Expanding coverage could improve health of older people

Previously uninsured adults reported more frequent hospitalizations, doctor visits and greater total medical expenditures.

Issue: August 2007

Expanding coverage for uninsured near-elderly individuals may be cost-effective, according to new study data.

Previously uninsured individuals were more likely to experience health decline before age 65 and have a persistently greater need for health care after age 65, thus accruing a bigger bill than their previously insured counterparts. This was discovered after researchers analyzed longitudinal data from the Health and Retirement Study. Researchers assessed self-reported health care use and spending from 1992 to 2004 among 5,158 adults who were uninsured or privately insured before gaining Medicare coverage.

This uninsured population reported more frequent hospitalizations (20%), doctor visits (13%) and greater total medical spending (51%) after gaining Medicare coverage compared with previously insured adults.

“Many Americans may enter the Medicare program at age 65 in worse health because they have been uninsured in their late 50s or early 60s, thereby requiring more services and costlier care after age 65 than they would if they had been previously insured,” J. Michael McWilliams, MD, research associate at Harvard Medical School and a practicing general internist at Brigham and Women’s Hospital, told Endocrine Today. “Providing health insurance coverage for these older uninsured adults may not only improve their health outcome but may also reduce their annual health care use after age 65.”

Analysis of care

Of the adults in the study, aged 53 to 61 years at the start, 3,773 (73.1%) reported having continuous private coverage, and 1,385 (26.9%) reported having been uninsured before age 65. More than half had been diagnosed with hypertension, heart disease, diabetes or stroke before the age of 65.

Those who were uninsured reported significantly fewer doctor visits and hospitalizations before age 65 compared with insured individuals. However, this group reported more visits, hospitalizations and total health care costs after age 65.

The rise in medical care spending for the previously uninsured was most prominent among Medicare beneficiaries with diabetes, heart disease, hypertension and stroke. The need for greater use of health services persisted at least through age 72, specifically for these previously uninsured individuals with CVD or diabetes, McWilliams said.

Consequences for uninsured

“The increase in services we observed after age 65 was not just a transient spike but rather a persistently greater level of utilization. This suggests that uninsured adults with CVD and diabetes went without important health services in their late 50s and early 60s and developed preventable and costly complications as a result,” he said.

It can be difficult for older individuals to afford health care coverage on the individual market if they cannot receive health benefits through their employer; it can be increasingly more difficult for those with chronic conditions.

The costs of expanding coverage for uninsured adults before age 65 may be partially offset by subsequent reductions in their health care use and spending after age 65, particularly for those who have CVD or diabetes, he said.

Costs of expanding coverage

From an economic perspective, expanding coverage would increase health care spending before age 65, and costs would be at least partially offset by reductions in spending after that age. From a practice standpoint, physicians would see patients with these chronic conditions at an earlier age, he said.

“A broader issue is that of the aging population. As baby boomers age into the near-elderly and then the elderly age groups, expanding coverage to uninsured adults before age 65 could significantly improve the health of a growing population of elderly Americans while costing less than previously thought,” McWilliams said. – by Katie Kalvaitis

For more information:
McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Use of health services by previously uninsured Medicare beneficiaries. N Engl J Med. 2007;357:143-153.