Out-of-pocket prescription drug costs for adults with cardiovascular risk factors under Amazon's direct-to-consumer pharmacy service.

BACKGROUND: US adults often overpay for generic prescription medications, which can lead to medication nonadherence that negatively impacts cardiovascular outcomes. As a result, new direct-to-consumer online medication services are growing in popularity nationwide. Amazon recently launched a $5/month direct-to-consumer medication subscription service (Amazon RxPass), but it is unclear how many US adults could save on out-of-pocket drug costs by using this new service. OBJECTIVES: To estimate out-of-pocket savings on generic prescription medications achievable through Amazon's new direct-to-consumer subscription medication service for adults with cardiovascular risk factors and/or conditions. METHODS: Cross-sectional study of adults 18-64 years in the 2019 Medical Expenditure Panel Survey. RESULTS: Of the 25,280,517 (SE ± 934,809) adults aged 18-64 years with cardiovascular risk factors or conditions who were prescribed at least 1 medication available in the Amazon RxPass formulary, only 6.4% (1,624,587 [SE ± 68,571]) would achieve savings. Among those achieving savings, the estimated average out-of-pocket savings would be $140 (SE ± $15.8) per person per year, amounting to a total savings of $228,093,570 (SE ± $26,117,241). In multivariable regression models, lack of insurance coverage (adjusted odds ratio [OR] 3.5, 95%CI 1.9-6.5) and being prescribed a greater number of RxPass-eligible medications (2-3 medications versus 1 medication: OR 5.6, 95%CI 3.0-10.3; 4+ medications: OR 21.8, 95%CI 10.7-44.3) were each associated with a higher likelihood of achieving out-of-pocket savings from RxPass. CONCLUSIONS: Changes to the pricing structure of Amazon's direct-to-consumer medication service are needed to expand out-of-pocket savings on generic medications to a larger segment of the working-age adults with cardiovascular risk factors and/or diseases.

Cardiovascular Health, Lifestyle Factors, and Social Determinants in Asian Subpopulations in the United States.

Asian Americans are often aggregated in national public health surveillance efforts, which may conceal important differences in the health status of subgroups that are included in this highly diverse population. Little is known about how cardiovascular health varies across Asian subpopulations and the extent to which lifestyle and social risk factors contribute to any observed differences. This national study used data from the National Health Interview Survey to evaluate the burden of cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) and cardiovascular diseases (heart attack, coronary heart disease, angina, stroke) across Asian groups (Chinese, Asian Indian, Filipino, Other Asian), and determine whether differences are related to lifestyle factors and/or social determinants of health. The weighted study population included 13,592,178 Asian adults. Filipino adults were more likely to have hypertension than Chinese adults (29.4% vs 15.4%; adjusted odds ratio [OR] 2.40, 95% confidence interval [1.91 to 3.02]), as were Asian Indians (15.7%; OR 1.59 [1.25 to 2.02]). These patterns were similar for hyperlipidemia and diabetes mellitus. For cardiovascular diseases, Filipino adults were significantly more likely to have coronary heart disease (4.2% vs 1.9%; OR 2.19 [1.32 to 3.56]), heart attack (2.6% vs 0.9%; OR 2.79 [1.44 to 5.41]), angina (1.8% vs 0.9%; OR 2.15 [1.06 to 4.32]), and stroke (2.1% vs 0.8%; OR 2.54 [1.42 to 4.55]) compared with Chinese adults, whereas there were no differences compared with Asian Indian adults. Adjustments for lifestyle factors and social determinants completely attenuated differences in coronary heart disease, heart attack, and angina among subpopulations. In conclusion, these findings demonstrate that cardiovascular risk factors and diseases vary significantly across Asian subpopulations, with Filipino adults experiencing the highest burden and Chinese adults the lowest, and that differences in cardiovascular disease are largely attenuated after adjustment for lifestyle and social determinants.

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity.

Importance: The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity. Objective: To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity. Design, Setting, and Participants: This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023. Main Outcomes and Measures: Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines. Results: The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage). Conclusions and Relevance: Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.

Changes in Health Care and Prescription Medication Affordability in the US During the COVID-19 Pandemic.

Importance: In the US, the COVID-19 pandemic led to a significant rise in unemployment and economic loss that disproportionately impacted low-income individuals. It is unknown how health care and prescription medication affordability changed among low-income adults during the COVID-19 pandemic overall and compared with their higher-income counterparts. Objective: To evaluate changes in health care affordability and prescription medication affordability during the COVID-19 pandemic (2021 and 2022) compared with pre-COVID-19 pandemic levels (2019) and whether income-based inequities changed. Design, Setting, and Participants: This retrospective cross-sectional study included adults 18 years and older participating in the National Health Interview Survey (NHIS) in 2019, 2021, and 2022. Low-income adults were defined as having a household income of 200% or less of the federal poverty level (FPL); middle-income adults, 201% to 400% of the FPL; and high-income adults, more than 400% of the FPL. Data were analyzed from June to November 2023. Main Outcomes and Measures: Measures of health care affordability and prescription medication affordability. Results: The study population included 89 130 US adults. Among the weighted population, 51.6% (95% CI, 51.2-52.0) were female, and the mean (SD) age was 48.0 (0.12) years. Compared with prepandemic levels, during the COVID-19 pandemic, low-income adults were less likely to delay medical care (2022: 11.2%; 95% CI, 10.3-12.1; 2019: 15.4%; 95% CI, 14.3-16.4; adjusted relative risk [aRR], 0.73; 95% CI, 0.66-0.81) or avoid care (2022: 10.7%; 95% CI, 9.7-11.6; 2019: 14.9%; 95% CI, 13.8-15.9; aRR, 0.72; 95% CI, 0.64-0.80) due to cost, while high-income adults experienced no change, resulting in a significant improvement in income-based disparities. Low-income and high-income adults were less likely to experience problems paying medical bills but experienced no change in worrying about medical bills during the COVID-19 pandemic compared with prepandemic levels. Across measures of prescription medication affordability, low-income adults were less likely to delay medications (2022: 9.4%; 95% CI, 8.4-10.4; 2019: 12.7%; 95% CI, 11.6-13.9; aRR, 0.74; 95% CI, 0.65-0.84), not fill medications (2022: 8.9%; 95% CI, 8.1-9.8; 2019: 12.0%; 95% CI, 11.1-12.9; aRR, 0.75; 95% CI, 0.66-0.83), skip medications (2022: 6.7%; 95% CI, 5.9-7.6; 2019: 10.1%; 95% CI, 9.1-11.1; aRR, 0.67; 95% CI, 0.57-0.77), or take less medications (2022: 7.3%; 95% CI, 6.4-8.1; 2019: 11.2%; 95% CI, 10.%-12.2; aRR, 0.65; 95% CI, 0.56-0.74) due to costs, and these patterns were largely similar among high-income adults. Improvements in measures of health care and prescription medication affordability persisted even after accounting for changes in health insurance coverage and health care use. These patterns were similar when comparing measures of affordability in 2021 with 2019. Conclusions and Relevance: Health care affordability improved for low-income adults during the COVID-19 pandemic, resulting in a narrowing of income-based disparities, while prescription medication affordability improved for all income groups. These findings suggest that the recent unwinding of COVID-19 pandemic-related safety-net policies may worsen health care affordability and widen existing income-based inequities.

Financial Burden of Health Care in the Privately Insured US Population.

This cross-sectional study examines how changes in privately insured families' contributions to insurance premiums and out-of-pocket spending have affected the financial burden of health care in recent decades.