Health of Previously Uninsured Adults After Acquiring Medicare Coverage

While I work through a re-jig of my Cost-Benefit Analysis syllabus (actually it’s really Cost-Effectiveness Analysis, but the University calls it Cost-Benefit Analysis and never comes into the classroom to check, so. The differences between Cost-Benefit, Cost-Effectiveness and Cost-Utility Analysis are not problematic to navigate CEA is a better umbrella). I will take your time up with some of it.

This is going to go into a discussion that we have, early on, concerning key issues “going forward”. Methodological, social, ethical, etc. It’s a graduate class, but the students usually have not had any real exposure to things like proper analysis, research, research papers, dissemination – which is to be expected, at that level. We take the first few weeks to give them a feel for (a) what’s out there, and what’s important, and (b) the aesthetic, the structure, of applied research. It’s well-worth the time spent.

So to this paper from the Journal of the American Medical Association:

Uninsured near-elderly adults, particularly those with cardiovascular disease or diabetes, experience worse health outcomes and use more health services as Medicare beneficiaries after age 65 years than insured near-elderly adults. Because chronic diseases are prevalent and insurance coverage is often unaffordable for older uninsured adults, the impact of near-universal Medicare coverage at age 65 years on the health of previously uninsured adults may be substantial.

Most studies assessing the health consequences of lacking coverage have relied on cross-sectional data and study designs that have not allowed coverage effects to be distinguished from unobserved differences between insured and uninsured persons. A few studies have used cross-sectional data that span multiple years or ages to conduct more rigorous comparisons. For example, an assessment of the introduction of Medicare in 1965 found no discernible impact on mortality for beneficiaries,15 but subsequent medical advances may have improved the effectiveness of health care for elderly Americans.16 A recent cross-sectional analysis of age profiles found that Medicare eligibility at age 65 years was associated with modest gains in self-reported general health status for less-educated adults and minority groups, but uninsured adults and those with specific conditions could not be longitudinally followed as they became eligible for Medicare.

The objective of our study was to assess the effect of Medicare coverage at age 65 years on trends in self-reported health outcomes from ages 55 through 72 years for previously uninsured adults, particularly those with cardiovascular disease or diabetes. We compared cohorts of insured and uninsured near-elderly adults using a quasi-experimental design and longitudinal data on a broad array of general, physical, and mental health measures from the nationally representative Health and Retirement Study. We hypothesized that acquiring Medicare coverage would attenuate adverse health trends for previously uninsured adults relative to previously insured adults, as improved access to care, greater use of beneficial medications and procedures, and more effective management of chronic conditions helped to alleviate symptoms, maintain functioning, and prevent or postpone complications.

You will find it is familiar to a lot of what was written here, concerning SCHIP: give people insurance, and you give them access to health care. Give them access to health care, and you improve their health. This does not include the argument that it is not the absence of insurance but the high cost of care that is the problem – this, too, will be a defining issue for the our retiree Boomer self-interest.

Back with McWilliams et al, some results (click for large version):

McWilliams Table 2

Among 5766 adults (79.7%) who completed at least 1 survey after age 65 years, previously uninsured adults were less likely to report coverage for prescribed medications after age 65 years (62.7% vs 77.9%; P < .001). Among the study cohort, 4443 adults (61.4%) reported diagnoses of hypertension, heart disease, stroke, or diabetes before age 65 years, of whom 3103 (69.8%) were insured and 1340 (30.2%) were uninsured. Among 838 adults with diabetes in our study cohort who were also surveyed in 2003, 541 (64.6%) underwent HbA1c testing.

Before age 65 years, summary health scores worsened at a greater rate for uninsured adults than for insured adults (mean annual trend, –0.23 vs –0.15; P = .002) and were significantly worse at age 65 years (mean score, 20.75 vs 22.29; P < .001) (Table 2). After age 65 years, however, this adverse trend differentially improved for previously uninsured adults (differential change in annual trend, +0.20; P = .002) such that summary scores after age 65 years indicated near maintenance of health for previously uninsured adults but continued deterioration for previously insured adults (mean annual trend after age 65 years, –0.07 vs –0.19; P = .049 [test not shown]). In comparisons of component health trends before and after age 65 years, previously uninsured adults reported significant improvements relative to previously insured adults in change in general health, agility, and depressive symptoms (Table 2). Persistently uninsured adults reported greater declines before age 65 years than intermittently uninsured adults and worse summary health scores at age 65 years (mean difference, –0.69; P = .07 [data not shown]), but changes in health trends after age 65 years were similar for these 2 groups of previously uninsured adults (P = .81).

Which is, more or less, what one would expect. Near-elderly non-insured (since I’m sure the survey did not specifically find people, give them insurance, then take it away again) are going to be in just-plain-shit health, relative to their peers. They are more likely to have lower incomes, more likely to have avoided preventive (or even early palliative or curative) physician care, less likely to have had any sort of access to medication (particularly in the US) – you name it, they didn’t get it or didn’t do it. Meaning when the retire and hit Medicare, they do.

This means two things: first, as this article shows, we observe health-gains from people having this access – indicating similar gains, probably greater gains, exist if they had such access all along. Meaning expanded health care/insurance, one way or the other.

Second, as per the SCHIP plaint, an ounce of prevention, etc. – particularly now, as Boomers retire. Every individual will invest in their health, to the extent that they believe they can afford to do so (this is also why insurance, coupled with rapidly appreciating care costs, is a recipe for serious problems). As this enormous lump of people retire, the burden that they place upon Medicare is going to be substantial. Couple that with moves by companies to get people off their books and onto government books, and the problem only becomes worse.

The issue for us will be pretty much this: the increasing importance of access to care, as more people retire. Of follow-up importance is the cost: as more people retire, will price-rationing hold, as an ideal? If not, how will the US system expand their use of non-price rationing? Will America soon need a US NICE or PBS, to hold back the tide? At what point (at what age, and what severity, at what condition) do we decide that it is “worth it” to help people? We cannot just help everyone via Medicare: put more people on it, and – in the US – it will be able to do less. With limited health care resources, how do we decide who gets the resources when an increasing bulk of the electorate transition to fixed-income retirees?

I don’t yet know the make-up of my students for CBA. I’m considering brining in some climate change/Bjorn Lomberg stuff, too. As well as agricultural problems.


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