Medicare closes gaps in racial and ethnic health care disparities

A cross-sectional study in JAMA Internal Medicine has found that entry to Medicare increases coverage rates, access to care, and self-reported health, and it also closes gaps in access and health between racial and ethnic groups.

“Recent research on how the impacts of the Medicare program differ by race/ethnicity or geography are sorely lacking,” said lead author Jacob Wallace, PhD, an assistant professor of public health at the Yale School of Public Health and Institute for Social and Policy Studies in New Haven, Connecticut. “This is an understudied aspect of the Medicare program — that it equalizes access to health insurance across localities and populations — and it is important to consider during a period in which Congress is actively debating whether to expand Medicare.”

The investigators analyzed a total of 2,434,320 respondents in the Behavioral Risk Factor Surveillance System (BRFSS) and mortality data from the U.S. Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research Data from January 2008 to December 2018.

Immediately after age 65 years, insurance coverage increased from 86.3% to 95.8% for Black Americans, from 77.4% to 91.3% for Hispanic Americans, and from 92.0% to 98.5% for White Americans.

This finding translates into a 53% reduction in the disparity between White Americans and Black Americans and a 51% reduction between White Americans and Hispanic Americans versus before age 65.

Medicare eligibility also was associated with narrowed disparities between White Americans and Hispanic Americans 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).

However, disparities between White Americans and Black Americans for these 3 metrics before and after age 65 were not significantly different.

But the share of people in poor self-reported health decreased by 3.8 percentage points among Hispanic Americans and 2.6 percentage points among Black Americans, compared to only 0.2 percentage points for White Americans.

Mortality-related disparities at age 65 years were unchanged.

“We were surprised that eligibility for Medicare was associated with reductions in racial and ethnic disparities in a set of economically, politically and geographically diverse states, rather than being concentrated in the regions of the country where uninsured rates are highest, like in the South,” Wallace told Contemporary OB/GYN®. “The states with the largest reductions in disparities were located all across the country, including Minnesota and Illinois in the Midwest, New York and New Jersey in the Northeast, and Texas and Oklahoma in the South.”

While the authors did not find a reduction in racial and ethnic disparities in death at age 65, “a growing body of evidence concludes that health insurance reduces mortality,” Wallace said.

The design of the current study, known as regression discontinuity, estimates the short-term impacts of Medicare. “If Medicare reduces long-term mortality by improving care management, our study is not well-suited to capturing those effects,” Wallace said.

Nonetheless, because the study demonstrates that Medicare leads to substantial reductions in disparities, “policies that expand Medicare, such as the proposal in Congress to reduce the Medicare eligibility age to 60, offer a viable path to addressing disparities and advancing health equity,” Wallace said.

More research is desperately needed to identify other policies that reduce racial and ethnic disparities, according to Wallace. “We must go beyond merely documenting racial and ethnic disparities and focus on identifying and crafting policies that eliminate them,” Wallace said.

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Disclosure

Wallace reports no relevant financial disclosures.

Reference

  1. Wallace J, Jiang K, Goldsmith-Pinkham P, and Song, Z. Changes in racial and ethnic disparities in access to care and health among US adults at age 65 years. JAMA Internal Medicine. Published online July 26, 2021. doi:10.1001/jamainternmed.2021.3922