Compared with individuals with private insurance, the uninsured have higher rates of morbidity and mortality.4,5,15–24
A previous study using the HRS database found that adults in late middle age who were uninsured from 1992 to 1996 had an increased risk of a major decline in overall health (ARR 1.63) and development of a new mobility difficulty (ARR 1.23) compared with people with continuous private insurance.4
Our current study shows that this elevated risk of a decline in overall health and physical functioning among uninsured adults in late middle age continued during the 2-year period during which they transitioned to Medicare coverage (t−2
). We also found no evidence that gaining Medicare coverage led to higher rates of improvements in overall health or physical functioning for the uninsured. In contrast, during our second 2-year observation period (t0
), at which point all subjects had been covered by Medicare for 2 to 4 years, previously uninsured individuals were no longer more likely to have their health deteriorate than subjects who had been privately insured. Together, these findings suggest that being uninsured may have residual effects even after an individual gains insurance coverage, but the duration of the period of increased risk appears limited.
There are several possible reasons why individuals who were previously uninsured could continue to be at increased risk of adverse health outcomes for a brief period even after they gain insurance. It may take time for people who have not had a regular source of care to establish a relationship with a physician. McWilliams et al.8
found that when people who were uninsured gained Medicare coverage, their rates of use of covered clinical services increased but still remained below rates of use for individuals who had been insured before gaining Medicare coverage. Even after a person establishes a medical home and begins to use services, it may still take time to get a patient's medical conditions controlled; diagnostic tests must be performed, new treatments initiated, and adjustments made to the therapeutic plan.
Even with ready access to physicians and rapid control of medical problems, being uninsured may have true lagged health consequences that persist for some time. For example, someone with diabetes who is uninsured and has inadequate access to care and suboptimal treatment may develop occult vascular, retinal, or renal damage that increases the risk for adverse health events for years to come even after the diabetes is controlled.
It remains possible that the true period of increased risk for uninsured individuals ended abruptly after they gained Medicare coverage. Participants were only interviewed every 2 years, so we cannot tell whether the declines in overall health and physical function among the uninsured from t−2 to t0 occurred before or after they gained Medicare. It is likely that some of the uninsured had health declines immediately before gaining Medicare, and some of these individuals may have even had improvements in their health after becoming insured. Nevertheless, the increased risk of worsening overall health and physical functioning from t−2 to t0 among the previously uninsured was seen even for participants who had been on Medicare for 1 year or more at the time of their t0 interview; this would be unlikely if the health declines among the previously uninsured occurred exclusively before their entry into Medicare.
Another possible reason for why the previously uninsured continued to have an increased risk of adverse health outcomes after gaining Medicare coverage is that they had less comprehensive insurance coverage and worse access to care than individuals who had been privately insured before Medicare coverage. Compared with the previous insured, the previously uninsured were less likely to report that they had supplemental insurance and more likely to say that they had been unable to take a prescribed medication because of costs (data not shown). However, adding these variables to the model only slightly attenuated the elevated risk of a health decline for the uninsured during the 2-year period when they transitioned to Medicare. Moreover, the fact that we did not find an elevated risk of adverse health outcomes for the previously uninsured during the second 2-year follow-up period (t0 to t2) argues against residual confounding as a major contributor of the increased risk of adverse health outcomes for the previously uninsured during the first 2-year follow-up period (t−2 to t0); any differences in access to care and insurance coverage between the individuals who had previously been uninsured and those who had private insurance should have been present during both 2-year study periods (t−2 to t0 and t0 to t2).
It is possible that there are some residual adverse health effects of being previously uninsured beyond 2 years. Although the ARR of a major decline in overall health was not significant (ARR 1.14; ), we did not have adequate power to detect an effect size of this magnitude. The HRS has not released 2-year follow-up data for people who first reported Medicare coverage at the 2002 interview (N = 1,091; 31.9% of the original cohort). Subsequent studies with a larger study population are needed to determine whether the increased risk of worsening overall health and physical functioning among the previously uninsured is completely gone after 2 years of Medicare coverage or whether some smaller risk remains. In addition, there were too few deaths during the t0 to t2 period to determine whether the previously uninsured have a residual increased risk of death, and a longer follow-up period is needed.
In addition to these limitations, we did not have data on the number of physician visits or the use of other major health care services before and after participants gained Medicare coverage. However, McWilliams et al.8
have reported that HRS participants who transitioned from being uninsured to having Medicare coverage increased their use of cholesterol screening, mammography, screening tests for prostate cancer, and arthritis-related medical visits. This supports the hypothesis that gaining Medicare increases use of health care services and eventually eliminates the increased risk of adverse health outcomes for individuals who previously lacked insurance. In addition, this study was conducted before passage of the new Medicare prescription-drug benefit. This new benefit could increase access to medications for individuals with limited incomes, including many of those who were uninsured before gaining Medicare coverage. If this occurs, the health benefits of gaining coverage may be even greater and occur more rapidly.
Our findings have important policy implications. Lack of health insurance among the near elderly is a major concern,25,26
but policies designed to expand coverage have so far been unsuccessful.27
One proposed option is to allow uninsured individuals to buy-in to Medicaid or Medicare with the help of government subsidies for the poor and near-poor.28
Hadley and Waidman7
estimated that Medicare and Medicaid would spend approximately $19 billion less on care for newly enrolled aged beneficiaries over their first 5 years of coverage if they were continuously insured over the 8 years before entering Medicare. This estimate of the benefits of expanded coverage only includes direct medical costs, whereas the indirect benefits of improved health are likely to be far larger.29
Most importantly, it is critical to expand coverage for people with diabetes, hypertension, and heart disease. Persons with these conditions experience the majority of the preventable mortality among uninsured older adults.6
If policies can significantly expand insurance coverage for the near elderly, our findings suggest that this would prevent or attenuate health declines for individuals who otherwise would have been uninsured.