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Supplements Prescription Drug Copays and Their Effect on Vulnerable Populations

Vulnerable Populations: Who Are They?

Despite efforts and goals in the United States to reduce or eliminate disparities in healthcare by 2010, significant disparities, including risk factors, access to healthcare, morbidity, and mortality, continue in vulnerable populations. For example, studies find that Americans living in poverty are much more likely to be in fair or poor health and have disabling conditions, and are less likely to have used many types of healthcare.

Vulnerable populations include the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness.2 It may also include rural residents, who often encounter barriers to accessing healthcare services.3 The vulnerability of these individuals is enhanced by race, ethnicity, age, sex, and factors such as income, insurance coverage (or lack thereof), and absence of a usual source of care.1,4-8 Their health and healthcare problems intersect with social factors, including housing, poverty, and inadequate education.2

Health Domains of Vulnerable Populations
The health domains of vulnerable populations can be divided into 3 categories: physical, psychological, and social.4 Those with physical needs include high-risk mothers and infants, the chronically ill and disabled, and persons living with HIV/acquired immunodeficiency syndrome.4 Chronic medical conditions include respiratory diseases, diabetes, hypertension, dyslipidemia, and heart disease. Eighty-seven percent of those 65 years and older have 1 or more chronic conditions, and 67% of this population have 2 or more chronic illnesses.9

In the psychological domain, vulnerable populations include those with chronic mental conditions, such as schizophrenia, bipolar disorder, major depression, and attention-deficit/hyperactivity disorder, as well as those with a history of alcohol and/or substance abuse and those who are suicidal or prone to homelessness.4

In the social realm, vulnerable populations include those living in abusive families, the homeless, immigrants, and refugees.4

The needs of these populations are serious, debilitating, and vital, with poor health in 1 dimension likely compounded by poor health in others. Those with multiple problems also face more significant comorbidities and cumulative risks of their illness than those experiencing a single illness.4

Overall, nonwhite women 45 to 64 years of age who are unemployed and uninsured with lower incomes and education levels tend to report the poorest health status.2

The Need to Focus on Vulnerable Populations
Although the needs of medically vulnerable populations are serious, are often debilitating or life-threatening, and require extensive and intensive medical and nonmedical services, these needs tend to be underestimated.4

Current financing and service delivery arrangements are not meeting the needs of these vulnerable populations. For example, the number of uninsured patients younger than 65 years of age grew by nearly 6 million between 2000 and 2004, with the greatest growth in those who are poor (46%) or near-poor (22%).10 In this population, approximately 35% to 45% have at least 1 chronic medical condition. More than half (58%) of those with a chronic illness without insurance report that they did not buy a prescription drug in 2003 because of cost compared with 39% of those with publicly funded insurance and 34% of those with private insurance.11

The numbers of these vulnerable populations are increasing, not only as the ranks of the uninsured grow, but as the population ages. For instance, the number of individuals with chronic medical conditions has risen from 125 million in 2000 to 133 million in 2005. This number continues to increase as the baby boom generation ages. By 2010, 141 million Americans are expected to have 1 or more chronic conditions, with an overall increase to 171 million people (37%) by 2030 (Figure 1).12

Chronic illnesses are significantly more prevalent among low-income and other disadvantaged populations. Additionally, the impact of these illnesses is more severe among the unemployed, uninsured, and less educated. For example, patients with a chronic illness who have less than a high school education are 3 times more likely to report being in poor health than those with the same illness who hold a college degree.2

Given the increasing number of vulnerable populations with 1 or more chronic health conditions, policymakers are becoming increasingly concerned about how to deal with the demands this population places on systems of care.4,9

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