August 02, 2021
3 min read
Steinbrook is editor at large and online editor of JAMA Internal Medicine. Wallace reports receiving research support from the Tobin Center for Economic Policy at Yale University. Please see the study for all other authors’ relevant financial disclosures.
Medicare eligibility was associated with sharp reductions in racial and ethnic disparities in health insurance coverage, access to care and self-reported health, according to findings published in JAMA Internal Medicine.
“States with the largest preexisting disparities in insurance coverage before age 65 years had the greatest reductions in disparities associated with Medicare eligibility,” Jacob Wallace, PhD, assistant professor at the Yale School of Public Health, and colleagues wrote. “However, racial and ethnic disparities were not eliminated by Medicare, supporting the view that disparities are shaped not only by policy decisions but also other social determinants of health, such as structural racism, that persist among elderly individuals.”
Wallace and colleagues conducted a cross-sectional study of 2,434,320 adults in the U.S. who responded to the Behavioral Risk Factor Surveillance System. The analysis also included state-age-year observations from the CDC’s Wide-Ranging Online Data for Epidemiologic Research. The researchers analyzed data from January 2008 to December 2018 to examine changes in health care access after respondents reached the Medicare eligibility age.
Among the study cohort, 56% of respondents were women, 77% were white, 12% were Black and 11% were Hispanic. The age of respondents ranged from 51 to 79 years.
Disparities correlate with Medicare eligibility
In a regression continuity analysis, Wallace and colleagues observed an increase in insurance coverage immediately after respondents reached 65 years of age, with greater increases among Black respondents (from 86.3% to 95.8%; difference of 9.5 percentage points) and Hispanic respondents (from 77.4% to 91.3%; difference of 13.9 percentage points) compared with white respondents (from 92% to 98.5%; difference of 6.5 percentage points). The increase in coverage correlated with a 53% and 51% reduction in disparity between white and Black and white and Hispanic individuals prior to Medicare eligibility. Also, self-reported poor health decreased by 3.8 percentage points among Hispanic individuals, 2.6 percentage points among Black individuals and 0.2 percentage points among white individuals.
The data further showed that Medicare eligibility lowered disparities between white and Hispanic individuals in access to care, which declined from 10.5% to 7.5% (P = .05), access to influenza vaccines, which declined from 8.1% to 3.3% (P = .01), and cost-related barriers, which declined from 11.4% to 6.9% (P < .001). However, the disparities in access to a usual source of care, access to influenza vaccines and cost-related barriers did not significantly decline between white and Black respondents after reaching 65 years of age, according to the researchers.
The decrease in disparities between white and Hispanic respondents was greater than the decrease between white and Black respondents nationwide except for the Northeast, where disparities between white and Black respondents were greater, according to Wallace and colleagues. The researchers attributed the majority of national-level reductions in health insurance coverage disparities to within-state reductions
“We were surprised to find that eligibility for Medicare was associated with reductions in racial and ethnic disparities in such a broad set of states, including those that are economically, politically and geographically diverse such as Minnesota and Illinois in the Midwest, New York and New Jersey in the Northeast, and Texas and Oklahoma in the South,” Wallace told Healio Primary Care.
The researchers suggested that expanding Medicare further could reduce existing disparities and close national coverage gaps.
“Our findings suggest that differential access to health insurance coverage contributes to the racial and ethnic disparities in accessing the health care system and, ultimately, patient health,” Wallace said. “Though we did not find changes in disparities in mortality right at age 65, we found that eligibility for Medicare substantially reduced disparities in self-reported health, and there is a large literature finding that measures of self-reported health are predictive of all-cause mortality.”
In a related editorial, Robert Steinbrook, MD, editor at large and online editor of JAMA Internal Medicine, discussed the timeliness of Wallace and colleagues’ findings.
“The U.S. is engaged in a national conversation about the effects of structural racism in many areas of society and how best to reduce racial and ethnic disparities, including disparities in access to health care and people’s perceptions of whether they are healthy,” Steinbrook wrote. “The study by Wallace et al suggests that expanding access to Medicare, such as by lowering the eligibility age, might be a straightforward approach to decreasing racial and ethnic disparities in insurance coverage and access to care and promoting health equity.”
He added that “it is a national disgrace that despite the trillions of dollars spent on health care, the U.S. is alone among developed nations in not providing health care to all its citizens.”