Prescription Drug Access Disparities Among Working-Age Americans

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Prescription Drug Access Disparities Among Working-Age Americans

Issue Brief No. 73 — December 2003

Marie C. Reed, J. Lee Hargraves

Racial and ethnic disparities in health care access have long been documented in the United States, but research from HSC drew particular attention to one dimension of these disparities that carried significant consequences for health outcomes: the ability to afford prescription medications. Using data from the Community Tracking Study 2001 Household Survey, Marie C. Reed and J. Lee Hargraves found that working-age African Americans and Latinos were substantially more likely than white Americans to report foregoing prescription drugs because of cost.

The Scope of Racial Disparities in Prescription Access

The survey data painted a stark picture. Nearly one in five African Americans (about 20 percent) and one in six Latinos (about 16 percent) between the ages of 18 and 64 reported that they had not purchased all of their prescribed medications in 2001 because they could not afford them. The comparable figure for non-Hispanic whites was roughly one in ten (about 11 percent). These gaps persisted after accounting for differences in income, insurance coverage, and other socioeconomic factors.

Chronic Conditions Amplify the Gap

The disparities were most pronounced among people living with chronic conditions such as diabetes, hypertension, heart disease, asthma, arthritis, cancer, and depression. More than 30 percent of African Americans and roughly a quarter of Latinos with at least one chronic condition did not fill all of their prescriptions in 2001 due to cost, compared with 17 percent of whites with chronic conditions. Among those with multiple chronic conditions, the numbers were even worse: more than 35 percent of blacks and 30 percent of Latinos with two or more chronic conditions went without needed medications, compared with just over 20 percent of whites.

The absolute size of the disparity gap grew with the number of chronic conditions. Between blacks and whites, the gap was 5 percentage points for those with no chronic conditions, 12 points for those with one condition, and 15 points for people with multiple conditions. Similar though generally smaller gaps existed for Latinos. This finding was particularly concerning because prescription medications are often critical to the ongoing management of chronic diseases, and failing to take prescribed drugs can lead to pain, worsening health, and increased risk of complications.

Insurance Type and Prescription Access

Insurance status was a powerful predictor of prescription drug access problems across all racial groups. Uninsured people were more than three times as likely as those with private coverage to have gone without at least one prescription due to cost. Among the uninsured with chronic conditions, roughly half reported cost-related prescription access problems regardless of race or ethnicity, reflecting the severe financial pressures that uninsured chronically ill Americans faced.

Among the privately insured, however, significant racial gaps persisted. Privately insured African Americans with chronic conditions were twice as likely as privately insured whites (22 percent versus 11 percent) not to have purchased all of their prescriptions because of cost. Privately insured Latinos with chronic conditions (18 percent) also fared worse than whites. Several economic factors helped explain these within-insurance-category disparities: employed blacks and Latinos generally earned less than whites, were less likely to work for employers offering plans with generous prescription benefits, and when offered a choice of plans, may have been more likely to select lower-premium options that provided thinner drug coverage and required higher out-of-pocket payments.

Rising Cost Sharing Threatens to Widen Disparities

The study warned that ongoing changes in prescription drug cost sharing could make these disparities worse. Private and public payers were increasingly requiring patients to pay more for their medications through higher copayments, tiered formularies that imposed higher costs for brand-name drugs, and coinsurance arrangements where patients paid a percentage of the total drug cost rather than a flat fee. Research had shown that even modest increases in out-of-pocket costs could cause price-sensitive patients, particularly those with low incomes, to stop filling their prescriptions.

Since African Americans and Latinos were more likely to have lower incomes and were already more likely to report problems affording their medications, rising out-of-pocket drug costs were expected to widen existing racial and ethnic disparities in prescription access. The greatest effect would fall on minorities with chronic conditions, for whom regular medication use was most important to maintaining health and preventing costly complications. The study concluded that increasing patient cost sharing for prescription drugs risked undermining broader efforts to reduce racial and ethnic disparities in health care access.

Sources and Further Reading

AHRQ — Federal health care quality research agency.

Health Affairs — Peer-reviewed health policy research.

Robert Wood Johnson Foundation — Health policy research.

Commonwealth Fund — Research on health care quality.