ObjectivesThe access barrier to medication has been a persistent and elusive challenge in the US healthcare system and around the globe. Cost-related medication non-adherence (CRN) is an important measure of medication non-adherence behaviours that aim to avoid costs. Longitudinal study of CRN behaviours for the ageing population is rare.DesignLongitudinal study using the Health and Retirement Study to evaluate self-reported CRN biennially.SettingGeneral population of older Americans.ParticipantsThree cohorts of Americans aged between 50 and 54 (baby boomers), 65–69 (the silent generation) and 80 or above (the greatest generation) in 2004 who were followed to 2014.InterventionObservational with no intervention.Primary and secondary outcome measuresLongitudinal CRN rates for three generational cohorts from 2004 to 2014. Population-averaged effects of a broad set of variables including sociodemographics, income, insurance status, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and comorbid conditions on CRN were derived using generalised estimating equation by taking into account repeated measurements of CRN over time for the three cohorts, respectively.ResultsThe three cohorts of baby boomer, the silent generation and the greatest generation with 1925, 2839 and 2666 respondents represented 12.3 million, 8.2 million and 7.7 million people in 2004, respectively. Increasing age was associated with decreasing likelihood of reporting CRN in all three generational cohorts (p<0.05), controlling for demographics, income, insurance status, functional status and comorbid conditions. All three generational cohorts had a higher prevalence of diabetes, cancer, heart conditions, stroke, a higher percentage of respondents with Medicare-Medicaid dual eligibility and lower percentage with private insurance in 2014 compared with 2004 (p<0.05).ConclusionThe paradox of decreasing CRN rates, independent of disease burden, income and insurance status, suggests populations’ CRN behaviours change as Americans age, bearing implications to social policy.

Objective To determine whether health systems in the United States modify treatment or discharge decisions for otherwise similar patients based on health insurance coverage. Design Regression discontinuity approach. Setting American College of Surgeons’ National Trauma Data Bank, 2007-17. Participants Adults aged between 50 and 79 years with a total of 1 586 577 trauma encounters at level I and level II trauma centers in the US. Interventions Eligibility for Medicare at age 65 years. Main outcome measures The main outcome measure was change in health insurance coverage, complications, in-hospital mortality, processes of care in the trauma bay, treatment patterns during hospital admission, and discharge locations at age 65 years. Results 1 586 577 trauma encounters were included. At age 65, a discontinuous increase of 9.6 percentage points (95% confidence interval 9.1 to 10.1) was observed in the share of patients with health insurance coverage through Medicare at age 65 years. Entry to Medicare at age 65 was also associated with a decrease in length of hospital stay for each encounter, of 0.33 days (95% confidence interval −0.42 to −0.24 days), or nearly 5%), which coincided with an increase in discharges to nursing homes (1.56 percentage points, 95% confidence interval 0.94 to 2.16 percentage points) and transfers to other inpatient facilities (0.57 percentage points, 0.33 to 0.80 percentage points), and a large decrease in discharges to home (1.99 percentage points, −2.73 to −1.27 percentage points). Relatively small (or no) changes were observed in treatment patterns during the patients’ hospital admission, including no changes in potentially life saving treatments (eg, blood transfusions) or mortality. Conclusions The findings suggest that differences in treatment for otherwise similar patients with trauma with different forms of insurance coverage arose during the discharge planning process, with little evidence that health systems modified treatment decisions based on patients’ coverage.

As the aging population percentage rapidly increases across the world, leading to an increase in the necessity of long-term care, it is crucial for the government of the United States to implement changes to create more sustainable, and sufficient programs. This policy brief intends to identify problems in the current United States long-term health care system, and will try to find a possible suggestion to impede the gaps in the system. To bring a direct comparison and possible solutions, this brief will also investigate South Korea, a country with similar aging demographics and economic development as the United States. South Korea ranks 10th in GDP, and the elderly population comprise of 17.5% of the entire population (compared to 16% for the U.S). The South Korean examples of the policy suggest a few practical solutions to the issue, such as an increase in basing long term care eligibility on health status of an individual, rather than an emphasis on income eligibility. Targeted policies such as South Korea’s Alzheimer detection program should be more widely utilized for most chronic diseases in the United States. These types of prevention services will be able to help decrease the total amount of funding spent on these patients. Learning from South Korea’s policies can provide the U.S. with services that can adequately address the elderly population’s need for assistance and care.