Changes in Racial and Ethnic Disparities in Access to Care and Health Among US Adults at Age 65 Years

Abstract

IMPORTANCE Medicare provides nearly universal health insurance to individuals at age 65 years. How eligibility for Medicare affects racial and ethnic disparities in access to care and health is poorly understood. OBJECTIVE To assess the association of Medicare with racial and ethnic disparities in access to care and health. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study uses regression discontinuity to compare racial and ethnic disparities before and after age 65 years, the age at which US adults are eligible for Medicare. There are a total of 2 434 320 respondents in the Behavioral Risk Factor Surveillance System and 44 587 state-age-year observations in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Data (eg, the mortality rate for individuals age 63 years in New York in 2017) from January 2008 to December 2018. The data were analyzed between February and May 2021. EXPOSURES Eligibility for Medicare at age 65 years.MAIN OUTCOMES AND MEASURES Proportions of respondents with health insurance, as well as self-reported health and mortality. To examine access, whether respondents had a usual source of care, encountered cost-related barriers to care, or received influenza vaccines was assessed. RESULTSOf 2 434 320 participants, 192 346 were Black individuals, 104 294 were Hispanic individuals, and 892 177 were men. Immediately after age 65 years, insurance coverage increased more for Black respondents (from 86.3% to 95.8% or 9.5 percentage points; 95% CI, 7.6-11.4) and Hispanic respondents (from 77.4% to 91.3% or 13.9 percentage points; 95% CI, 12.0-15.8) than White respondents (from 92.0% to 98.5% or 6.5 percentage points; 95% CI, 6.1-7.0). This was associated with a 53% reduction compared with the size of the disparity between White and Black individuals before age 65 years (5.7% to 2.7% or 3.0 percentage points; 95% CI, 0.9-5.1; P = .003) and a 51% reduction compared with the size of the disparity between White and Hispanic individuals before age 65 years (14.6% to 7.2% or 7.4 percentage points; 95% CI, 5.3-9.5; P < .001). Medicare eligibility was associated with narrowed disparities between White and Hispanic individuals in access to care, lowering disparities in access to a usual source of care from 10.5% to 7.5% (P = .05), cost-related barriers to care from 11.4% to 6.9% (P < .001), and influenza vaccination rates from 8.1% to 3.3% (P = .01). For disparities between White and Black individuals, access to a usual source of care before and after age 65 years was not significantly different: 1.2% to 0.0% (P = .24), cost-related barriers to care from 5.8% to 4.3% (P = .22), and influenza vaccinations from 11.0% to 10.3% (P = .60). The share of people in poor self-reported health decreased by 3.8 percentage points for Hispanic respondents, 2.6 percentage points for Black respondents, and 0.2 percentage points for White respondents. Mortality-related disparities at age 65 years were unchanged. Medicare's association with reduced disparities largely p...

Evaluation of the Association Between Medicare Eligibility and Excess Deaths During the COVID-19 Pandemic in the US

“…Eligibility for Medicare at age 65 years, which has been associated with an immediate and substantial reduction in the uninsurance rate and improvements in measures of access to care, 5 was not associated with mortality during the COVID-19 pandemic. These null findings may reflect the influence of state and federal policies that directed payments to hospitals for COVID-19 treatment and eliminated cost sharing for COVID-19 testing, both of which aimed to broaden access to COVID-19 testing and treatment.…”

“… 3 Concerningly, however, COVID-19 also led to a crisis of coverage in the US because rising unemployment led to many US adults losing their employer-sponsored health insurance coverage. 4 This study compared deaths among individuals slightly younger and older than 65 years—when most US adults become eligible for Medicare 5 —to examine the relationship between access to health insurance coverage (vs no insurance) and COVID-19 mortality.…”

The American Public Health Association Endorses Single-Payer Health System Reform

“…The proportion of those without health insurance spiked during the economic hardship associated with the SARS-CoV-2 pandemic and the degree of health disparities and the income gap continue to widen further in the United States 1. Our reliance on an employer-based coverage strategy must be seriously reconsidered, in light of the economic and demographic disparities in coverage that result 2. Private payer employment-based insurance and private for-profit insurance must be abandoned, given the inefficient scale of administrative costs and wasted health care expenditures associated with the current system 3.…”

“…1 Our reliance on an employer-based coverage strategy must be seriously reconsidered, in light of the economic and demographic disparities in coverage that result. 2 Private payer employment-based insurance and private for-profit insurance must be abandoned, given the inefficient scale of administrative costs and wasted health care expenditures associated with the current system. 3 SP finance reform is the single best approach to address the problems in the US health care industry.…”

Reimagining Financing and Payment of Long-Term Care

“…Indeed, although the Medicare program has its own problems and challenges, Medicare enrollment at the age of 65 years is associated with substantial improvements in access to health care and reductions in inequities among older adults. 33 …”