美国国家公共电台 NPR When Insurers Don't Cover Drugs, Prescriptions Often Go Unfil（在线收听）

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What happens when insurance companies deny coverage for medications? It doesn't just force people to pay for drugs themselves; a survey finds that for almost half of Americans, when insurance denies payment, they do not get the drugs at all. The poll comes from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. NPR's Patti Neighmond reports.

PATTI NEIGHMOND, BYLINE: Sally Radoci is 78 and on a fixed income. She has severe acid reflux.

SALLY RADOCI: I have to eat very small meals. And when I eat, sometimes it feels like everything is stuck in my chest, and I get really bad pain, and then I have to throw up.

NEIGHMOND: Radoci is retired and on Medicare. She also pays for a supplemental insurance policy to cover the cost of drugs, but it will only pay for the generic version of her heartburn medication. Her doctor prescribed the brand name. She says the generic version just doesn't work for her.

RADOCI: No, it's not as effective. No, definitely not.

NEIGHMOND: She can't afford the brand name, so now she has extremely painful episodes of acid reflux about three times a month. Our poll shows that, like Radoci, the vast majority of Americans have health insurance that includes prescription drug coverage, but 1 in 3 say that in the past year, insurance didn't cover the costs of medication for themselves or their household members. Robert Blendon with the Harvard Chan School directed our poll.

ROBERT BLENDON: So what you see is insurers are not paying for some drugs that physicians are recommending and the patients think they need.

NEIGHMOND: When that happened, most of the highest earners paid for the medication themselves. But Blendon says that was not the case for everyone else.

BLENDON: Half of the people who were middle class or moderate income are not getting them because they can't afford to go out and pay for it themselves.

NEIGHMOND: Bottom line, he says, it's just not fair.

BLENDON: This idea that if we save money, we all have to make tough choices together - the tough choices really don't affect the most wealthy people in the United States; they just affect people who are middle and lower income.

NEIGHMOND: And this could leave lower- and middle-income individuals more vulnerable to disease and other health problems. For Sally Radoci, one example is her EpiPen. She's allergic to bees and needs the EpiPen to inject life-saving medication in case she gets stung.

RADOCI: And the last time I was stung, the doctor said, each time you get stung can be very serious, and it can result in death. So he said, always carry the EpiPen. And in my case, I do a lot of gardening. And I'm by myself, so it just felt safe to have my EpiPen with me just in case.

NEIGHMOND: But this time, when she went to the pharmacy to get the EpiPen prescribed by her doctor, she was told her insurance wouldn't cover the cost.

RADOCI: It was close to $600. And I said, well, how about the generic? Could I get the generic? And she said, well, that's $398. And I said, you're kidding. She said no. I said, OK, then just forget it.

NEIGHMOND: So today, when Radoci gardens, she wears long sleeves and long pants to try to protect herself against bees. The situation, she says, is upsetting.

RADOCI: I have three insurances. I'm always paying a lot of copays. I pay a lot for my drugs. It's very frustrating. I think when you have insurance, I think that you should be able to get the drug you need.

NEIGHMOND: One unexpected finding from our poll on income inequality is that even people who can afford to cover the cost of their medications sometimes don't. This is one of the first polls to survey the top 1%, people earning over $500,000 a year. And 18% of them chose not to fill prescriptions when insurance wouldn't cover it. Tina Smith is one of them. She runs a technology consulting firm in Minneapolis. Last year, when her doctor prescribed a medication to treat the skin condition rosacea, she got a shock.

TINA SMITH: When I went to fill the prescription, the cost for the prescription was over $600.

NEIGHMOND: She says for the past seven years, the medication cost about $20. So this was a huge increase, and Smith decided not to get it.

SMITH: Because I felt that it was fiscally irresponsible, and I have no interest in funding Big Pharma any more than I absolutely have to. I feel Big Pharma has been robbing the American people for years, and they continue to increase the costs of prescriptions.

FREDERICK ISASI: Drug prices have been escalating actually for, in a significant way, at least the last couple decades.

NEIGHMOND: Frederick Isasi is director of the consumer advocacy group Families USA.

ISASI: But in the last five or six years, it's really hit a crescendo.

NEIGHMOND: Not surprisingly, the smallest increase were in generic drugs. But the adjective small, he says, pretty much ends there.

ISASI: You know, an average increase for drugs might be 15% or 16% annually, which is, you know, much, much faster than our paychecks or inflation. But you could see a doubling or tripling of drug costs year over year, depending on the ability of that drug company to have no competition.

NEIGHMOND: He says health care costs are swallowing up more and more of family's discretionary income, not only in higher drug prices but also in higher deductibles, copays and cost-sharing. We spoke with representatives of both the pharmaceutical and health insurance industries, and they point the finger at each other. Insurers say the financial squeeze Americans are experiencing is because of high drug prices; the drugmakers say it's high insurance and hospital costs.

Whatever the reason, Harvard health economist and primary care physician Ben Sommers says not getting needed medication is not good news.

BENJAMIN SOMMERS: There's more and more evidence that having health insurance really does improve people's health and lives, and medications are one of the key parts of that because it is such a mainstay of how we manage a lot of chronic conditions.

NEIGHMOND: Now, Sommers says not all medications are equal.

SOMMERS: Some of the medications we prescribe are, really, kind of options to a patient. You say, look - this medication may help you feel better while you have this infection or while you are having some heartburn, but if you feel fine without it, that's OK.

NEIGHMOND: But others are critical - cholesterol-lowering statins, for example, or insulin to keep blood sugar under control.

SOMMERS: And sometimes people won't even notice they're not taking it. You know, not all these conditions have symptoms. You know, you can be building up dangerous levels of high blood sugar or cholesterol without noticing it until it's too late.

NEIGHMOND: Sadly, Sommers says he's not surprised by the findings of our poll. He says at least a quarter of his patients don't get new prescriptions filled because they say they just don't have the money. Patti Neighmond, NPR News.

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