Jacob Wallace1, Karen Jiang2, Paul Goldsmith-Pinkham3, Zirui Song4,5. 1. Yale School of Public Health, New Haven, Connecticut. 2. Yale University, New Haven, Connecticut. 3. Yale School of Management, New Haven, Connecticut. 4. Harvard Medical School, Boston, Massachusetts. 5. Massachusetts General Hospital, Boston.
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 Participants: This 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. Results: Of 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 persisted after the US Affordable Care Act took effect in 2014. Conclusions and Relevance: In this cross-sectional study that uses a regression discontinuity design, eligibility for Medicare at age 65 years was associated with marked reductions in racial and ethnic disparities in insurance coverage, access to care, and self-reported health.
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 Participants: This 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. Results: Of 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 persisted after the US Affordable Care Act took effect in 2014. Conclusions and Relevance: In this cross-sectional study that uses a regression discontinuity design, eligibility for Medicare at age 65 years was associated with marked reductions in racial and ethnic disparities in insurance coverage, access to care, and self-reported health.