Medications, Rationing, and Health Care: The Role of Pharmacists in Bridging the Gap

A major obstacle to comprehensive services in the direct care of the medically underserved or uninsured population is access to affordable medications. Often, a consumer can walk into a clinic, an urgent care office, or an emergency room, and receive appropriate medical care only to find that the prescriptions they walk out with will be too expensive for his or her budget. Even those consumers with prescription coverage often find that substantial co-payments or restrictive formularies block their access to these much-needed pharmaceuticals.

When trying to maneuver their way through the health care system, consumers are often the last to learn what prescription benefits they lack. Many times, consumers assume that a provider's prescription guarantees coverage. Even worse off are patients who lack health insurance coverage altogether. Having just been hit with the expense of an office or hospital visit, these patients enter the pharmacy having to pay for the entire cost of medications. For low-income U.S. citizens who are not privately covered or on Medicare, some recourse may be found in Medicaid (if household income is low enough to meet the state limit), for pharmaceuticals, Medicaid Programs or Medication Assistance Programs (MAPs). Other groups, such as undocumented immigrants, face more impenetrable barriers to acquiring prescribed medications, as neither Medicaid nor MAPs may be open to them.

It is not unusual for frontline clinicians to resort to creative ways of finding medications, including using multiple samples or donations from whoever is willing to assist. This practice, although noble, often results in gaps in treatment especially when dealing with consumers who have chronic medical conditions such as diabetes, hypertension, or dyslipidemia.¹ When samples run out or a newer product hits the market, it is often necessary to make changes in the regimen to keep the consumer treated. These changes, if not communicated clearly to consumers, can and do result in situations where consumers duplicate medication, stop treatment altogether, or receive the wrong treatment due to frequent changes in dosing. Since a chronic condition often requires years of medication, situations like these expose a consumer to unnecessary risk.

Although the U.S. health care system does not explicitly ration medication, the practical fact is that patient access is sharply limited, even when the drugs are properly prescribed. Much planning goes into selecting the medications that will be included on formularies, for example, in a process that includes considerations of therapeutic benefits, indications, and cost. The determination to exclude certain items is often driven by the need to cover more consumers with limited funds and even by simple things such as pharmacy shelf space. Even more prohibitive are investigational pharmaceuticals, the costs of which are often so prohibitive that consumers regularly are denied access despite having insurance benefits.

A modern example of a specific population for whom health care is rationed is Native Americans. While recognizing Indian tribes as sovereign nations, the U.S. authorized federal funds for Indian health services through the Snyder Act of 1921.² Most Indian Health Service (IHS) providers are not geographically accessible to urban Indians, although over half (about 56%) of the Native American population now live in urban areas. Disparities in health coverage and care show that American Indians continue to be at a disadvantage in the U.S. health system and are nearly three times as likely as whites to be uninsured.³ Health care providers encounter major obstacles when trying to achieve access to pharmaceuticals for these consumers.

A second modern example of rationing of pharmaceuticals is the recently created Medicare drug program. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created prescription drug benefits that will be added to Medicare in 2006. The Medicare consumer suddenly faces a mountain of confusing information regarding enrollment, benefits, and making the transition to Medicare coverage of some prescription costs. The new legislation emphasizes the Medicare Part D formulary, a complex account of what is and is not covered. A case in point is that the MMA will exclude from coverage those categories of drugs for which...