Introduction

Prescription drug costs in the United States are a major concern for Americans (1). According to a recent study from RAND, prescription drug prices in the United States are nearly three times higher than for those living in 33 other Organisation for Economic Co-operation and Development countries (2). Out-of-pocket costs for retail drugs rose 4.8% to $63 billion between 2020 and 2021 (3). Rising prescription costs may be particularly challenging for older adults. Previous research has found that most adults age 65 and older (older adults) report taking prescription medication, and nearly one-quarter have reported difficulty affording prescription medications (4).

Although Medicare provides nearly universal health coverage for older adults, prescription coverage for adults age 65 and older is not universal. Some older adults enroll in prescription drug coverage through Medicare Part D. Adults enrolled in Medicare Part D typically pay a premium for coverage and are also responsible for any copays associated with prescription medication costs. Low-income adults may be eligible for a Medicare Part D subsidy, which covers the premium cost and reduces their copays (5,6). Other older adults have prescription drug coverage through their private health plans or may purchase supplemental coverage for prescription medication costs. Having prescription drug coverage through Part D, private health plans, or supplemental coverage may reduce the cost of medications for older adults. However, many older adults with prescription coverage may still face high prescription costs due to cost-sharing requirements such as premiums and deductibles. Previous research has found that nearly one in five older adults do not have prescription drug coverage at all (4,7).

Access to prescription drugs among older adults is complex and the type of prescription drug coverage, changing prescription drug formularies, cost-sharing requirements, and complicated medication regimes may impact out-of-pocket medication costs and cause older adults to use strategies to reduce costs like skipping doses or delaying filling a prescription (4,6,8–11). High out-of-pocket costs may not only deter older adults from using medication as prescribed, but also from getting needed medication. Moreover, the cost of prescription drugs may necessitate tradeoffs between taking medications and meeting other needs, such as food or housing costs (7).

Much of the literature on cost-related nonadherence (CRN) among older adults focuses on identifying its correlates (9–17). Less attention has been paid to differences in prescription drug use or coverage, or the varying strategies used to reduce prescription costs by older adults’characteristics.

This report provides a more complete picture of prescription drug coverage, use of prescription drugs, and CRN among older, community-dwelling adults in the United States that may inform research and policy making. This report explores two types of CRN: 1) not getting prescription medication due to cost in the past 12 months; and 2) not taking medication as prescribed due to cost (skipping doses, delaying filling a prescription, and taking less medication than prescribed) in the past 12 months.

Methods

Results

Prescription medication use

In 2021–2022, 88.6% of older adults took prescription medication in the past 12 months (Table 1). Prescription medication use was similar for men and women. Adults ages 65–74 (86.9%) were less likely than those ages 75–84 (91.3%) and age 85 and older (91.2%) to take prescription medication. White adults (89.7%) were more likely than Black (87.4%), Hispanic (83.9%), and Asian (83.8%) adults to take prescription medication. Taking prescription medication in the past 12 months increased with increasing family income, number of chronic conditions, and decreasing urbanization level. Adults with Medicare only and older adults with no prescription drug coverage were less likely than those with other types of health coverage or any prescription drug coverage (private or public) to have taken prescription medication in the past 12 months.

Table 1

Percentage of adults age 65 and older who took prescription medication in the past 12 months, by selected characteristics: United States, 2021–2022.

Prescription drug coverage

Any prescription drug coverage

In 2021–2022, 82.7% of older adults had any prescription drug coverage (Table 2). Prescription drug coverage was higher among men (84.6%) than women (81.1%), and among White adults (83.4%) compared with Hispanic adults (79.4%) (differences between other race and Hispanic-origin groups were not significant). Adults with incomes greater than 400% FPL (86.1%) were more likely than those with incomes of less than 100% FPL (81.0%), 100% to less than 200% FPL (78.2%), and 200% to less than or equal to 400% FPL (81.7%) to have any prescription drug coverage. Married adults (84.7%) were more likely than widowed (80.1%), divorced or separated (80.1%), or never married (79.4%) adults to have any prescription drug coverage. The percentage of adults with any prescription drug coverage was highest among those with dual-eligible health coverage (100%), followed by those with other (97.5%), private (91.9%), Medicare Advantage (74.9%), and Medicare only (59.9%) coverage. Having no prescription drug coverage at all increased with age and decreased with education and number of chronic conditions.

Table 2

Percentage of adults age 65 and older with any prescription drug coverage, private drug coverage, public drug coverage, or no prescription drug coverage, by selected characteristics: United States, 2021–2022.

Private prescription drug coverage

Among older adults, 68.7% had private prescription drug coverage (Table 2). Men (68.4%) and women (68.9%) had similar rates of private prescription drug coverage. White adults (72.9%) were more likely than adults of other and multiple races (59.8%) and Black (58.5%), Hispanic (54.0%), and Asian (53.6%) adults to have private prescription drug coverage. Private prescription drug coverage increased with increasing family income, from 38.4% among those with incomes of less than 100% FPL to 78.7% among those with incomes greater than 400% FPL. Married adults (74.0%) were more likely than cohabiting (64.8%), widowed (64.3%), divorced or separated (60.6%), or never married (55.8%) adults to have private prescription drug coverage. Private prescription drug coverage was highest among adults with private health insurance coverage (90.4%) followed by those with Medicare Advantage (74.6%), Medicare only (59.9%), and other (24.8%) coverage. Private prescription drug coverage decreased with age and increased with education level. Adults with food insecurity (48.4%), in fair or poor health (60.3%), and with disabilities (61.5%) were less likely than their counterparts who are food secure (69.8%), in excellent, very good, and good health (71.2%), and without disabilities (70.3%) to have private prescription drug coverage.

Public prescription drug coverage

Among older adults, 14.0% had public prescription drug coverage (Table 2). Men (16.2%) were more likely than women (12.1%) to have public prescription drug coverage. White adults (10.5%) were less likely than adults of other and multiple races (19.1%) and Black (23.4%), Hispanic (25.3%), and Asian (26.8%) adults to have public prescription drug coverage. Public prescription drug coverage decreased with increasing family income, from 42.5% among those with incomes of less than 100% FPL to 7.4% among those with incomes greater than 400% FPL. Married adults (10.7%) were less likely than widowed (15.7%), cohabiting (17.0%), divorced or separated (19.5%), or never married (23.7%) adults to have public prescription drug coverage. Public prescription drug coverage was highest among adults with dual-eligible coverage (100.0%), followed by those with other (72.8%), private (1.5%), and Medicare Advantage (0.3%) coverage. Public prescription drug coverage increased with age and decreased with education level. Adults with food insecurity (31.4%), in fair or poor health (22.8%), and with disabilities (22.7%) were about twice as likely than their counterparts who are food secure (13.1%); in excellent, very good, and good health (11.4%); and without disabilities (12.0%) to have public prescription drug coverage.

Prescription drug nonadherence due to cost

Did not get prescription medication

In 2021–2022, 3.6% of older adults did not get prescription medication due to cost in the past 12 months (Table 3). Women (4.0%) were more likely than men (3.1%) to not get prescription medication. The percentage of adults not getting prescription medication decreased by age, from 4.3% among those ages 65–74 to 1.6% among those age 85 and older. Black (5.3%) and Hispanic (5.3%) adults were more likely to not get medication due to cost compared with White (3.2%) and Asian (2.0%) adults. Adults with family incomes of 100% to less than 200% FPL were the most likely to not get prescription medication compared with other income groups. Adults living in food insecure families (18.1%) were six times more likely than adults living in food secure families (2.9%) to not get prescription medication. Adults in fair or poor health (7.3%) and with disabilities (6.1%) were more than twice as likely than their counterparts in excellent, very good, and good health (2.5%) and without disabilities (3.0%) to not get prescription medication. Not getting prescription medication increased with an increasing number of chronic conditions. Adults with either private (3.5%) or public (2.9%) prescription drug coverage were less likely than older adults without prescription drug coverage (4.5%) to not get prescription drugs due to cost.

Table 3

Percentage of adults age 65 and older who did not get prescription medication due to cost and did not take medication as prescribed to reduce costs in the past 12 months, by selected characteristics: United States, 2021–2022.

Did not take medication as prescribed

In 2021–2022, 3.4% of older adults did not take medication as prescribed due to cost in the past 12 months (Table 3). The percentage of adults not taking medication as prescribed decreased by age, from 4.1% among those ages 65–74 to 1.7% among those age 85 and older. Adults with family incomes greater than 400% FPL were the least likely to not take medication as prescribed compared with other income groups. Adults living in food insecure families (16.8%) were six times more likely than adults living in food secure families (2.8%) to not take medication as prescribed. Older adults in fair or poor health (7.3%) and with disabilities (6.1%) were more than twice as likely than their counterparts in excellent, very good, and good health (2.3%) and without disabilities (2.8%) to not take medication as prescribed. Not taking medication as prescribed increased with the increasing number of chronic conditions. Adults with either private (3.4%) or public (2.6%) prescription drug coverage were less likely than adults without prescription drug coverage (4.4%) to not take medication as prescribed.

In 2021–2022, 2.2% of older adults took less medication than prescribed, 2.7% delayed filling a prescription, and 1.7% skipped medication doses due to cost (Table 3). Differences by sociodemographic and health characteristics were also seen for these three cost-reducing strategies. For each strategy, adults ages 65–74 were more likely than those ages 75–84 or 85 and older to engage in CRN. Black adults were more likely to take less medication than prescribed or delay filling a prescription than White or Asian adults. Adults with family incomes greater than 400% FPL were the least likely to engage in any of the three cost-reducing strategies compared with the other income groups. Adults living in food insecure families were more than six times more likely than adults living in food secure families to take less medication than prescribed, delay filling a prescription, or skip medication doses. Adults in fair or poor health and with disabilities were also more likely than their counterparts in excellent, very good, and good health and without disabilities to engage in each cost-reducing strategy. The percentage of adults who took less medication than prescribed, delayed filling a prescription, or skipped prescribed doses increased with an increasing number of chronic conditions.

Summary

This report provides a detailed picture of prescription drug use, coverage, and CRN among community-dwelling older adults in the United States. In 2021–2022, 88.6% of older adults took prescription medication, 82.7% had prescription drug coverage, 3.6% did not get prescription medication due to cost, and 3.4% did not take medication as prescribed due to cost. Previous reports have found similar use of prescription drugs and prescription drug coverage among older adults (4,22,23). Prescription drug use varied by most sociodemographic, health, and disability measures examined in this report, ranging from 80% to 90% among older adults for most measures.

Most older adults in the United States can enroll in prescription drug coverage through Medicare Part D either through a separate plan or through many of the Medicare Advantage plans (24), and others may enroll in private plans or purchase supplemental coverage. In addition to premium costs and copays associated with prescription drug coverage, if an older adult does not enroll in Medicare Part D when they are first eligible and cannot document alternative coverage, they may be subject to an enrollment penalty increasing the cost of obtaining prescription coverage. These additional costs may contribute to about one out of five older adults not having prescription drug coverage (4,7).

Across most sociodemographic and health characteristics, the percentage of older adults reporting any prescription drug coverage generally ranged from 75% to 85%. However, among older adults who relied on only Medicare coverage for their health expenses, about 60% reported that they had enrolled in prescription drug coverage.

Both measures of CRN (not getting prescription medication due to cost or not taking medication as prescribed due to cost) varied by most sociodemographic, health, and disability measures examined. The highest levels of CRN were among older adults in fair or poor health, those with disabilities, and those who experienced food insecurity. Studies have found a dose-response relationship between food insecurity and CRN, with high levels of food insecurity increasing the likelihood of CRN (12,13,25). In addition, CRN increased with the number of chronic conditions. Both of these risk factors for CRN have been previously noted (11,26). Food insecurity has also been associated with CRN for specific conditions, for example among adults with diabetes, stroke survivors, and older adults with hypertension (14,15,27).

Reducing household food insecurity and hunger is a Healthy People 2030 objective (28). A recent study found that more than 7% of adults age 60 and older (5.5 million) live with food insecurity (29). The interrelationship between food insecurity and CRN has been previously documented and both measures share many of the same risk factors, including low income and presence of chronic conditions (12,13,25). The reasons for higher levels of CRN among food insecure older adults are complex and factors may exist, such as the ability to obtain food or family support, that NHIS does not measure.

In 2022, 47.9% of older adults had been diagnosed with arthritis, 20.1% with diabetes, 48.1% with high cholesterol, and 58.5% with hypertension (30–33). Together, prescriptions for diabetes, high cholesterol, hypertension, and pain accounted for more than 45% of all prescriptions in the United States (34). Although a majority of older adults have prescription drug coverage, previous studies have shown that many older adults still cannot afford their medication (7). Out-of-pocket costs have risen significantly for Medicare beneficiaries since 2016 (3), which may contribute to CRN, especially for prescriptions costing more than $75 out of pocket (3). Cost-saving strategies to reduce prescription drug costs may have implications for health status and, in the past, have been associated with increased emergency room use and hospitalization compared with adults who followed recommended pharmacotherapy (35,36).

One strength of NHIS is its low item nonresponse on questions about prescription drug use and CRN (about 1%). For the measure of prescription drug coverage, nonresponse ranged from 1% for the questions about single-service coverage to about 5% for the question about Medicare Part D coverage. In addition, CRN can be analyzed in combination with other measures available in NHIS, including problems paying medical bills, worry about healthcare costs, forgone care, and healthcare access and use. However, NHIS responses are self-reported and may be subject to recall bias. In addition, NHIS does not collect information on actual out-of-pocket costs for prescribed medications, which conditions medications are prescribed for, or which medications are subject to cost-saving strategies and CRN. While this report presents unadjusted estimates of prescription drug use and coverage and two measures of CRN, it highlights differences in each of these outcomes by sociodemographic and health characteristics. As a result, these findings may inform efforts to reduce disparities in healthcare access and health outcomes for older adults.

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Technical Notes

National Center for Health Statistics

Brian C. Moyer, Ph.D., Director

Amy M. Branum, Ph.D., Associate Director for Science

Division of Health Interview Statistics

Stephen J. Blumberg, Ph.D., Director

Anjel Vahratian, Ph.D., M.P.H., Associate Director for Science

Division of Analysis and Epidemiology

Irma E. Arispe, Ph.D., Director

Kimberly A. Lochner, Sc.D., Associate Director for Science

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Cohen RA, Mykyta L. Prescription medication use, coverage, and nonadherence among adults age 65 and older: United States, 2021–2022. National Health Statistics Reports; no 209. Hyattsville, MD: National Center for Health Statistics. 2024. DOI: https://dx.doi.org/10.15620/cdc/160016. [PMC free article]