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Supplements Prescription Drug Copays and Their Effect on Vulnerable Populations

Vulnerable Populations: Who Are They?

Enabling Factors of Vulnerability
Shi and Stevens evaluated data on 32,374 adults from the 2000 National Health Interview Survey and identified 3 risk factors for poor access to healthcare: low income, lack of health insurance, and lack of regular care. They found that those without insurance were 7 times (odds ratio [OR], 7.33; confidence interval [CI], 6.24-8.62) less likely to get the healthcare they need and 4.5 times (OR, 4.55; CI, 3.81-5.45) more likely to not fill a prescription. Meanwhile, adults with low incomes were more likely to delay or not receive necessary medical, dental, and mental healthcare and to not fill prescriptions.13

Overall, researchers found that about 1 of 5 US adults has multiple risk factors for unmet health needs, creating up to a 5-fold difference in the rates of these unmet needs, such as delayed medical care between those with the greatest number of risk factors and those with the least. As Shi and Stevens noted, "Low income, no health insurance coverage, and lacking a regular source of care are closely related risk factors that build upon each other to influence the likelihood of having an unmet health need due to cost."

Vulnerable Populations and Chronic Conditions
As already noted, a key identifying characteristic of vulnerable populations is the presence of 1 or more chronic illnesses. Although certain chronic conditions, such as dyslipidemia, may not presently be disabling to the patient, they have potentially disabling effects in the future. In addition, although some individuals with chronic conditions live full, productive, and rewarding lives, others live with isolation, depression, and physical pain resulting from their illness.14

Outpatient Care. The most common chronic conditions among those 65 years and older are hypertension, arthritis, heart disease, and eye disorders. Among those 18 to 64 years, the most common chronic conditions are hypertension, respiratory disease, arthritis, and mental health diseases.9 The United States spends disproportionately more on healthcare for those with chronic illnesses than for those without. Not surprising, individuals with a chronic condition are twice as likely to report they have “bad health†days as those without a chronic illness.2Overall, 83% of US healthcare spending is for 48% of the noninstitutionalized population with 1 or more chronic conditions.9 Any incremental advancement achieved from outpatient intervention that improves outcomes may significantly impact healthcare costs.

Impact of Coverage. When comparing the insured versus those without healthcare coverage, the cost of healthcare delivery is disproportionately greater for the uninsured. Whereas 74% of private health insurance spending is attributed to 45% of those with chronic health conditions, 72% of all healthcare spending for the uninsured is attributed to 31% of patients with chronic conditions, and 83% of Medicaid spending is for 40% of noninstitutionalized beneficiaries with chronic conditions.9 In addition, although the majority of those with chronic conditions have health insurance (primarily due to public coverage), their increased out-of-pocket expenses put significant strain on the ability to pay for healthcare. Although 45% of patients make gradual payments over time, 16% borrow from their retirement fund, 11% take funds from their child's educational fund, and 8% declare bankruptcy.9

Comorbid Disease. Patients with multiple chronic illnesses are at an increased risk for hospitalization and require more prescriptions. As seen in Figure 2, those with 3 chronic conditions fill an average of 25.4 prescriptions per year,9 which translates to more out-of-pocket expenses. Overall, average annual out-of-pocket spending on healthcare for those with 1 or more chronic conditions is $827, compared with $505 per year of out-of-pocket spending for all Americans. The majority of out-of-pocket expenses for patients with chronic conditions is for prescription drugs, whereas patients without chronic conditions spend the most on dental care.Patients 65 years and older with 3 or more chronic conditions spend about $650 per year on medications, compared with $110 for those without any chronic conditions and $225 for those with only 1. Meanwhile, patients younger than 65 years with 3 chronic conditions spend nearly $450 per year on medications, compared with less than $50 for those with none and $110 for those with 1.15 Figure 3 shows total out-of-pocket healthcare spending based on the number of chronic conditions.

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