Aside from nursing home care, the exclusion of prescription drugs is one of the most significant historical shortcomings of the Medicare program. Until now, prescription drug coverage for Medicare beneficiaries has been a patchwork of public and private policies with varying levels of coverage and eligibility requirements. The end result has been heartwrenching. Many near-poor and low income older adults sacrificed essential medications to pay for rent and groceries because they were not poor enough to qualify for Medicaid.
There is a great dichotomy here: Was this legislation about helping the poor or helping the drug companies? Prescription drugs are the fastest growing component of national health expenditures (Levit et al., 2003). It is not surprising that the majority of these expenditures are for newer and more expensive drugs. It is not known if this is due to postdevelopment marketing strategies or pharmacoepidemiological research, which seeks to frame the appropriate use of medications against drug company claims. Somehow, I am doubtful it is due to the latter.
Will the program eliminate disparities in access to prescription medications for older adults? Some critics point to the "doughnut hole" for mid-range prescription costs. In practice, government support would stop at the $2,250 point. Older adults would be responsible for the next $2,850 in drug costs and only when the cumulative drug bill reaches $5,100 would Medicare begin paying 95% of all further costs.
What about immediate relief? Older adults will be eligible to purchase a discount drug card this April for about $30. These cards will allow for a 15% to 25% drug savings over current prices. Evidendy the legislature is certain that drug companies will not raise prices to offset any benefit reaped from this discount program. What is amazing to me is why politicians thought we needed a law to create the discount card program, but it is an election year!
What about other disparities in the program? There is evidence that racial and socioeconomic differences in procuring prescription drugs will persist even after coverage becomes available. For example, one study found that White beneficiaries are more likely to purchase medications than non-White and Black beneficiaries, even when controlling for such factors as health status, income, and education (Fillenbaum et al., 1993).
How could the program have been improved? America's leaders are banking on good old-fashioned capitalism to change the landscape of financing health care for the nation's older adults. In essence, Capitol Hill is hoping private payers will supplement the Federal program because there is a profit to be made in marketing gap insurance to older Americans. The American Association of Retired Persons, who endorsed this legislation, is one such party. However, without the government's ability to negotiate drug prices, prescription drug costs will inevitably increase (Rogowski, Lillard, & Kington, 1997).
What does all this mean for nursing? Ensuring appropriate and costeffective prescription drug use among older adults will be a challenge in the years to come. Prescription drug coverage does not guarantee compliance or the appropriate prescriptive use of medications by providers, both of which are of particular concern in elderly individuals (Molony, 2003). Polypharmacy, drug toxicities, delirium, and other more severe adverse outcomes will not decrease with this legislation. Nurses, primary care providers, and pharmacists must collaborate in the clinical monitoring of older adults. Teaching about the side effects of medications and identifying medication-related problems will be paramount in this effort.
- Fillenbaum, G.G., Hanion, J.T., Corder, E.H., Ziqubu-Page, T-, Wall, W.E., Jr., & Brock, D. (1993). Prescription and nonprescription drug use among black and white community-residing elderly. American Journal of Public Health, 83(11), 1577-1582.
- Levit, K., Smith, C., Cowan, C., Lazenby, H., Sensenig, A., & Catlin, A. (2003). Trends in U.S. health care spending, 2001. Health Affairs (Millwood), 22(1), 154-164.
- Molony, S. (2003). Beers' criteria for potentially inappropriate medication use in the elderly. Journal of Gerontological Nursing, 29(11), 6-7.
- Rogowski, J., Lillard, L.A., & Kington, R. (1997). The financial burden of prescription drug use among elderly persons. Gerontologist, 37(4), 475-482.