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Gaps in Coverage Create Health Insurance Instability for the Elderly

by Richard A. Sherer

Geriatric Times

July/August 2004

Vol. V

Issue 4

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By itself, the most recent U.S. census estimate of 43.6 million uninsured Americans is a staggering number. However, new data indicate that the total number of Americans who may go without health insurance for a significant period is even higher, and that has disturbing implications for policy-makers and providers.

"Given these dynamics, policymakers should think of 'uninsured' as referring not to people, but rather to gaps in coverage over time," according to a recent study published in Health Affairs (2003;22[6]:244-256). Researchers Pamela Farley Short, Ph.D., and Deborah R. Graefe concluded, "At least as many people are repeatedly uninsured as experience a one-time interruption in generally stable coverage."

The authors pointed out:

Half to two-thirds of the people who are uninsured over the course of any year move into or out of coverage during that year. High turnover means that many of the approximately forty million people who are now uninsured will not be among the forty million who are uninsured a year from now.

Researchers at the Commonwealth Fund, a private foundation that supports independent research on health and social policy issues, also found, "A total of 84.8 million Americans under age 65 were uninsured for at least one month between 1996 and 1999."

Lack of health insurance is especially pronounced among the near-elderly population--older adults between the ages of 55 and 64, who, Short and Graefe found, "were the most likely to lack coverage for the entire four-year period." Twenty-two percent of the near-elderly group were uninsured for the whole study period.

Another study published in JAMA (2003;290[6]:757-764), noted:

Near-elderly adults are a vulnerable and growing population. Adults aged 55 to 64 years now represent 8.7% of the US population, and by 2015 this group is expected to grow to 61.9 million--almost 20% of the total population.

"Few people are continuously uninsured for as long as four years," Short and Graefe reported, "but many of the uninsured are exposed to major financial and health risks over time."

Those risks are magnified among people approaching Medicare age. This may have significant impacts on the government costs of providing care in the coming decades. "Uninsured people use fewer health services than their insured counterparts," according to the Institute of Medicine (IOM). "When they do use services, they are more likely to use costly emergency room services or require hospitalization that could have been avoided if they had received timely primary care."

Researchers are now looking at the long-term health consequences of postponing needed medical care until age 65.

"In their first few months in the program, many people do things they've put off doing, especially things like, say knee surgery, things that are elective but can be put off," Marilyn Moon, Ph.D., vice president and director of the health program at the American Institutes for Research, told Geriatric Times. "That tends to mean an increase in Medicare expenses for a while. It's a rational expectation when you think that the whole reason that a lot of private insurers exclude pre-existing conditions is exactly that."

"People without insurance in their early 60s are going without needed services," John Z. Ayanian, M.D., M.P.P., said in an interview with GT. Ayanian is co-author of a study that examined changes in the usage patterns for preventive or diagnostic procedures among adults ages 60 to 64 before and after they became eligible for Medicare.

In the JAMA study, Ayanian and his colleagues wrote, "Both continuously and intermittently uninsured adults were significantly less likely than continuously insured adults to report having received each [studied] preventive service prior to Medicare eligibility."

The authors pointed out how, for adults aged 55 to 64 years, the increased risks of experiencing major health problems and the associated substantial medical expenses mean "the consequences of lacking insurance may be more severe."

"A few years after becoming eligible, they narrowed the gap by about half," Ayanian told GT.

The researchers found that 76% of continuously insured participants received cholesterol testing before becoming eligible for Medicare, rising to 82.8% after reaching the eligibility age. By contrast, only 61.9% of the intermittently uninsured participants and 40.6% of the continuously uninsured participants received cholesterol testing. Those numbers increased to 71.9% and 65.1% respectively after the participants reached Medicare eligibility.

Uninsured women were significantly less likely to have mammograms before becoming eligible for Medicare. Among the intermittently uninsured participants, 57.7% had mammograms before becoming eligible, compared with 71.2% after they became eligible. Only 45.7% of the continuously uninsured women received mammograms prior to attaining Medicare eligibility; that figure rose to 66.8% after eligibility. Among continuously insured women, the figures were 76% before eligibility and 81.8% after eligibility.

Continuously uninsured men were far less likely to have a prostate examination prior to reaching Medicare eligibility. Only 28.9% of continuously uninsured men and 55.4% of intermittently uninsured men had prostate exams, compared with 74.1% among continuously insured men. After Medicare eligibility, the figure for continuously uninsured men rose to 61.1%; for intermittently uninsured, 71.3% and for continuously insured men it was 81.1%.

One reason the disparity continues after uninsured people reach Medicare age is that "many of the people who were previously uninsured did not have access to private supplemental coverage," Ayanian said.

People without health insurance are at greater risk than those with insurance, according to a report from the Kaiser Commission on Medicaid and the Uninsured. The report continued:

Eight studies of outcomes of specific diseases (breast cancer, colorectal cancer, cardiovascular disease, and trauma) found that the odds of dying within a particular time period were from about 1.2 to 2.1 times greater for an uninsured person with the particular condition compared to a privately insured person. Another seven studies of adult mortality from all causes found comparably higher relative odds of dying for the uninsured compared to the privately insured and quantitatively consistent estimated effects of greater medical care use. ... Other research ... strongly suggests that the mechanism underlying these results is a combination of less preventive care, later diagnosis at a more advanced stage of disease, and less therapeutic care after diagnosis among the uninsured.

The full report is available online at <www.kff.org>.

A study by the Agency for Healthcare Research and Quality (AHRQ), published in Health Affairs (2001;20[2]:204-213), found, "Older workers and their spouses are more likely than younger workers to incur costly health-related expenditures, making the financial protection and access to care afforded by health insurance increasingly important."

Jessica P. Vistnes, Ph.D., a senior economist and co-author of the AHRQ report, recently told GT that "people who are in the 54 to 65 age group who have greater health problems than those who are younger also have more difficulty in trying to purchase coverage. Women are also in worse economic shape and have more difficulty buying insurance because they may be earning less and are more likely to be in poverty. We found that 60% of the near-elderly workers who are uninsured for a full year have health problems that make it harder to get employment."

"The implications are that any time you ignore a problem like the uninsured and assume there will be no consequences, you're likely to be wrong," said Moon. "People who have health care needs are going to be a cost to the system. If you have delayed taking care of those needs, they are more likely to be expensive than if they had been taken care of six months or a year earlier. This is particularly true for older Americans. It might have some off-setting savings if you could provide them access to system at an earlier age."

The government at one point considered a proposal to allow an early buy-in to the Medicare system for some near-elderly individuals, but that plan has been shelved.

"We need to improve options for coverage among near-elderly adults," said Ayanian. "There are different ways to do that: A Medicare buy-in would be one option for low-income individuals who need a subsidy. Another would be state-based insurance programs, such as Medicaid. One of the challenges is that many patients at this age range face challenges to buying on their own insurance because of pre-existing conditions."