The onset of Medicare eligibility at age 65 leads to sharp changes in the health insurance coverage of the U.S. population. These changes lead to increases in the use of medical services, with a pattern of gains across socioeconomic groups that varies by type of service. While routine doctor visits increase more for groups that previously lacked insurance, hospital admissions for relatively expensive procedures like bypass surgery and joint replacement increase more for previously insured groups that are more likely to have supplementary coverage after 65, reflecting the relative generosity of their combined insurance package under Medicare.One fifth of non-elderly adults in the United States lacked health insurance coverage in 2005. Most of these were from lower-income families, and nearly one-half were African American or Hispanic (DeNavas-Walt, Proctor, and Lee, 2005). Many analysts have argued that unequal insurance coverage contributes to disparities in health care utilization and health outcomes across socioeconomic groups. Even among the insured there are differences in copayments, deductibles, and other features that affect service use. Nevertheless, credible evidence that better insurance causes better health outcomes is limited (Brown et al., 1998; Levy and Meltzer, 2001). Both the supply and demand for insurance depend on health status, confounding observational comparisons between people with different insurance characteristics.In contrast to the heterogeneity among the non-elderly, fewer than one percent of the elderly population are uninsured, and most have fee-for-service Medicare coverage. The transition occurs abruptly at age 65, the threshold for Medicare eligibility. Building on this fact, in this paper we use a regression-discontinuity framework to compare health-related outcomes among people just before and just after 65. Our analysis extends existing research on the effects of the age 65 threshold (Lichtenberg, 2002; Dow, 2002; Decker and Rapaport, 2002;Decker, 2002aDecker, , 2002band McWilliams et al., 2003) in two main ways. First, we examine a wider range of outcomes. We use survey data from the National Health Interview Survey (NHIS) to analyze changes in self-reported access to care, and in the number of recent doctor visits and hospital stays. We supplement these data with hospital discharge records from California, Florida, and New York, which allow us to measure changes in hospital admissions for specific conditions NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript and procedures, and by hospital type. Second, we focus on the differential effects of Medicare eligibility on different subgroups, and use the pattern of inter-group differences to assess whether these impacts arise through changes in insurance coverage, insurance generosity, or other channels. We also quantify the extent to which the onset of Medicare eligibility reduces or increases disparities in use of different types of services.Our main finding is that Medicare eligibility causes a ...

We use an event study approach to examine the economic consequences of hospital admissions for adults in two datasets: survey data from the Health and Retirement Study, and hospitalization data linked to credit reports. For non-elderly adults with health insurance, hospital admissions increase out-of-pocket medical spending, unpaid medical bills and bankruptcy, and reduce earnings, income, access to credit and consumer borrowing. The earnings decline is substantial compared to the out-of-pocket spending increase, and is minimally insured prior to age-eligibility for Social Security Retirement Income. Relative to the insured non-elderly, the uninsured non-elderly experience much larger increases in unpaid medical bills and bankruptcy rates following a hospital admission. Hospital admissions trigger less than 5 percent of all bankruptcies.

The health insurance characteristics of the population changes sharply at age 65 as most people become eligible for Medicare. But do these changes matter for health? We address this question using data on over 400,000 hospital admissions for people who are admitted through the emergency room for "non-deferrable" conditions-diagnoses with the same daily admission rates on weekends and weekdays. Among this subset of patients there is no discernible rise in the number of admissions at age 65, suggesting that the severity of illness is similar for patients on either side of the Medicare threshold. The insurance characteristics of the two groups are much different, however, with a large jump at 65 in the fraction who have Medicare as their primary insurer, and a reduction in the fraction with no coverage. These changes are associated with significant increases in hospital list chargers, in the number of procedures performed in hospital, and in the rate that patients are transferred to other care units in the hospital. We estimate a nearly 1 percentage point drop in 7-day mortality for patients at age 65, implying that Medicare eligibility reduces the death rate of this severely ill patient group by 20 percent. The mortality gap persists for at least two years following the initial hospital admission.

This paper estimates the effect of alcohol consumption on mortality using the minimum drinking age in a regression discontinuity design. We find that granting legal access to alcohol at age 21 leads to large and immediate increases in several measures of alcohol consumption, including a 21 percent increase in the number of days on which people drink. This increase in alcohol consumption results in a discrete 9 percent increase in the mortality rate at age 21. The overall increase in deaths is due primarily to a 14 percent increase in deaths due to motor vehicle accidents, a 30 percent increase in alcohol overdoses and alcohol-related deaths, and a 15 percent increase in suicides. Combining the reduced-form estimates reveals that a 1 percent increase in the number of days a young adult drinks or drinks heavily results in a .4 percent increase in total mortality. Given that mortality due to external causes peaks at about age 21 and that young adults report very high levels of alcohol consumption, our results suggest that public policy interventions to reduce youth drinking can have substantial public health benefits.

Health insurance characteristics shift at age 65 as most people become eligible for Medicare. We measure the impacts of these changes on patients who are admitted to hospitals through emergency departments for conditions with similar admission rates on weekdays and weekends. The age profiles of admissions and comorbidities for these patients are smooth at age 65, suggesting that the severity of illness is similar on either side of the Medicare threshold. In contrast, the number of procedures performed in hospitals and total list charges exhibit small but statistically significant discontinuities, implying that patients over 65 receive more services. We estimate a nearly 1-percentage-point drop in 7-day mortality for patients at age 65, equivalent to a 20% reduction in deaths for this severely ill patient group. The mortality gap persists for at least 9 months after admission.