis, it was

reconstructed into two categories (Metro, which included “large central metro, large fringe metro, and medium and small metro”; and

Non-metro, which included nonmetropolitan counties). COPD is Chronic Obstructive Pulmonary Disease.

January 2022

DATA POINT

DISCUSSION

Our analysis of 2019 national survey data shows that 5.3 million individuals (3.5 million adults 65 and older and

1.8 million Medicare beneficiaries younger than 65) reported affordability problems with prescriptions.

We also found that rates of affordability problems and not getting needed prescriptions due to cost varied by

respondent characteristics and age group. Among adults over 65, who represent the majority of Medicare

beneficiaries, there are major inequities across dimensions including race/ethnicity, income, and chronic

conditions. Black and Latino beneficiaries were 1.5 to 2 times as likely to experience medication-related

affordability challenges as White beneficiaries in this age range. Beneficiaries with chronic conditions such as

diabetes and those with lower incomes were also more likely to experience these challenges.

Rates of medication affordability problems among Medicare beneficiaries younger than 65 were much higher

than among adults 65 and older. Medicare beneficiaries younger than 65 are generally sicker than the general

population, since they qualify for Medicare based on having a disability or ESRD.

Comorbidities are common

in this population. In addition, Medicare beneficiaries younger than 65 are also more likely to have low

incomes and be dually-enrolled in Medicare and Medicaid.

Our findings indicate substantial disparities in access to needed medications among Medicare beneficiaries.

Potential approaches to improving affordability of prescription drugs in Medicare include direct price

negotiations to reduce the cost of expensive medications, limitations on price increases over time, changes to

the Medicare Part D benefit to reduce patient cost-sharing and cap beneficiaries’ out-of-pocket spending, and

applying Part D pharmacy price concessions at the point of sale.

4,6

The findings in this report suggest that such

changes would likely improve equitable access to prescription drugs and help improve medication affordability

for millions of Medicare beneficiaries.

January 2022

DATA POINT

REFERENCES

1. Mulcahy AW, C.; Tebeka, M.; Schwam, D.; Edenfield, N.; Becerra-Ornelas, A. International Prescription Drug Price

Comparisons. 2021;

https://www.rand.org/content/dam/rand/pubs/research_reports/RR2900/RR2956/RAND_RR2956.pdf. Accessed

November 12, 2021.

2. Cohen R, Cha, A. Strategies Used by Adults With Diagnosed Diabetes to Reduce Their Prescription Drug Costs,

2017–2018. 2019; https://www.cdc.gov/nchs/data/databriefs/db349-h.pdf. Accessed November 12, 2021.

3. Cohen R, Boersma, P. Strategies Used by Adults Aged 65 and Over to Reduce Their Prescription Drug Costs,

2016–2017. 2019; https://www.cdc.gov/nchs/data/databriefs/db335-h.pdf. Accessed November 10, 2021.

4. Office of the Assistant Secretary for Planning and Evaluation - U.S. Department of Health and Human Services.

Comprehensive Plan for Addressing High Drug Prices: A Report in Response to the Executive Order on

Competition in the American Economy. 2021; https://aspe.hhs.gov/reports/comprehensive-plan-addressing-

high-drug-prices. Accessed November 10, 2021.

5. Martin K. Essential Facts About Drug Pricing Reform - Medicare Part D Redesign. 2021;

https://www.commonwealthfund.org/publications/explainer/2021/may/medicare-part-d-redesign. Accessed

November 10, 2021.

6. U.S. Department of Health and Human Services. Proposed Rule: Medicare Program; Contract Year 2023 Policy

and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs. 2022;

https://public-inspection.federalregister.gov/2022-00117.pdf, p. 315. Accessed January 7, 2022.

7. Centers for Medicare and Medicaid Services. 2021 Annual Report of The Boards of Trustees of The Federal

Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 2021;

https://www.cms.gov/files/document/2021-medicare-trustees-report.pdf. Accessed November 22, 2021.

8. Centers for Disease Control and Prevention NHIS. About the National Health Interview Survey. 2021;

https://www.cdc.gov/nchs/nhis/about_nhis.htm. Accessed November 9, 2021.

9. Bramlett M, Dahlhamer, J., Bose, J. Weighting Procedures and Bias Assessment for the 2020 National Health

Interview Survey. 2021;

https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2020/nonresponse-report-

508.pdf. Accessed November 9, 2021.

10. U.S. Department of Health and Human Services. Who is eligible for Medicare? 2021;

https://www.hhs.gov/answers/medicare-and-medicaid/who-is-eligible-for-medicare/index.html. Accessed

November 12, 2021.

11. Jacobson G, Griffin, S., Neuman, T., Smith, K. Income and Assets of Medicare Beneficiaries, 2016-2035. 2017;

https://www.kff.org/medicare/issue-brief/income-and-assets-of-medicare-beneficiaries-2016-2035/. Accessed

November 12, 2021.

January 2022

DATA POINT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D

Washington, D.C. 20201

For more ASPE briefs and other publications, visit:

aspe.hhs.gov/reports

ABOUT THE AUTHORS

Wafa Tarazi is a Health Economist in the Office of Health Policy in the Office of the Assistant Secretary for Planning and

Evaluation.

Kenneth Finegold is a Senior Social Science Analyst in the Office of Health Policy in the Office of the Assistant Secretary

for Planning and Evaluation

Steven Sheingold is the Director of Healthcare Financing Policy in the Office of Health Policy in the Office of Assistant

Secretary for Planning and Evaluation.

Nancy De Lew is the Associate Deputy Assistant Secretary of the Office of Health Policy in the Office of Assistant Secretary

for Planning and Evaluation.

Benjamin D. Sommers is the Deputy Assistant Secretary of the Office of Health Policy in the Office of Assistant Secretary

for Planning and Evaluation.

SUGGESTED CITATION

Tarazi, W., Finegold, K., Sheingold, S., De Lew, N., and Sommers,

BD. Prescription Drug Affordability among Medicare Beneficiaries

(Issue Brief No. HP-2022-03). Office of the Assistant Secretary for

Planning and Evaluation, U.S. Department of Health and Human

Services. January 2022.

All material appearing in this report is in the public domain and

may be reproduced or copied without permission; citation as to

source, however, is appreciated.

DISCLOSURE

This communication was printed, published, or produced and

disseminated at U.S. taxpayer expense.

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HP-2022-03