To our knowledge, the current analysis is the first to demonstrate the health care utilization and health consequences of the insurance disruption that occurs for women when their husbands transition to Medicare. Using an IV approach, we found that women who experienced insurance disruptions due to their spouse transitioning to Medicare had an increased probability of changing their clinic or provider and were more likely to receive certain preventive services (pelvic exam/Pap smear), yet they were also significantly more likely to utilize the ER for medical treatment, to take less medicine than prescribed or delay filling a prescription because of cost, and also have lower average mental health scores as assessed by the SF-12. This finding serves to resolve the apparent inconsistencies in the literature that have previously demonstrated both increased and decreased probabilities of receiving preventive services following an insurance disruption (Flocke, Stange, and Zyzanski 1997
; Burstin et al. 1998
; Kasper, Giovannini, and Hoffman 2000
; Franks, Cameron, and Bertakis 2003
). Furthermore, the findings described for women who had husbands who transitioned to Medicare are consistent with the literature that has focused on the consequences of switching insurance plans. Prior research, for example, has found insurance changes in younger populations to not necessarily impact the likelihood of having a primary care provider (Burstin et al. 1998
), but they instead increase the likelihood of changes in usual source of care (Cunningham and Kohn 2000
; Franks, Cameron, and Bertakis 2003
), difficulties and delays in obtaining needed care (Kahana et al. 1997
; Burstin et al. 1998
), and ER visits (Franks, Cameron, and Bertakis 2003
). These findings have serious implications for near-elderly women who are likely to be particularly vulnerable to the adverse consequences associated with discontinuities in care because of their chronic disease burden. The current investigation, however, also demonstrated that women who experienced a disruption due to their husband's Medicare transition were more likely to have received a Pap test in the prior year. This is consistent with research that has demonstrated diagnostic testing expenditures to be higher within the first years of plan enrollment (Franks, Cameron, and Bertakis 2003
), although the same pattern was not found in the current analysis for mammograms. This finding may in part be due to the U.S. Preventive Service Task Force recommending mammograms every 12–33 months, as opposed to annually.
The use of an IV approach in the current analysis allowed for the control of both unknown and known, but unmeasured, confounders. This is a key improvement relative to prior research given that insurance changes are likely brought about via a combination of forced change (Kahana et al. 1997
; Cunningham and Kohn 2000
), as well as personal choice (Cunningham and Kohn 2000
). In the current analysis, the IV method produced different results than the traditional multivariable approach, underscoring the importance of considering the endogenous nature of insurance disruption in analyses examining the impact these disruptions have on perceived access to care, health care utilization, and health status.
The current analysis has several limitations. First, the study population lacks diversity. Although this aided the ability to find a valid IV as the women in the sample were a homogeneous group, there may be an issue with the extent to which findings are generalizable, particularly to women who are uninsured or experience gaps in insurance coverage. This said, it is likely that the relatively high levels of income in the study population would lead to an underestimation of the effect of an insurance disruption on study outcomes, as the women in this study likely have greater economic resources to offset the effect of a disruption than would women with lower levels of income and education. Further, the study sample is representative of two-thirds of the birth cohort nationwide in terms of education and race/ethnicity. Second, health status and insurance was assessed simultaneously. Thus, it is difficult to ascertain whether the lower levels of mental health experienced by women who experienced an insurance disruption preceded or were a consequence of the disruption. Third, there were significant differences between women with husbands aged 65–66 and women whose husbands were <65 in terms of the husbands' employment status and insurance type and source. These differences are not entirely surprising given retirement is an event known to occur with greater frequency at age 65. Given a spouse's age and retirement are known in advance, it may be reasonable to assume that the decision to change insurance is planned. Prior research suggests that married couples often coordinate their retirement decisions (Johnson 2004
) and take into consideration their spouse's health care/insurance needs when planning to retire (Karoly and Rogowski 1994
; Gruber and Madrian 1995
; Rogowski and Karoly 2000
; Blau and Gilleskie 2001
). Despite advance knowledge of the event and planning, however, negative consequences are evident. Furthermore, it is likely that these results represent a best-case scenario, as women with fewer socioeconomic resources would likely experience a greater degree of disruption and its adverse consequences. Last, the WLS included plan characteristics traditionally used to distinguish managed care plans, but not breadth of insurance coverage. That said, the fact that respondents who switched to less managed plans were less likely to have a usual place of care and were more likely to have public insurance suggests that these factors may play a role in the mechanism by which insurance disruption can lead to adverse outcomes even among women who transitioned to less managed plans.
Despite these limitations, our primary finding—that women with husbands who transitioned to Medicare have a higher probability of insurance disruptions, which in turn adversely impacts access to care and increases ER utilization—has important implications for future studies of insurance disruptions in the near-elderly. Indeed, these findings suggest that there are hidden negative implications of insurance disruptions for near-elderly women, despite the fact that women in this age group are more likely than other age groups to be insured (Morrisey and Jensen 2001
; Mutschler 2001
; Holahan 2004
) and despite the fact that this group of women is more likely to receive certain preventive services (e.g., Pap/pelvic exams). These findings further suggest that health systems and insurers should adopt strategies to encourage continuous access to care to help minimize the negative impact of insurance changes. The fact that one in five near-elderly women experiences changes to their insurance each year (Sloan and Conover 1998
) at a time when most are living with at least one chronic disease further underscores the importance of timely access to medical services in the face of insurance change. Indeed, the health care services women in this age range receive is critical, given this is the time during the life course when many chronic conditions first emerge, and health care utilization during this time is likely to have important implications for future health outcomes (Xu and Jensen 2005
). The increase in ER visits and the delay in filling or taking prescription medications among women who experience insurance disruptions due to their husbands' Medicare transitions may have important implications for health care utilization as they turn 65 and become Medicare eligible themselves.