Sam Uretsky

Poor Go Off Their Meds

It’s old news, but on Oct. 22, the New York Times put it on the front page: People aren’t filling their prescriptions. There have been a number of studies, following different populations, but the basic fact is that after people have visited the physician, a significant percentage, 30.7% in a study conducted in Denmark but only 4.4% in a study of Medicare patients in the US, failed to fill their prescriptions.

The most common reason for not filling the prescriptions in the American study were high price, and the drug not being covered by insurance, which is the equivalent of high price. A report published in 2006, before the current downturn, found that rates of unfilled prescriptions in the US ranged from 1.6% to 22% depending on who was being surveyed. The rates of unfilled prescriptions were considerably higher among those who don’t have the money to pay for them.

This has been a known problem for years, but the economic downturn has made it worse. There has been a lot of talk about liquidity, and maintaining the ability and willingness of banks to make loans, but that’s not terribly important if nobody has a reason to borrow money. We’re in the sort of downward spiral that Keynes predicted, because if people don’t buy, then the people who aren’t being bought from don’t have any income, and so on. People who were laid off by Bear Sterns and Lehman Brothers aren’t in the market for a new car, which is bad news for Ford and GM. Then, at some level, somebody has to choose between filling the prescription, paying the rent or eating. For some of us, the choices have become that stark.

This is macroeconomics 101—private virtue can be public vice. When business gets slow, the rational businessman lays off staff—which cuts into the customer base for his own and other businesses. Just at a time when the societal goal is to pump money into the economy, rational behavior is to contract, reduce spending.

In terms of Maslow’s Hierarchy of Needs, the choices—rent, food, prescription drugs—are the bottom, the base of the pyramid. Technically, prescription drugs aren’t listed, but they represent basic health, just as rent represents shelter against storms. These are the most basic physical needs, the stuff that’s required even before love and self esteem. They can be rephrased as homelessness, famine and plague—and we have them today.

It gets worse. The Times article seemed to focus on sales of atorvastatin (brand name Lipitor), a popular drug whose sales have been in decline in a manner probably related to the general economy. In deciding which to skip—rent, food, drugs—the rational decision is to omit the drugs. Homelessness and hunger have immediate consequences, while failure to fill prescriptions may cause problems in the future. Atorvastatin lowers serum cholesterol, reducing risk of heart attack and stroke—but that’s some time in the future. High cholesterol doesn’t hurt. Neither does high blood pressure or type II diabetes. In their initial stages, there are no alerts or warnings. One representation of Maslow’s hierarchy lists “homeostasis” at the base of the pyramid, but the homeostatic mechanisms that do such a good job of alerting us to a missed lunch, are lousy when it comes to a blocked coronary artery. As people are forced to do without basic necessities, there’s a good chance that we’ll see a decline in basic preventive care, with a corresponding rise in cardiovascular complaints, kidney disease and amputations. That will be a function of how many people are forced to discontinue treatment for hypertension, hypercholesterolemia and type II diabetes. If the recession expands, and is prolonged, given the prevalence of these three conditions in the United States, it could result in a health care crisis.

The answer seems to be basic, and of course isn’t. Just as the government should be working on mortgage relief for those facing eviction, and food relief, there should be some provision for expanding the availability of prescription drugs. The states, of course, facing deficits, are trying to find ways to cut back on programs, including Medicaid, and Congress, which has been tossing billions of dollars in every direction, may suddenly get its back up at another rescue plan.

But the numbers indicate that we haven’t bottomed out yet, and this mess could take a long time to go away. The estimated $2 trillion loss in pension funds and 401(k)s can’t be recouped quickly, and that means that the Baby Boomers will go into retirement with less income than anticipated. That’s a lot of consumer spending that won’t be available to maintain the economy. So, unless we plan to stimulate the economy by increasing the income of cardiac surgeons and possibly morticians, it would be wise to think about those people who aren’t taking their medicine.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

From The Progressive Populist, December 1, 2008

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