Overall, we found that almost 4 of 10 older adults had enrolled in the Medicare Part D program between the period of April 1, 2006, to October 31, 2007. We also observed a gradual increase in enrollment rates over time, with program participation reaching about 50% toward the latter stages of the study, which was about a year and half after rollout of the program. The results of these analyses also suggest somewhat distinct Medicare Part D program enrollment profiles among Blacks and Whites. Enrollment rates were higher in Blacks compared with Whites and the program enrollment pattern among Blacks appears to have been motivated by financial and health needs more so than among Whites. Black enrollees generally were more disadvantaged in terms of lower socioeconomic status and poorer physical health. They were also more likely to be unmarried females, have less education and income, have more medical conditions, and greater physical disability as measured by ADLs and poorer physical function than those who did not enroll. Among Whites, enrollees were older females with less education than nonenrollees, but health was apparently not associated with Whites having enrolled in the program. In the multivariate analyses, older age, female, being married, lower income, worse physical function, and better cognitive function were associated with program enrollment.
Location was a prominent factor in program enrollment. Whereas less than one fifth of White enrollees enrolled in their doctor's office, nearly half of Black enrollees enrolled in their doctor's office, which is somewhat surprising given historic health care access barriers encountered by Blacks. But whether our survey participants were contacted by CMS and encouraged to enroll in their doctor's office or if access to health care is typically a problem for our participants is unknown. Indeed, one of CMS's major program strategies was
making contact with and counseling vulnerable populations, particularly widows and unmarried women and those less educated and with lower incomes (Heiss et al., 2006
). Furthermore, whether this enrollment process was facilitated by the physicians themselves, the nursing staff, other health care practitioners, or administrative staff is unclear; regardless, the doctor's office proved to be an efficient mechanism for reaching the Black population in this large-scale nationwide educational and outreach campaign. Our findings suggest that the doctor's office can be a vital source of program education, information, and intervention, particularly for older Blacks. Other national, state, and local programs such as Medicaid, civic engagement programs, Meals on Wheels, adult day care, caregiving, and senior housing programs may improve their outreach and impact by exploring collaborative relationships with doctor's offices.
Similar to Neuman and colleagues’ (2007)
findings, we also observed a knowledge gap evident among Blacks who did not enroll in the program. More than one third of Black nonenrollees reported that they were unaware of or confused by the program or plans. However, the fact that 13% of Blacks and 2% of Whites reported that they did not know about the program, actually aligns with CMS's report that “85 percent of seniors were aware of the open-enrollment period” (CMS, 2007
). Beyond the basic knowledge of the Medicare Part D program, the complexity of the program added to consumer lack of knowledge and confusion (Summer et al., 2008
). In fact, Hsu and colleagues (2008)
recently reported that the majority of beneficiaries were unaware of or had limited knowledge of the coverage gap, otherwise known as the doughnut hole, which happens when beneficiaries with moderate to high drug expenses are personally responsible for a substantial portion of their drug costs (Goldman & Joyce, 2008
The import of our findings to program policy is pronounced when considering the projected increase in the U.S. Black elderly population; by 2050, 14% of the Black population will be aged 65 or older compared with 8% today (U.S. Bureau of the Census, 1996
). Similar increases are projected for other race and ethnic groups. It remains to be seen whether or not improving access to prescription drugs through the Medicare Part D program contributes to minimizing health disparities in old age. In addition to working closely with doctors’ offices, pharmacies, and drug plans, CMS can expand its outreach efforts by establishing collaborative relationships with consumer advocacy groups, including Area Agencies on Aging, community-based organizations, and public health departments. Continued monitoring is required to assess the long-term impact of the program, especially among vulnerable subpopulations whose lower incomes oftentimes force difficult decisions of choosing food over medicine (Madden et al., 2008
). For example, cost-related medication nonadherence (CRN) is especially high in minority groups. CRN refers to “cost-coping behaviors” such as skipping, splitting, sharing, or substituting pills, switching to cheaper prescriptions, and getting free samples; one study reported that one third of their sample engaged in cost-coping behaviors (Hsu et al., 2008
). Soumerai and colleagues (2006)
reported CRN prevalent behaviors in 18% of African Americans compared with 12% in Whites, and Madden and colleagues (2008)
noted only small reductions in CRN and forgoing basic needs on the heels of Medicare Part D implementation.
Our findings raise the possibility that Medicare Part D serves the health needs of older Blacks more directly than those of older Whites, given the more consistent associations between program enrollment and markers of poor health in our data among Blacks. The reasons for the differential pattern of enrollment correlates by race are unclear and merit further investigation. One possibility is that, on average, a lower portion of older Blacks had supplemental insurance that included prescription drug benefits before introduction of the Medicare Part D program. Unfortunately, we cannot test this theory as we do not have information on participants’ supplemental health insurance coverage. Another possibility is that older Blacks are more likely to have comorbid chronic health conditions, leading to a greater proportion of them depending on multiple drug regimens for the management of their conditions. A note of caution here is that our data come from a population of older Blacks and Whites who live in a large Midwestern urban area. Although similar findings may be found in other urban areas across the country, they cannot necessarily be generalized to smaller towns and rural areas or to populations with other racial or ethnic backgrounds.
The general consensus is that the Medicare Part D prescription drug program survived its initial implementation challenges and is a success. More than 90% of the current 44 million Medicare beneficiaries now have comprehensive prescription drug coverage (CMS, 2007
; Goldman & Joyce, 2008
; Heiss et al., 2006
), whereas in 1999, 38% of Medicare beneficiaries reported that they had no drug coverage (Laschober, Kitchman, Neuman, & Strabic, 2002
). The fact that our population is rapidly aging and growing increasingly racially and ethnically diverse merits a sustained investment in ensuring that all older adults reap the Medicare Part D program's rewards.
Continued program monitoring is critical because the stakes are high for the prescription drug benefit's success. The Congressional Budget Office (2007)
has estimated the cost of the program to be $811.5 billion for 2007–2016. Various stakeholders anticipate a wide range of program benefits. CMS anticipates being able to ensure increased plan competition resulting in lower costs and better options that are easy for consumers to understand, and physicians anticipate that their patients will be able to fill and use their prescriptions as intended (Bach & McClellan, 2006
). Policymakers expect reduced emergency department use and reduced unnecessary hospitalizations. These and other program outcomes will have tremendous economic and public health implications, particularly with regard to eliminating the widely documented race or ethnic health disparities in older populations (Levine et al., 2001
; USDHHS, 2000
). Evidence of differential program enrollment experiences and varying sociodemographic and health correlates of enrollees by race emphasize opportunities for targeting educational and health care outreach initiatives for medication therapy needs, barriers, and adherence. The long-term impact of the differential use of this new program on Black–White health disparities remains uncertain and requires continued monitoring.
Supported by grants from the National Institutes of Health: National Institute on Aging (AG11101) and the National Institute of Environmental Health Sciences (ES10902).