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Original Investigation | Health Care Reform

Cognition and Take-up of Subsidized Drug Benefits by Medicare Beneficiaries

Ifedayo O. Kuye, AB; Richard G. Frank, PhD; J. Michael McWilliams, MD, PhD
JAMA Intern Med. 2013;173(12):1100-1107. doi:10.1001/jamainternmed.2013.845.
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Published online

Importance Take-up of the Medicare Part D low-income subsidy (LIS) by eligible beneficiaries has been low despite the attractive drug coverage it offers at no cost to beneficiaries and outreach efforts by the Social Security Administration.

Objective To examine the role of beneficiaries' cognitive abilities in explaining this puzzle.

Design and Setting Analysis of survey data from the nationally representative Health and Retirement Study.

Participants Elderly Medicare beneficiaries who were likely eligible for the LIS, excluding Medicaid and Supplemental Security Income recipients who automatically receive the subsidy without applying.

Main Outcomes and Measures Using survey assessments of overall cognition and numeracy from 2006 to 2010, we examined how cognitive abilities were associated with self-reported Part D enrollment, awareness of the LIS, and application for the LIS. We also compared out-of-pocket drug spending and premium costs between LIS-eligible beneficiaries who did and did not report receipt of the LIS. Analyses were adjusted for sociodemographic characteristics, household income and assets, health status, and presence of chronic conditions.

Results Compared with LIS-eligible beneficiaries in the top quartile of overall cognition, those in the bottom quartile were significantly less likely to report Part D enrollment (adjusted rate, 63.5% vs 52.0%; P = .002), LIS awareness (58.3% vs 33.3%; P = .001), and LIS application (25.5% vs 12.7%; P < .001). Lower numeracy was also associated with lower rates of Part D enrollment (P = .03) and LIS application (P = .002). Reported receipt of the LIS was associated with significantly lower annual out-of-pocket drug spending (adjusted mean difference, −$256; P = .02) and premium costs (−$273; P = .02).

Conclusions and Relevance Among Medicare beneficiaries likely eligible for the Part D LIS, poorer cognition and numeracy were associated with lower reported take-up. Current educational and outreach efforts encouraging LIS applications may not be sufficient for beneficiaries with limited abilities to process and respond to information. Additional policies may be needed to extend the financial protection conferred by the LIS to all eligible seniors.

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Figure. Adjusted rates of Medicare Part D enrollment, low-income subsidy (LIS) awareness, and LIS application by cognition and numeracy. Adjusted rates of Part D enrollment, LIS awareness, and LIS application are displayed by quartile of cognition score (A) and number of correctly completed numeracy tasks (B) among Medicare beneficiaries likely eligible for the LIS but not automatically receiving it.

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