African American and Hispanic senior citizens who lack prescription drug benefits are three times more likely than white seniors to cut back on taking their medications, according to a study from researchers at San Francisco Veterans Affairs Medical Center. Although income level and medication cost also influenced decisions to restrict medication, ethnicity was an independent risk factor, the researchers said.
The researchers had no definitive explanation for their findings, saying that more research is needed to explain why minority patients who lack insurance are more likely to cut back on their prescription coverage. However, they said the study shows that money is not the only factor that affects whether uninsured seniors take their prescription drugs.
"Forgoing medications for lack of coverage is a very real phenomenon. This study calls attention to the magnitude of this problem, particularly among certain disadvantaged communities," said Michael Steinman, MD, a fellow in the VA National Quality Scholars Program at SFVAMC and University of California, San Francisco.
Seniors without prescription drug coverage were an oft-debated campaign issue during the presidential election last fall; both major candidates offering a different plan to add drug coverage to the Medicare benefit program.
But until now the scope of this problem had not been rigorously studied, Steinman said. "This is the only paper we're aware of that analyzes the scope of this problem in detail," he said.
The researchers surveyed 4,900 people over age 70, asking them, "at any time in the last two years have you ended up taking less medication than was prescribed for you because of cost?" They asked about income, assets, insurance coverage, monthly prescription drug costs, and ethnicity.
Eight percent of seniors without coverage said they had cut back on their medication, which represents more than one million Americans doing without their prescribed drugs. The factors most clearly associated with a senior taking less of their medications were low income, high out-of-pocket costs for prescription drugs, and African-American or Hispanic ethnicity.
Nearly 21 percent of African-Americans and Hispanics reported that they had restricted their medications, and for some groups in the study, the risks appear to be even higher, Steinman said. "Our data suggests that among minority seniors with low income and high drug costs, as many as 43 percent of people without coverage could be restricting their medication," he said.
Even when the researchers statistically adjusted for the influences of low income, and the high monthly price tag of medications, African-Americans and Hispanics still were three times as likely to have cut back on their medications as white people surveyed, the researchers found.
These findings were quite surprising, Steinman said. "We can only guess why African-Americans and Hispanics would be more likely to restrict their medications," he said. "It could be that attitudes about resource allocation may be different for different ethnicities."
"If you have a limited amount of money each month, and you have to pay for medicine, food, telephone service, and rent from that, then in some cases not taking your medications is an understandable choice," Steinman said.
Rather than focus on the effect of ethnicity, Steinman hopes the study will emphasize the sheer numbers of people forced to make these difficult financial choices. "The point is, no one should be forced to make these choices," he said.
The study did not measure the effect of skipping medications on survival or other outcomes, but Steinman pointed out that there are risks with either decision. "Even if choosing the medications might help them to do better in terms of their survival, they may be suffering in other ways, for instance from not having a telephone or proper nutrition," he said.
A Medicare prescription drug benefit is likely to reduce the numbers of those going without their medications, Steinman argued. However, "plans that focus only on the poorest of the poor may to little to help other vulnerable groups. We're learning that this kind of approach will still leave far too many people out in the cold," he said.
Co-authors on the study included Laura Sands, PhD, UCSF assistant professor of medicine, and Kenneth Covinsky, MD, MPH, staff physician at SFVAMC and UCSF assistant professor of medicine.
Michael Steinman was supported in part by the VA National Quality Scholars Fellowship Program.
The San Francisco Veterans Affairs Medical Center has been a primary affiliate of University of California, San Francisco since 1974. The UCSF School of Medicine and the SFVAMC collaborate to provide education and training programs for medical students and residents at SFVAMC. SFVAMC maintains full responsibility for patient care and facility management of the medical center. Physicians at SFVAMC are employed by the Department of Veterans Affairs and also hold UCSF faculty appointments.