Introduction

In the race to vaccinate as many people in the U.S. as possible, several benchmarks have been proposed, including President Biden’s goal of reaching 70% of adults in the U.S. with at least one dose by July 4. Whether or not this is attainable is unknown, as the pace of vaccination has slowed, and progress has varied substantially across states. Moreover, even where the 70% target is reached, whether nationally or in a particular state, achievement of the goal for the overall population may mask differences in vaccination rates across groups, particularly by race/ethnicity. To date, vaccination rates among Black and Hispanic people have lagged behind those of White people, largely due to access and logistical barriers as well as concerns about safety and potential side effects. As such, even if broad national vaccination goals are achieved, these groups may remain at higher risk, which could lead to widening health disparities and limit the nation’s recovery from the pandemic.

To further explore potential disparities in meeting vaccination benchmarks, researchers at Stanford University and KFF (Kaiser Family Foundation) used current state-reported vaccination data by race/ethnicity to project vaccine coverage going forward, by state and nationally. Specifically, using the current pace of vaccination, we projected the share of people ages 12 and older who would receive at least one dose of a COVID-19 vaccine as of July 4 for four racial/ethnic groups (White, Black, Hispanic, and Asian) and assessed when 70% of each group would have received at least one dose. We were not able to include other groups in the analysis due to data limitations.

Our focus on vaccinations among those ages 12 and older differs from President Biden’s goal, which is based on those 18 and older. We use a 70% vaccination rate as an illustrative measure for examining potential disparities across groups that may underlie an overall coverage rate.  We focus on those ages 12 and older due to lack of systematic data on vaccinations by race/ethnicity and age. Our projected coverage levels will be lower than those among adults given that younger adolescents have only more recently become eligible for vaccination. Reporting on race and ethnicity is incomplete and inconsistent across states. Previous reporting on racial/ethnic disparities in vaccination through the Centers for Disease Control and Prevention (CDC) and other sources has not adjusted for these data discrepancies, resulting in reported coverage levels that likely underestimate actual population coverage. Although we have adopted a standard set of definitions and rules for reconciling unknown or discrepant data elements to enable transparent and comparable estimation of coverage over time and place, results must be interpreted as approximations in the context of missing and sometimes noisy data.

Findings

At the current pace of vaccination, 65% of those ages 12 and older would be at least partially vaccinated by July 4, but rates would be lower for Hispanic, and especially Black, people. Asian people are the only group estimated to exceed a 70% vaccination rate, while White people (66%) and Hispanic people (63%) will be shy of reaching this level, and only about half (51%) of Black people will have received at least one COVID-19 vaccine dose by July 4, based on current trends (Figure 1). If the current pace of vaccination continues, Hispanic people nationally would reach a 70% threshold by the end of July (July 27), White people would reach this threshold by early August (August 2), but Black people would still not have reached this coverage level by the beginning of September. Hispanic people are projected to reach 70% coverage faster than White people despite having a lower rate of vaccination as of July 4, because their recent pace of vaccination has been faster than White people.

Progress toward achieving a 70% vaccination rate among those ages 12 and older by July 4, and disparities across race/ethnic groups, would also vary significantly across states. At the current vaccination pace, Asian people are on track to reach 70% of those ages 12 and older with at least one COVID-19 vaccine dose in nearly all reporting states (40 of 44), and White people are on track in just over a third of reporting states (18 of 47). Hispanic people are projected to reach this threshold in 13 of 44 reporting states, while Black people are estimated to reach this coverage level in only 5 of 47 reporting states (Figure 2, Tables 1 and 2).

To reach a 70% vaccination rate by July 4, the pace of vaccination would need to increase substantially in many states, particularly for Black people. Nationally, the daily pace of new vaccinations would need to be 7% faster than the current pace to achieve 70% vaccination coverage among Hispanic people ages 12 and older by July 4, while the pace for Black people would need to be over two and a half times faster than the current pace. The increases in vaccination rates needed to reach this coverage level also vary across states. The pace would need to at least double in 24 of 44 states reporting data for Hispanic people, 24 of 47 states reporting data for White people, and 36 of 47 states reporting data for Black people (Table 3).

If the pace of new vaccinations continues to slow even further, disparities between groups in achieving progress toward coverage goals would persist. For example, a slowdown of 25% would mean that, overall, the share of those ages 12 and older estimated to have received at least one COVID-19 vaccine dose would drop from 65% to 64%. Asian people would still reach a 70% coverage rate, coverage among White people would remain below this threshold, with 65% receiving at least one dose, and there would be larger gaps for Hispanic and Black people, with 61% and 50% receiving at least one dose by July 4, respectively. These patterns play out at the state level as well.

Implications

It remains to be seen whether President Biden’s goal of at least 70% of adults receiving at least one COVID-19 vaccine dose by July 4 will be achieved, particularly given the slowdown in vaccinations. Regardless of when this goal is achieved, it is important to recognize that this national benchmark may mask underlying disparities. This illustrative analysis, which examines potential disparities toward achieving a 70% coverage rate among people ages 12 and older, shows that Black and Hispanic people will likely be left behind even if and when national goals are achieved, with substantial variation across the country. As such, even if the nation, overall, reaches a broad level of protection through vaccination, certain groups and communities will remain at increased risk for COVID-19. These disparities in vaccination may lead to further widening of the disproportionate impacts of COVID-19 on people of color and health disparities more broadly. These findings underscore the importance of continuing to prioritize vaccine equity and focused efforts to deliver vaccinations to underserved people and areas, as well as the importance of maintaining these efforts even after broader national goals are achieved.

Stanford University and KFF (Kaiser Family Foundation) researchers used current state-reported vaccination data by race/ethnicity to project vaccine coverage, by state and nationally, among people ages 12 and older for four racial/ethnic groups (White, Black, Hispanic, and Asian). Specifically, we used data on distribution of vaccines administered by race/ethnicity extracted from state reporting dashboards by KFF, total numbers of people who have received at least one dose from the Centers for Disease Control and Prevention, and total population data from the 2019 American Community Survey to estimate the share of people ages 12 years and older receiving one or more COVID-19 vaccination doses, by state and race/ethnicity, through June 7. We then estimated coverage rates through September 1 based on the average daily vaccination rate implied by the change in coverage between May 24 and June 7 for each racial/ethnic group, by state.

Data on vaccination coverage by race/ethnicity vary by state in terms of reporting groups and completeness. We applied the following data processing steps to produce comparable estimates. We assumed vaccinations reported as “unknown” race/ethnicity were distributed proportional to shares of vaccinations with known race/ethnicity in each state. Examining vaccinations reported as “other” race/ethnicity, we found that in most states, the shares attributed to “other” greatly exceeded population shares (implying coverage >100%). We therefore adjusted shares by assuming “other” were vaccinated proportional to eligible population, and proportionally redistributed remaining vaccinations among specified racial/ethnic groups. We adjusted shares to avoid double-counting in states that report shares by race separate from shares by ethnicity. For racial/ethnic groups not reported by specific states, we assumed these groups were vaccinated proportional to population size and scaled down shares of vaccines to reported groups accordingly. We capped coverage among any racial/ethnic group at 100% of the eligible population, and in cases where implied coverage exceeded 100%, we proportionally redistributed the excess across other groups.

A handful of states required exceptions to the standard approach. The share of vaccinations by race/ethnicity from Nebraska was unavailable on June 7. As a result, projections for Nebraska were based on race/ethnicity-specific vaccination rates spanning May 10 to May 24. The share of vaccinations by race/ethnicity from Idaho and Tennessee were unavailable from May 24. As a result, projections for these states were based on the three-week period spanning May 17 to June 7. CDC reported coverage in New Hampshire decreased slightly between May 24 and June 7, likely due to reconciling reporting issues. As a result, projections for New Hampshire were also based on the three-week period spanning May 17 to June 7. The share of vaccinations by race/ethnicity for Pennsylvania reported in the state dashboard do not include vaccinations for Philadelphia County. Since Philadelphia County includes a substantial fraction of the Black, Hispanic, and Asian population living in Pennsylvania, we separately extracted and included data from the Philadelphia County dashboard.

Limitations of this analysis include reliance on several assumptions to address incomplete and heterogeneous reporting of vaccination data by race/ethnicity across states. Previous reporting on racial/ethnic disparities in vaccination through the CDC and other sources has not adjusted for these data discrepancies, resulting in reported coverage levels that likely underestimate actual population coverage. Although we have adopted a standard set of definitions and rules for reconciling unknown or discrepant data elements to enable transparent and comparable estimation of coverage over time and place, results must be interpreted as approximations in the context of missing and sometimes noisy data. Future work should continue to update these estimates and further assess uncertainty due to model assumptions.

Replication code and data are available at: https://github.com/PPML/covid_vaccination_coverage_disparities

Introduction

Prescription drugs have returned to the national policy debate, with both Congress and the administration developing proposals to address drug prices. Though attention in current federal actions is largely focused on Medicare and private insurance drug prices, federal legislation also has been recently introduced or enacted that would affect Medicaid prescription drug policy. States also remain concerned about the budgetary impact of new, high cost drugs and Medicaid drug spending, given fiscal pressures. Understanding utilization and spending patterns in Medicaid can help illustrate the potential effects of proposed policy changes or targeted policy actions.

This brief analyzes data on Medicaid drug spending and utilization from 2015 to 2019, the period after the major expansion of Medicaid under the ACA and through most recent complete data available. It examines trends across drug groups, brand or generic status, and biologic status and takes a closer look at some of the drug groups that are experiencing changes in utilization and spending or have been the subject of recent policy debates. As described in more detail in Appendix B, it is based on Medicaid State Drug Utilization Data merged with IBM Micromedex RED BOOK data to analyze trends by drug group and brand or generic status. It also incorporates data from the Food and Drug Administration (FDA) to analyze trends among biological products. Because of data restrictions, spending does not reflect rebates. This analysis updates previous analysis of Medicaid outpatient prescription drug trends.

Background: Structure of the Medicaid Prescription Drug Benefit

The Medicaid prescription drug benefit is an optional benefit that all states provide. The state may provide the benefit in a fee-for-service environment or through managed care. Most states provide the benefit through managed care, although some states have moved to carve out specific classes or the pharmacy benefit altogether. State Medicaid programs reimburse pharmacies for prescription drugs based on the ingredient costs for the drug and a dispensing fee for filling the prescription; they do not buy drugs directly from manufacturers.

Under the Medicaid Drug Rebate Program (MDRP), manufacturers that want their drugs covered by Medicaid must sign an agreement with the Secretary of Health and Human Services stating that they will rebate a specified portion of the Medicaid payment for the drug to the states, who in turn share the rebates with the federal government. In return, Medicaid must cover almost all FDA-approved drugs that those manufacturers produce.¹  However, state Medicaid programs can and do implement drug utilization management techniques, such as preferred drug lists and prior authorizations, to manage utilization and spending.

In addition to federal statutory rebates, most states negotiate supplemental rebates. Both statutory and supplemental rebates account for a sizeable share of prescription drug spending, lowering aggregate drug spending by about 55% in 2019. Rebates also increased during the period of this analysis, leaving Medicaid net spending in 2019 almost the same as net spending in 2015. Rebates vary across brand and generic drugs and specialty and non-specialty drugs due to the rebate formulas and rules that require Medicaid to receive the “best price” available to other purchasers (excluding certain government programs).²  A CBO analysis recently found that on average, Medicaid obtained rebates of approximately 77% of the Medicaid retail price for certain brand-name drugs.³   Medicaid rebates also include an inflation-based component to account for rising prices over time, which insulates the program from large price hikes. The specific rebate on a given drug is proprietary for both statutory and supplemental rebates. Because of this, it is not possible to include them in this analysis of trends by drug or drug group. While rebates have implications for net Medicaid spending, understanding trends in gross spending and utilization provides important context for pharmacy benefit policy by highlighting underlying cost factors.

Trends in Prescription Drug Utilization and Spending

Medicaid drug utilization and spending before rebates followed similar trends from 2015-2018 but diverged in 2019. Medicaid outpatient drug utilization increased from 695.7 million prescriptions in 2015 to 763.7 million in 2017, an average annual growth of 5% (Figure 1). Following a similar pattern, Medicaid spending before rebates also increased from $55.8 billion in 2015 to $64.6 billion in 2017, representing average annual growth of 8%. From 2017 to 2018, utilization and spending both declined by 3%, decreasing from 763.7 million prescriptions and $64.6 billion down to 742.3 million prescriptions and $62.9 billion, respectively. This decline likely reflects declines in Medicaid enrollment, which declined by 1.6 million in 2018. From 2018 to 2019, utilization decreased by 1%, down to 731.3 million prescriptions, while spending diverged and grew by 9%, up to $68.5 billion. The increase in spending before rebates in 2019 may reflect the launch of expensive new brand drugs and increasing list prices.

Trends by Drug Group

The top ten most frequent drug groups by number of prescriptions accounted for over half of all prescriptions each year from 2015 through 2019 and were relatively stable during the period. The exception is antihyperlipidemic drugs, which replaced anxiolytics (a type of psychotherapeutic) as the 10^th most prescribed drug group starting in 2017 (Table 1 and Appendix Table A1). Further, the same groups made up the top five drug groups by utilization every year. Throughout all years, analgesics/antipyretics accounted for the largest number of prescriptions, and psychotherapeutic agents accounted for the second largest number of prescriptions. In 2019, both groups together accounted for 20% of all Medicaid prescriptions (Figure 2). Within the drug group psychotherapeutic agents, antidepressants made up more than 70% of all psychotherapeutic prescriptions each year.

Similarly, the ten most costly drug groups accounted for almost two thirds of Medicaid spending before rebates each year, and the composition of the top ten most costly drug groups before rebates remained relatively stable throughout the period (Table 2 and Appendix Table A2). Throughout all years, antivirals accounted for the largest share of gross drug spending. Although they switched places in 2017, antidiabetic agents and psychotherapeutic agents consistently ranked second and third in spending by year. In 2019, antivirals, antidiabetic agents, and psychotherapeutic agents together made up 30% of gross spending on Medicaid outpatient prescriptions (Figure 3). Additionally, five of the most prescribed drug groups were also five of the most costly drug groups each year: antidiabetic agents, psychotherapeutic agents, adrenals & combinations, analgesics/antipyretics, and anticonvulsants. Psychotherapeutic agents were consistently the second most prescribed drug group and second or third most costly drug group before rebates each year, highlighting the key role Medicaid plays in covering and financing behavioral health care. However, these trends in gross spending may not reflect net payment, given differences in rebates to Medicaid across brand and generic drugs, among other factors.⁴ 

Antivirals

While utilization of antivirals overall increased over the period, the number of prescriptions for antiretrovirals (drugs largely used to treat or prevent HIV) and other drugs used for hepatitis C treatment have declined slightly in recent years. Medicaid plays a substantial role in covering people with HIV or Hepatitis C, providing insurance to 42% of the 1.2 million people with HIV and a disproportionate share of the 2.4 million people with hepatitis C in the US. Prescription drugs are a core component of treatment for these health conditions. Utilization of antiviral drugs increased over the period by 21% driven by increased use of other antiviral drugs, such as those that treat the flu. Utilization of antiretrovirals and other hepatitis C drugs decreased slightly over the period, making up 30% of antiviral prescriptions by 2019 (Figure 4). Declines in antiretrovirals may in part reflect substitution toward single-dose regimens, which increased by approximately 0.4 million prescriptions over this period. It could also represent greater stability in prescription regimens within a calendar year or be indicative of churn in the Medicaid program including with private insurance and the Ryan White HIV/AIDS Program. Declines in hepatitis C drugs could reflect utilization controls state Medicaid programs placed on hepatitis C drugs over the period or declining demand as a growing number of people receive the curative treatment. Over the period, antiretrovirals are more commonly prescribed than hepatitis C drugs due to the relatively larger number of people with HIV covered by Medicaid, expanded reach of these drugs through introduction of pre-exposure prophylaxis (PrEP) drugs to prevent HIV, and the fact that antiretrovirals are a maintenance drug taken over a lifetime (versus curative hepatitis C drugs taken over one course).

Over the entire period, antivirals were consistently the most costly drug group in Medicaid before rebates, driven by spending for drugs used to treat HIV and hepatitis C drugs. Antivirals accounted for 11% of gross Medicaid outpatient drug spending in 2019 (Figure 3). Antiretrovirals and hepatitis C drugs accounted for, on average, 91% of Medicaid antiviral spending each year before rebates (Figure 5). Gross spending on antivirals is disproportionate to their utilization (they were not among the top ten most frequently prescribed drug groups) and reflects the high cost of these drugs. While gross spending on hepatitis C drugs has decreased since 2016 due to competition, these drugs, like Harvoni and Sovaldi, account for a relatively large share of spending due to their high per-treatment cost.

Opioids

Patterns of prescriptions for opioids have shifted in recent years, with an increase in the number of prescriptions to treat opioid addiction and overdose and a decline in the number of prescriptions to treat pain. Opioids were widely prescribed during the period of study, with opiate agonists, partial agonists, and antagonists together accounting for 5.4% of all Medicaid outpatient prescriptions in 2015. However, opioid prescriptions declined over time, decreasing from 37.3 million prescriptions in 2015 to 28.9 million prescriptions in 2019 (Figure 6). While most opioids are used to treat pain, the opiate partial agonist, buprenorphine, and the opiate antagonists, naloxone and naltrexone, are used to treat addiction and overdose.⁵  Buprenorphine and opiate antagonists made up an increasing share of opioid prescriptions during the period, growing from 9% in 2015 to 30% in 2019. If opioids are examined aside from buprenorphine and opiate antagonists, the number of opioid prescriptions fell from 34.1 million in 2015 to 20.3 million in 2019, a 41% decline.

While overall gross spending on opioids remained relatively stable during the period, buprenorphine and opiate antagonists made up an increasing share of opioid spending before rebates. The share of gross opioid spending on buprenorphine and opiate antagonists grew from 36% in 2015 to 71% in 2019 (Figure 7). At the same time, gross spending on other opiate agonist and partial agonist prescriptions, the vast majority of which are generic, decreased by 49% over the period, reflecting the decline in the number of prescriptions to treat pain.

Antidiabetics

Antidiabetics were consistently in the top 10 most prescribed and most costly drug groups throughout the period of study. Their use grew 17% from 2015 to 2019, and Medicaid gross spending grew 53% from 2015 to 2019 (Appendix Table A1 and Figure 8). While insulins remained the largest source of gross spending on antidiabetics, non-insulin antidiabetic treatments, such as glucagon-like peptide-1 (GLP-1) receptor agonists and sodium glucose co-transporter (SGLT) inhibitors accounted for a growing share of spending (Figure 8).

Medicaid spending on insulins before rebates remained relatively stable throughout the period. While the price of an insulin prescription nearly doubled between 2012 and 2016, Medicaid gross spending on insulin has remained around $4 billion since 2016, apart from 2017 when spending on insulins rose to $4.2 billion (Figure 8). Further, Medicaid gross spending per unit of insulin leveled off in 2016, then began to fall from a high of $0.33 in 2017 to $0.30 in 2019 (Figure 9). It is not clear from this data what has been driving this trend. Across payers, there has been a national pattern of declining insulin prices in recent years due to recent approvals of biosimilars and generics. However, because brand drugs are lower cost on net for the Medicaid program, likely due to high rebate amounts, Medicaid insulin utilization remains concentrated in brand drugs, and generic drugs are not similarly driving down insulin spending for Medicaid.

Molecular Targeted Therapy

Gross Medicaid spending on molecular targeted therapy (a type of targeted cancer treatment) more than doubled during the period of study. Spending on these drugs grew from the 12^th most costly drug group in 2015 to the 5^th most costly drug group in 2019 (Table 2 and Figure 10). Spending on these drugs is disproportionate to their utilization, with these drugs making up only 0.1% of prescriptions but 5% of overall Medicaid spending by 2019 (Figure 3). This growth reflects the rising cost of cancer treatment and signifies a shift toward more tailored cancer treatment, using therapies to target specific molecular features of tumors alongside other cancer treatments.

Trends by Brand and Generic Status

State preference for brand or generic drugs is complex due to the incentives created by the Medicaid Drug Rebate Program. Because generic drugs have lower list prices than brand-name drugs but are still therapeutically equivalent to their corresponding brand drugs, state Medicaid programs may implement required generic substitution policies to steer utilization to generic drugs where possible.^6 ,7  However, because Medicaid rebates are higher on brand-name drugs than generics, net costs may actually be lower for brand-name drugs in Medicaid, leading some states to implement “brand over generic” programs. This is especially the case at the initial entrance of a generic equivalent into the market, when a state may still have supplemental rebate agreements and other large rebates that offset the price of the brand drug. Estimates suggest these programs can lead to substantial savings.

Generic drugs accounted for the vast majority of Medicaid outpatient prescriptions while brand drugs accounted for the vast majority of Medicaid spending before rebates during the period. The increase in number of Medicaid prescriptions from 2015 to 2017 was driven by the growing number of generic drugs, while the number of brand drug prescriptions over this period changed very little. The number of both brand and generic prescriptions fell from 2017 to 2019, but brand prescriptions decreased more quickly (14% drop) compared generic prescriptions (3% drop) (Figure 11). However, brand drugs consistently accounted for a relatively large share of Medicaid spending before rebates from 2015 through 2019, and this share increased slightly over time (from 74% to 79%) (Figure 12). The growth in brand spending despite decreases in both brand and generic prescriptions reflects national trends caused by increasing list prices for brand drugs and the launch of expensive new drugs during the period. Gross brand spending increased 8% from 2018 to 2019, likely driven by the launch of high cost, new specialty brand drugs like Biktarvy, Hemlibra, and Epidiolex. Other analysis shows that while other drugs have lost exclusivity over this period, the savings due to introduction of competition for those drugs are not keeping pace with the increased spending from the new drugs launching. There have also been price increases for existing brand drugs, like Humira, but Medicaid may be protected from some of these price hikes over time due to the inflationary component of the MDRP.

Trends by Biologic Status

Biologics account for a very small share of prescriptions but a disproportionate share of gross Medicaid drug spending. Biologics are products, such as drugs or vaccines, derived from living organisms with chemical structures more complicated than traditional small molecule drugs. Biosimilars are products that are deemed “highly similar” or “interchangeable” with a referenced biologic. Biologics tend to be priced expensively and face less competition from biosimilars than small molecule brand drugs face from generics. Additionally, while there has been an increase in both biologics and biosimilars approved by the FDA from 2015 to 2019, some FDA approved biosimilars are not due to enter the US market for a few years or have delayed market entry to avoid patent litigation. Across the entire period from 2015-2019, relatively few prescriptions in Medicaid were biologics, but the amount Medicaid spends before rebates on biological products is outsized. While biological products consistently accounted for a little over 1% of Medicaid outpatient prescriptions every year, they accounted for between 15% and 21% of Medicaid spending on prescriptions before rebates over the period (Figure 13).

Looking Ahead

Medicaid prescription drug policy is likely to remain an issue at both the federal and state levels due to budgetary constraints and the entry of new, high-cost drugs. States remain concerned about the entry of new high-cost drugs to the market and report that developing strategies and policies to address these drugs is a top priority. There has also been recent policy discussion about strategies at the federal level to address the cost of new therapies through the FDA accelerated approval pathway as well as gene and cell therapies.

Congress may take action to address drug prices in both Medicaid and in the health system more broadly. Recent COVID-19 relief legislation includes a provision that lifts the Medicaid rebate cap (currently set at 100% AMP) beginning in 2024 and is estimated to reduce direct Medicaid spending by $14.5 billion. For drugs with large price increases over time, the Medicaid program may receive rebates from manufacturers that exceed the price of the drug. Reducing drug prices remains a focus of policymakers, particularly for individuals in Medicare and with private insurance, but any policies that change underlying drug prices will also have implications for Medicaid drug spending.

Appendix A: Tables

Appendix B: Methodology

This analysis of Medicaid prescription drug utilization and spending trends used 2015 through 2019 State Drug Utilization Data (SDUD), downloaded in early January 2021, merged with data from IBM Micromedex RED BOOK. The SDUD is publicly available data provided as part of the Medicaid Drug Rebate Program. It provides data on the number of prescriptions, Medicaid spending before rebates, and cost-sharing for rebate-eligible Medicaid outpatient drugs. At the time of download, 2019 data were the most recent full year of data available. The RED BOOK data is from December 2020. The use of RED BOOK data does not represent and should not be characterized as a RED BOOK endorsement of any data, findings, or other content presented in this report.

The SDUD and the RED BOOK data were merged at the NDC-level to consistently identify the drug name, as well as to incorporate brand versus generic status and the therapeutic/pharmacologic category of the product. Branded-generic drugs were classified as generic drugs. Using the FDA’s Purple Book, a list of all FDA-licensed biological products regulated by the Center for Drug Evaluation and Research (CDER) and the Center for Biologics Evaluation and Research (CBER) as of December 2020, biological products in the SDUD were identified based on drug name.

Limitations

The SDUD provides spending and utilization data by NDC, quarter, managed care or fee-for-service, and state. It also provides this data summarized for the whole country. CMS has suppressed data cells with fewer than 11 prescriptions, citing the Federal Privacy Act and the HIPAA Privacy Rule. This analysis used the national data because less data is suppressed at the national versus state level.

This analysis does not include rebates because rebate data is unavailable to the public at the NDC level. Rebates have a considerable effect on Medicaid drug spending overall, lowering net spending, but this effect varies at the drug level as different drugs receive different rebates. Additionally, although Medicaid beneficiaries largely self-administer drugs that are prescribed in an outpatient setting, medical practitioners must administer some drugs. Although states are instructed to collect drug rebates on physician-administered outpatient drugs that are not billed as a bundled service, physician-administered drugs subject to a rebate can vary from state to state. Because biologics and other specialty drugs are often physician-administered, it is possible that the data reflects lower Medicaid spending and utilization of certain drugs of this kind.

1. 42 USC § 1396r-8(a)(1). ↩︎
2. For brand name drugs, the rebate is 23.1% of Average Manufacturer Price (AMP) or the difference between AMP and “best price,” whichever is greater. Best price is defined as the lowest available price to any wholesaler, retailer, or provider, excluding certain government programs, such as the health program for veterans. For generic drugs, the rebate amount is 13% of AMP, and there is no best price provision. Rachel Dolan, Understanding the Medicaid Prescription Drug Rebate Program (Washington, DC: KFF, November 2019) https://modern.kff.org/medicaid/issue-brief/understanding-the-medicaid-prescription-drug-rebate-program/ ↩︎
3. CBO analysis of 176 top-selling brand-name drugs in Medicare Part D. CBO computed the average price of those drugs per standardized prescription—a measure that roughly corresponds to a 30-day supply of medication. Congressional Budget Office, A Comparison of Brand-Name Drug Prices Among Selected Federal Programs (CBO, February 2021), https://www.cbo.gov/system/files/2021-02/56978-Drug-Prices.pdf ↩︎
4. On average, Medicaid obtains rebates on brand drugs that are 77 percent of the average Medicaid retail price but only 60% for specialty drugs. The inflation-based component of the rebate averaged 31 percent of the retail price in Medicaid for specialty drugs and 43 percent for nonspecialty drugs. Congressional Budget Office, A Comparison of Brand-Name Drug Prices Among Selected Federal Programs (CBO, February 2021), https://www.cbo.gov/system/files/2021-02/56978-Drug-Prices.pdf ↩︎
5. Buprenorphine, Naltrexone, and Methadone are FDA approved drugs used in Medication Assisted Treatment for opioid addiction. Buprenorphine and Methadone reduce withdrawal symptoms, and Naltrexone is an antagonist and blocks the effects of both opioids and alcohol. Naloxone is an antagonist that can reverse an opioid overdose. Methadone is administered when used to treat OUD, which is not reported in the Medicaid SDUD data. See Lisa Clemans-Cope, Emma Winiski, Victoria Lynch, and Marni Epstein, Rapid Growth in Medicaid Prescriptions and Spending to Treat Opioid Use Disorder and Opioid Overdose from 2010 to 2018 (Washington, DC, Urban Institute, July 2020), https://www.urban.org/research/publication/rapid-growth-medicaid-prescriptions-and-spending-treat-opioid-use-disorder-and-opioid-overdose-2010-2018/view/full_report. ↩︎
6. Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2015 Annual Report, Prescription Drug Fee-For-Service Programs, CMS, December 2016, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/2015-dur-summary-report.pdf; Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2016 Annual Report, Prescription Drug Fee-For-Service Programs, CMS, October 2017, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/2016-dur-summary-report.pdf; Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2017 Annual Report, Prescription Drug Fee-For-Service Programs, CMS, October 2018, https://www.medicaid.gov/medicaid/prescription-drugs/downloads/drug-utilization-review/2017-dur-summary-report.pdf; Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2018 Annual Report, Prescription Drug Fee-For-Service Programs, CMS, https://www.medicaid.gov/medicaid/prescription-drugs/downloads/drug-utilization-review/2018-dur-ffs-summary-report.pdf; Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2019 Annual Report, Prescription Drug Fee-For-Service Programs, CMS, https://www.medicaid.gov/medicaid/prescription-drugs/downloads/2019-dur-ffs-summary-report.pdf; See also “Section VI – Generic Policy and Utilization Data” in state DUR Reports, https://www.medicaid.gov/medicaid/prescription-drugs/drug-utilization-review/annual-reports/index.html. ↩︎
7. Of the states that required more the restrictive requirements, a majority required preauthorization to enable a pharmacist to provide a brand drug when a generic was available. States included other requirements, such as requiring the submission of a MedWatch Form and requiring a medical reason to override the use of a generic, and some implement more than one restrictive requirement. Ibid. ↩︎

Key Findings

• The latest KFF Health Tracking Poll finds majorities of the public saying many current health care proposals being discussed by lawmakers are important priorities for Congress to focus on in the coming months, and few (less than one five) saying each of the health priorities “should not be done.” While majorities of the public say each of the health care priorities asked about is important for Congress to work on, proposals aimed at lowering prescription drug prices are a top priority for Democrats, independents, and Republicans.
• Overall, nearly nine in ten (88%) favor allowing the federal government to negotiate for lower prices on medications, including three-fourths (77%) of Republicans, nine in ten independents (89%) and 96% of Democrats. And while majorities of the public continue favoring this proposal after hearing that people and the federal government could save money on their prescription drugs if this policy were implemented, majorities oppose this policy proposal when the public hears argument made by pharmaceutical companies that it could lead to less research and development for new drugs, or that access to newer prescriptions could be limited.
• The COVID relief bill passed in early March 2021 provided additional financial assistance to people who buy their own health insurance. The vast majority of those who are eligible for this financial assistance are either unsure whether the COVID-19 relief package included this financial assistance (82%) or say it did not happen (9%), while about one in ten (9%) are aware of this increased financial assistance. Additionally, only a small minority of those potentially eligible for additional financial help or coverage report going online to see if they qualify for a different or cheaper health insurance plan.
• With COVID-19 vaccine distribution still a domestic priority (especially among Democrats), majorities of the public also say the U.S. should take at least a “major role” when it comes to distributing COVID-19 vaccines internationally. Views of the U.S.’s role in distributing vaccines differs by party, with nearly nine in ten Democrats in support of the U.S. taking at least a major role while more than half of Republicans say the U.S. should take a “minor role” or “no role at all.” Attitudes shift in favor of U.S. involvement when the public is told that distributing COVID-19 vaccines can help other countries without hurting the U.S.’s own supply, that the coronavirus outbreak is worse in other countries and they need access to the vaccines in order to stop the spread of the virus, or that providing vaccines to other countries could help the U.S. achieve immunity necessary to curb the pandemic.

Health Care Priorities For Congress

On May 28^th President Biden unveiled his $6 trillion budget for the following fiscal year, with broad calls on Congress to create a public option, lower the Medicare eligibility age to 60, lower prescription drug costs for people with Medicare and job-based coverage, and lower ACA deductibles. The plan also includes making permanent the 2-year financial assistance offered to people who buy their plans on the marketplace that was part of the COVID relief bill. The latest KFF Health Tracking Poll asks the public how much of a priority these, along with other health care priorities, are for Congress to focus on in the coming months and finds majorities saying each is at least an important priority and few (less than one five) saying each of the health priorities “should not be done.”

About nine in ten U.S. adults say allowing federal government negotiations with drug companies to get a lower price on prescription drugs (92%), allowing state governments to negotiate lower drug prices (89%), expanding Medicare coverage to include hearing aids, dental and vision coverage (90%), and placing a limit on out-of-pocket costs that seniors have to pay each year for things like prescription drugs (88%) are “top priorities” or an “important, but not top priorities.” At least seven in ten say continuing efforts to make sure U.S. residents are able to receive a COVID-19 vaccine (81%), expanding government health insurance coverage for lower-income people in non-expansion states (78%), and creating a government-administered public option that would be available to all Americans (71%) are at least important for Congress to work on. A slightly smaller share, but still a majority, say lowering the age of Medicare eligibility from 65 to 60 (66%) and making permanent the two-year expansion of additional financial help for people who buy their own insurance from the COVID relief bill (64%) are important priorities.

While majorities of the public say each of the health care priorities asked about are at least an important one for Congress to work on, proposals aimed at lowering prescription drug prices are a top priority for Democrats, independents, and Republicans. Majorities, across partisans, say both allowing the federal government and private insurance to negotiate for lower prices on prescription drugs and allowing states to negotiate with drug companies should be a “top priority for Congress.” Majorities of Democrats (66%), independents (56%), and Republicans (58%) also say placing a limiting on out-of-pocket costs like prescription drug costs for seniors is a “top priority.”

Other health proposals asked about in the survey, including continuing efforts to make sure U.S. residents are able to receive a COVID-19 vaccine, expanding government health insurance coverage for lower-income people in non-expansion states, and expanding Medicare coverage to include hearing aids, dental and vision coverage, are viewed as top priorities by majorities of Democrats, but by smaller shares of Republicans.

Expanding Government’s Role In Providing Health Insurance

While President Biden campaigned on creating a government public option that would compete with private insurance and be available to all Americans, more recently he has expressed support for expanding government insurance by lowering the age of eligibility for Medicare. Both of these proposals are more incremental efforts to expand the government’s role in health coverage than the hotly contested Medicare-for-all proposal that dominated much of the 2020 Democratic presidential primary. Previous KFF polling has found that while Medicare-for-all is favored by a majority of Democrats and independents, a public option garners support among four in ten Republicans (in addition to large majorities of Democrats and independents) and lowering the age of eligibility for Medicare garners bipartisan support (85% of Democrats, 75% of independents, and 69% of Republicans).

The latest KFF polling finds that while older adults, especially Republicans, are less likely to prioritize these policy proposals, both of these proposals aimed at expanding the government’s role in health insurance are important priorities among younger populations. About seven in ten Democrats 18-49 years old saying creating a public option is a top priority, compared to 58% of Democrats 50 and older. Lowering the age for Medicare eligibility is also an important priority for Democrats but with lower shares saying it is a top priority (eight in ten 18-49 year olds say it is at least an important priority as do about three-fourths of Democrats 50 and older). Both of these proposals also have support among younger Republicans (18-49 years old) with at least half saying each is at least an important priority.

Views of The Aca Remain Partisan

More than 11 years after the ACA was signed into effect, views of the 2010 health care law remain politically partisan. The latest KFF Health Tracking poll finds a larger share of the public hold favorable views of the law than unfavorable ones (53% vs. 35%), but still only a slight majority of the public view the law favorably.

Views of the ACA are still largely driven by party identification with vast majorities of Democrats (85%) expressing support for the legislation while 77% of Republicans view the law unfavorably. A larger share of independents view the law favorably (54%) than unfavorably (32%). This has remained largely unchanged over the past 5 years with more than seven in ten Republicans expressing unfavorable views of the ACA since the 2015 King v. Burwell challenge to the law. In comparison, majorities of Democrats, independents, and Republicans view both Medicare and Medicaid favorably.

Financial Assistance for People Who Purchase Their own health Insurance

The COVID relief bill passed in early March 2021 provided additional financial help for people who buy their own health insurance coverage. The vast majority of those likely eligible for this financial assistance are either unsure whether the COVID-19 relief package included this financial assistance (81%) or say that it did not happen (11%). Less than one in ten (7%) are aware of this increased financial assistance. Additionally, only a small minority of those potentially eligible for additional financial help or coverage have reported going online to see if they qualify for a different or cheaper health insurance plan. Among those under 65 years old, nine percent of those who are either uninsured or buy their own coverage report going online in the past two months to see if they qualify for a different or cheaper health insurance plan or Medicaid as part of the COVID relief package.

Prescription Drug Costs and Regulation

Throughout this spring, Democratic lawmakers have discussed allowing the Department of Health and Human Services to negotiate the prices of brand-name drugs. While this proposal is opposed by most Republican lawmakers, the latest KFF Health Tracking Poll finds it supported by a majority of the public, regardless of party identification.

Overall, nearly nine in ten (88%) favor allowing the federal government to negotiate for lower prices on medications, including three-fourths (77%) of Republicans, nine in ten Independents (89%) and 96% of Democrats. Nearly nine in ten across age groups favor the proposal. This pattern is consistent with previous KFF polling conducted prior to the pandemic in which 90% of Democrats, 87% of independents, and 80% of Republicans favored this proposal.

Despite widespread support for allowing the federal government to negotiate drug prices, public opinion can change in the course of a national debate and certain messages can dampen support for this proposal. Support starts high and remains high (90%) when people hear that people could save money on their prescription drugs if this policy were implemented. Eight in ten (81%) say that they favor this proposal after hearing that the federal government could save money if they were allowed to negotiate for lower drug prices for people on Medicare. However, opposition to this policy proposal rises to about two-thirds when the public hears assertions that this proposal could lead to less research and development for new drugs, or that access to newer prescriptions could be limited.

Both of the arguments against allowing the federal government to negotiate with drug companies are effective across partisanship, with support for the proposal dropping among Democrats to as low as 39% and among Republicans to 24% (both down more than fifty percentage points) after these arguments are read.

What Does The Public Think Drives Prescription Drug Costs?

The public sees profits made by pharmaceutical companies as the largest factor contributing to the price of prescription drugs. About eight in ten across partisans say profits made by pharmaceutical companies are a “major factor” in the price of prescription drugs. This is followed by about seven in ten (68%) who say the cost of research and development is a “major factor” contributing to the price, and about half (52%) saying that the cost of marketing and advertising is a major contributing factor to the cost of prescription drugs.

Despite the introduction of the three FDA authorized vaccinations for emergency use for COVID-19 and increased attention on the research and development component of pharmaceutical companies, the share of the public who say the cost of research and development is a “major factor” contributing to the price of prescription drugs has remained relatively unchanged since 2019, when eight in ten said “profits made by pharmaceutical companies”, seven in ten (69%) said “the cost of research and development” and half (52%) said the “cost of marketing and advertising” were major factor in the price of prescription drugs. The latest KFF Health Tracking Poll finds that patterns across partisans have remained stable from 2019.

The latest KFF Health Tracking Poll finds about two-thirds (63%) say there is “not as much regulation as there should be” for limiting the price of prescription drugs, while about half (48%) say there is “about the right amount” of regulation of pharmaceutical companies for making sure prescription drugs are safe for people to use. Few say there is “too much regulation” on either limiting the price (10%) or making sure they are safe for people to use (8%).

Majorities across partisans, including seven in ten Democrats, 65% of independents and nearly six in ten Republicans (57%), say there is “not as much regulation as there should be” when it comes to limiting the price of prescription drugs. Partisans are also similar in their views on regulation to make sure prescription drugs are safe for people to use. A slight majority Democrats (56%) say there is “about the right amount of regulation” on safety of prescription drugs as do nearly half (47%) of Republicans who say the same. Few across partisans say there is “too much” of either type of regulation.

This is only a slight shift from previous KFF polling before the coronavirus pandemic, when the share of the public who say there is “not as much regulation as there should be” on safety was 44% (down to 39% in the most recent poll). The main shift has occurred among Democrats with a majority now saying there is “about the right amount of regulation” while back in 2019, about half had said there is “not as much as there should be.”

U.S. Role In Distributing COVID-19 Vaccines To Foreign Countries

The Biden administration recently announced that by the end of June it would share 80 million COVID-19 vaccine doses with other countries, making it the largest single government donor of vaccines globally so far. The U.S. is also the largest donor to COVAX, the internationally coordinated effort to purchase and distribute vaccines worldwide. A majority of the public (66%) says that when it comes to distributing COVID-19 vaccines to other countries, the U.S. should take a “leading role” (27%) or a “major role” (39%). Views of the U.S.’s role in distributing vaccines differs by party, with nearly nine in ten Democrats in support of the U.S. taking a at least a major role (87%), while Republicans are more split, with more than half saying the U.S. should take a “minor role” (34%), or take “no role at all” (24%).

After hearing more information about the U.S. distribution of COVID-19 vaccines to other countries, larger shares of the public say that the U.S. should take at least a major role. At least three in four U.S. adults say they think the U.S. should play at least a major role after hearing that the U.S. has enough supply of the COVID-19 vaccines to help other countries without hurting its own supply (78%), the coronavirus outbreak is worse in other countries and they need access to the vaccines in order to stop the spread of the virus (77%), or that providing vaccines to other countries could help the U.S. achieve immunity necessary to curb the pandemic (76%).

Each of these messages shift attitudes across partisans, including among Republicans. After hearing each of these messages, at least half of Republicans say the U.S. should take a leading or major role in vaccine distribution. Most notably, six in ten Republicans say the U.S. should take a leading or major role after hearing that the U.S. has enough supply to help other countries without hurting itself.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted May 18-May 25, 2021, among a nationally representative random digit dial telephone sample of 1,526 adults ages 18 and older (including interviews from 327 Hispanic adults and 307 non-Hispanic Black adults), living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Phone numbers used for this study were randomly generated from cell phone and landline sampling frames, with an overlapping frame design, and disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity subgroups within each frame. Specifically, the cell phone frame was stratified as: (1) High Hispanic: Cell phone numbers associated with rate centers from counties where at least 35% of the population is Hispanic; (2) High Black: Cell phone numbers associated with remaining rate centers from counties where at least 35% of the population is non-Hispanic Black; (3) Else: numbers from all remaining rate centers. The landline frame was stratified as: (1) High Black: landline exchanges associated with Census block groups where at least 35% of the population is Black; (2) Else: all remaining landline exchanges. The sample also included 162 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Another 134 interviews were completed with respondents who had previously completed an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n = 46; including 19 in Spanish) or non-Hispanic Black (n=88). Computer-assisted telephone interviews conducted by landline (248) and cell phone (1,278, including 963 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2019 U.S. American Community Survey (ACS), on sex, age, education, race, Hispanic origin, and region, within race-groups, along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January- June 2020 National Health Interview Survey The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of potentially undocumented respondents and of prepaid cell phone numbers, as well as the likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.