Answer the following questions based on the reading The impact of Medicare on Access to And...
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Answer the following questions based on the reading "The impact of Medicare on Access to And Affordability of Health Care". All the questions can be answered with the information available in the reading in combination with lecture material. 1- According to this reading, is this statement true or false? [0.5 point] When a person is insured (i.e., has health insurance), this means this person has no accessibility issues regarding healthcare anymore. Explain. 2- From a policy perspective, why does the author think that is it important to look at the impact of Medicare on accessibility to healthcare and affordable coverage? [1 point] 3- Are comparisons between Medicare recipient's accessibility and accessibility of the privately insured an accurate approach to use to address the research question of this paper? [Hint: Think of counterfactuals and what is being compared] [1 point] 4- How does the author propose to solve the issue raised in Question 3? Do you think the proposed solution is a good approach regarding how to look at the causal impact of Medicare? Explain. [1 point] 5- In the solution proposed in Q4 what is the author exactly testing? (You can think of the causal effect to answer the question)? [0.5 point] By Paul D. Jacobs The Impact Of Medicare On Access To And Affordability Of Health Care ABSTRACT Medicare pays for roughly one in four physician visits in the United States, yet a rigorous understanding of how Medicare currently affects access to and affordability of care for its enrollees is unavailable. Using data from the Medical Expenditure Panel Survey-Household Component and the National Health Interview Survey, I tested for changes in access to care and affordability around age sixty-five, when most people gain eligibility for Medicare. I found that Medicare eligibility is associated with a 1.5-percentage-point reduction in reports of being unable to get necessary care (a 50.9 percent reduction compared with the percentage at age sixty-four) and a 4.1-percentage-point (45.3 percent) reduction in not being able to get needed care because of the cost. Recently, policy makers have proposed various ways of extending Medicare coverage. These results suggest that incremental Medicare expansions could have positive access and affordability benefits for enrollees compared with the insurance options available to them before they turn sixty-five. T he Medicare program pays for roughly one of every four physician visits in the United States, and in 2019 it covered roughly 60 million people. The program has also long enjoyed favorable public opinion among both seniors and the nonelderly. Yet although its scope is broad and opinion among beneficia ries is favorable, a rigorous understanding of how Medicare currently affects access to health care for its enrollees is not available. The greater health needs and lower income of its primarily elderly and disabled population, as well as the high cost of health care, underscore the impor- tance of assessing how Medicare beneficiaries perceive the affordability of their care. Perhaps as a result of the program's populari- ty, policy makers have proposed extending Medicare coverage by incrementally reducing the age of eligibility, offering a "buy-in" option, or offering Medicare to a wider swath of the American public, possibly by expanding cover- age to the entire US population. Alternatively, as a means of reducing federal obligations for health spending, some have proposed increasing the age of eligibility for Medicare. As a conse- quence, a more thorough understanding of the impacts of Medicare on health care access and affordability is important for evaluating the vari- ous proposals for changing who is covered under the program. Medicare can influence access to care or per- ceptions of affordability through a variety of channels. Medicare covers a different set of ser- vices than private insurance, and in the case of routine dental care, for example, the traditional Medicare fee-for-service program does not pro- vide any coverage. As a result, people who newly enroll in Medicare may experience access or affordability issues for dental or other non- covered services. Alternatively, the increasing prevalence of high-deductible health plans and other increases in cost sharing among private plans could increase the perceived affordability of Medicare. For people with limited or no health coverage before age sixty-five, access to care and perceived affordability may well improve on en- rolling in Medicare. Understanding access and affordability issues is critical for Medicare's high-need and low- income population, yet a gap exists in what we know about Medicare's current role in providing accessible care and affordable coverage. Re- search broadly shows that access to care not only is an outcome of whether someone has coverage but also depends on their type of health insur- ance. And although research consistently sug- gests that Medicare provides roughly compara- ble access compared with private insurance, previous efforts have generally relied on simple comparisons between people with different types of insurance. For instance, Medicare ben- eficiaries report that their access to care is com- parable to or better than that of people with private insurance," beneficiaries are able to find a new doctor without a problem,' and physicians accept new beneficiaries at roughly the same rate as they do patients with private insurance." How- ever, a fundamental shortcoming with this line of inquiry is that the populations being com- pared are inherently different. More rigorous analyses of Medicare have been conducted assessing discontinuities using the age of eligibility. These studies have documented changes in mortality at age sixty-five as well as changes in the receipt of care, including mam- mography and rehabilitation. Only one study to date has rigorously assessed changes in ac- cess-to-care measures for Medicare enrollees.2 However, these authors studied only two access measures (whether people delayed care or did not get care because of cost in the past year) and used data that are now nearly two decades old. In this study I used more recent data and a regression discontinuity design to test for changes in multiple measures of access and affordability just before and just after the attain- ment of age sixty-five, when most people gain Medicare eligibility. This design exploited the fact that only a small share of the near-elderly US population is enrolled in Medicare and a large majority of people obtain Medicare as their primary source of coverage at age sixty-five. Study Data And Methods POPULATION I examined measures of access to and affordability of care using data from both the 2008-17 Medical Expenditure Panel Survey- Household Component (MEPS-HC) and the 2008-18 National Health Interview Survey (NHIS). The primary sample was limited to respondents ages 57-72, excluding people age 65 at the time of the interview because survey questions on access to care and affordability typ- ically cover the previous twelve months. ACCESS OUTCOMES Using MEPS-HC data, I as- sessed the percentage-point change at age sixty- five in whether people had a usual source of care, had a routine checkup in the past year, delayed getting necessary medical care in the past year, and were unable to get necessary care in the past year. Using data from the NHIS Sample Adult file, I examined changes in the following re- ported experiences (all in the past twelve months): people were told by a doctor's office that they would not accept the person as a new patient, they were told by a doctor's office that they did not accept the person's health coverage, they could not get an appointment soon enough, they waited too long in the doctor's office, and they had trouble finding a doctor who would see them. AFFORDABILITY OUTCOMES To assess percep- tions of affordability, I examined whether people were unable to get or delayed getting necessary medical care because of the cost in the past twelve months (MEPS-HC) and questions asking whether people did not get care in the past twelve months because they could not afford it for five types of care (NHIS Sample Adult file): general medical care, prescription medicines, dental care, specialist care, and follow-up." COVERAGE In supplemental analyses I used MEPS-HC data to assess changes at age sixty-five in whether people had any health insurance cov- erage at the time of the survey (see the online appendix)." ANALYSIS Results were expressed as percent- age-point differences in those reporting issues accessing or affording care before and after the age of Medicare eligibility. In addition, to show the relative importance of these changes, results were calculated as the percentage change in the outcomes compared with means for the sixty- four-year-old population in my sample. I also calculated results by educational attainment and race/ethnicity. Results were also calculated for survey years before and after the implemen- tation of the Affordable Care Act (ACA) to test whether increases in insurance coverage for the nonelderly population minimized potential changes arising from newly obtaining coverage at the threshold of age sixty-five. Using a regression discontinuity design, I test- ed for discontinuous changes in measures of ac- cess to care and affordability of coverage before and after reaching age sixty-five. This design ex- ploited the fact that only 6-11 percent of the near- elderly US population (ages 57-64) are enrolled in Medicare, whereas 81 percent are enrolled in Medicare as their primary source of coverage upon turning age 65." A number of previous studies have used the age of Medicare eligibility to assess the program's impact on health, health spending, and care-related outcomes. Because people cannot control their age or the age cutoff for Medicare, differences in outcomes at the eli- gibility age can be attributed to the effects of the program and not underlying differences in the groups being compared. 10.12.17 Adjusted results were derived from ordinary least squares regressions with different linear age trends before and after age sixty-five. Regres- sions controlled for the survey year and whether the person was working. The sensitivity of the results to using quadratic age trends is in the appendix." All regressions used MEPS-HC and NHIS sampling weights, and standard errors were adjusted for clustering by year of age. Re- sults with standard errors adjusted for complex survey design were not appreciably different. LIMITATIONS A concern with this analysis may be that people retire at age sixty-five because of eligibility for Medicare, and changes in work status could influence the outcomes. However, the full retirement age for Social Security eligi- bility has increased over time. This change, cou- pled with reduced availability of employer- provided pensions and higher educational attainment of older workers, appears to have increased labor-force participation among older workers and led to relatively stable participation around age sixty-five." As a precaution, all mod- els controlled for whether the person was work- ing. In addition, in supplemental analyses I con- firmed that both working status and Medicaid EXHIBIT 1 coverage did not show significant discontinu- ities at age sixty-five (see the appendix)." Anoth- er concern is that regression discontinuity esti- mates could be sensitive to the age range used to form the sample. In the appendix I show that key results are not sensitive to different ranges." I 57 58 59 60 61 Study Results UNADJUSTED RESULTS Unadjusted, the percent- age of people in the US ages 57-72 who did not have a usual source of health care declined with age during the sample period (exhibit 1). Exhib- it 1 suggests a consistent decline in the percent- age without a usual source of care by age from about 15.0 percent at age fifty-seven to 6.3 per- cent at age seventy-two. The break in the two lines suggests an abrupt change in those report- ing no usual source of care from 11.9 percent at age sixty-four to 8.9 percent at age sixty-five and 7.9 percent at age sixty-six. Based on the trend for all ages in the sample, we would expect a 1.2- percentage-point decline from age sixty-four to age sixty-six. Instead, the percentage without a usual source of care fell 4.0 percentage points (from 11.9 to 7.9 percent). Unadjusted NHIS data show that 6.3 percent of respondents age sixty-four reported problems obtaining needed medical care because of its cost, compared with 3.7 percent for those age sixty-six (exhibit 2). Based on the trend, afford- ability as a barrier to care would be expected to decline 0.8 percentage points from age sixty-four to age sixty-six; the actual decline of 2.6 percent- age points was more than threefold larger. ACCESS TO CARE AND COVERAGE Sample respondents were 2.6 percentage points less Percent of people in the US without a usual source of care, by age, 2008-17 16% - 14% - 12% - 10% - 8% - 6% - 4% - 2% - 0%- 65 Age (years) 66 67 69 70 71 72 Sounce Author's analysis of data for 2008-17 from the Medical Expenditure Panel Survey-Household Component. NOTES Lines are derived from a regression allowing different linear trends for age before and after age sixty-five. Sample included people ages 57-72. EXHIBIT 2 Percent of people in the US who needed but did not get medical care in the past year because they could not afford it, by age, 2008-18 9%- 8% - 7% - 6%- 5%- 4%- 3%- 2%- 1%- 0%- 1 57 58 59 EXHIBIT 3 60 61 Sounce Author's analysis of data for 2008-18 from the National Health Interview Survey NOTES Lines are derived from a regression allowing different linear trends for age before and after age sixty-five. Sample included people ages 57-72. likely to lack a usual source of care after becom- ing Medicare eligible (p=0.002) compared with younger respondents (exhibit 3). At age sixty- six, respondents were also less likely to be unable I 62 63 Access and affordability measures ACCESS TO CARE No usual source of care No check-up in past year 6 65 Age (years) Doctor does not accept new patients Doctor does not accept insurance Unadjusted and adjusted measures of access to and affordability of care before and after reaching Medicare eligibility age, 2008-18 Unadjusted Adjusted Difference (percentage Difference points) (96) Could not get appointment soon enough Wait too long for appointment Trouble finding doctor Unable to get necessary care Not easy to get needed care AFFORDABILITY OF CARE Medical care needed, not gotten because of cost Medical care needed, delayed because of cast Could not afford dental care Could not afford prescription drugs Could not afford specialist care Could not afford follow-up care Unable to get or delayed necessary care because of cost I I I 66 67 68 69 70 71 72 to get necessary care (1.5 percentage points; p <0.001) and less likely to not find it easy to get needed care (2.3 percentage points; p <0.001). Across the access measures, percent- Source NHIS NHIS NHIS NHIS NHIS MEPS-HC 11.9 MEPS-HC 27.3 Age 64 (%) NHIS NHIS NHIS NHIS NHIS NHIS MEPS-HC 2.7 3.8 5.7 4.1 2.7 MEPS-HC 3.0 MEPS-HC 6.7 6.3 9.1 11.1 6.7 10 m- 16 43= ANMO 42 3.3 1.0 Age 66 7.9 24.3 22 3.1 6.1 4.4 25 1.5 3.6 556 3.7 5.5 9.5 5.8 24 21 0.2 Difference (percentage points) -40 -3.0 -0.5 -0.7 0.4 0.3 -02 -15 -3.1 -2.6 -3.6 -1.7 -09 -18 -12 -0.7 -26 -1.9 0.1 -0.3 0.5 0.5 -0.5 -1.5*** -23 -29 -1.4" -0.5 -21 -1.7*** -0.7*** -22.1 -6.8 22 -8.8 8.0 13.4 -16.8 -50.9 -34.7 -46.0 -45.3 -128 -7.4 -50.9 -51.8 -75.4 age-point reductions ranged from 1 to 3 perdut This study found no age but represented fairly sizable tions in the percentage of people with an access evidence of issue. There was a 22.1 percent (2.6-percentage- point) reduction in people without a usual deteriorating access source of care after age sixty-five and a 50.9 per- cent (1.5-percentage-point) reduction in those or affordability at the saying they were to necessary care. As shown in the appendix, the results were very similar when I included those age sixty-five." Medicare eligibility age. As displayed in appendix exhibit 3, there was a 14.9-percentage-point increase in having any source of health insurance coverage at the Medi- care eligibility age." AFFORDABILITY From the NHIS data, the Medi- care eligibility age was associated with a 2.9- percentage-point reduction in those who said they could not get care because of cost and a 4.1-percentage-point reduction in those saying they delayed care because of the cost (exhibit 3). By type of care, there were significant reduc- tions in the percentage saying they could not afford dental care (1.4 percentage points; p=0.027), specialist care (2.1 percentage points; p <0.001), and follow-up care (1.7 per centage points; p <0.001). From the MEPS-HC data, the percentage saying they were unable to get or were delayed in getting necessary care because of the cost fell 0.7 percentage points (p <0.001) at age sixty-six. Reductions in afford- ability issues represented fairly large effects when expressed as a percentage of those with problems before reaching age sixty-five. Com- pared with people age sixty-four, 46.0 percent fewer (2.9 percentage points) people age sixty- six said they could not get care because of the cost and the number of people saying they could not afford follow-up care fell by 51.8 percent (1.7 percentage points). BEFORE AND AFTER ACA IMPLEMENTATION As displayed in appendix exhibit 1, the percentage change in having a usual source of care was iden- tical when limiting the sample to the years before or after the 2014 implementation of the ACA (-2.6 percentage points)." Estimates for all changes in access and affordability were not sta- tistically different before and after ACA imple- mentation. Access and affordability improved upon the attainment of Medicare eligibility after ACA implementation, including reductions in those without a checkup in the last year and in not getting needed medical care because of cost. Appendix exhibit 3 suggests that although the increase in insurance coverage at the age of Medicare eligibility was larger before 2014 (17.5 percentage points), there was nevertheless a substantial increase after ACA implementation (11.7 percentage points)." SOCIOECONOMIC STATUS Several access mea- sures improved more for people without a col- lege degree than for those with a college degree, whereas other changes were statistically indis- tinguishal The percentage without a check-up fell by 3.9 percentage points (p <0.01) for those without a college degree compared with no sta- tistically significant change for those with a col- lege degree (exhibit 4). (Results by socioeco- nomic status, including comparisons to means at age sixty-four, are in the appendix.)" Afford- ability measures for people without a college. degree improved more than for those with a de- gree. Those without a college degree saw a larger decline upon becoming eligible for Medicare in not getting medical care (-2.7 percentage points) or delaying medical care because of the cost (-3.9 percentage points) than those with a degree (-1.3 and -1.7 percentage points, respec- tively). By race and ethnicity, people identifying as Hispanic and non-Hispanic White appeared to gain more from Medicare eligibility than people identifying as non-Hispanic Black. For example, the changes in those without a usual source of care upon reaching the Medicare eligibility age were -2.4 and -5.5 percentage points (p <0.05 for both) for non-Hispanic Whites and His- panics, respectively, compared with no statisti- cally significant change for non-Hispanic Blacks (p>0.10). Improvement in the percentages saying that care was unaffordable also appeared to accrue to non-Hispanic Whites and Hispanics more so than to non-Hispanic Blacks. The percentage of people saying care was delayed because of the cost declined by 3.4 percentage points both for non-Hispanic Whites and for Hispanics (p <0.01 for both) compared with a decline of 1.7 percentage points (p <0.10) for non-Hispan- ic Blacks. Similarly, there were significant de- clines for both non-Hispanic Whites and His- panics in the percentage saying that they could not afford dental or follow-up care, whereas the EXHIBIT 4 Percentage-point changes in adjusted measures of access to and affordability of care before and after attainment of Medicare eligibility age, by educational attainment and race/ethnicity, 2008-18 Access and affordability measures ACCESS TO CARE No usual source of care No check-up in last year Doctor does not accept new patients Doctor does not accept insurance Could not get appointment soon enough Wait too long for appointment Trouble finding doctor Unable to get necessary care Not easy to get needed care AFFORDABILITY OF CARE Medical care needed not gotten because of cost Medical care needed but delayed because of cost Could not afford dental care Could not afford prescription drugs Could not afford specialist care Could not afford follow-up care Unable or delayed necessary care because of cost changes for non-Hispanic Blacks were not statis- tically significant. Appendix exhibit 3 shows that increases in insurance coverage were large for Hispanics (28.5 percentage points) and non-Hispanic Blacks (17.1 percentage points) compared with non-Hispanic Whites (13.1 percentage points)." (Source of coverage also differed by race, with 15.2 percent of non-Hispanic Blacks enrolled in Medicaid at age sixty-four versus 5.1 percent for non-Hispanic Whites.) 5 No college degree Discussion In this article I use potential discontinuities at age sixty-five to identify the impact of near- universal Medicare eligibility on a wide range of access and affordability measures, finding that many of these measures improved after at tainment of the Medicare eligibility age. In some cases, access and affordability improved for a substantial portion of those age sixty-four who reported access issues: The number reporting that they were unable to get necessary care fell by 1.5 percentage points (50.9 percent), and the number saying that they needed medical care but could not get it because of the cost fell by 2.9 percentage points (46.0 percent). Supplemental analyses showed that the esti- mates were not different before versus after ACA -1.9 -3.9*** -0.3 -0.8 0.5 0.3 -0.5 -1.8 -2.1** -2.7 -3.9**** -18** -0.5 -2.2*** -1.8*** -0.9*** College degree 21 0.0 0.4 0.6 0.5 -0.4 -0.8 -2.8 -1.3**** -1.7*** -1.0 0.3 -1.1" -1.0 White, non- Hispanic -2.4** -2.0 -0.1 -03 0.5 0.5 -0.4 -1.5 -27 -2.4**** -3.4**** -1.6*** 0.0 -1.8 -1.7 -0.8**** Black, non- Hispanic -2.0 -25 0.0 -0.7 0.4 0.9 -0.7 -15* 1.1 -0.8 -1.7* 12 -07 -1.6 0.8 -0.6 Sounce Author's analysis of data for 2008-17 from the Medical Expenditure Panel Survey-Household Component and for 2008-18 from the National Health Interview Survey. WOTEs Sample included people ages 57-64 and ages 66-72. People age 65 were excluded because most questions had a one-year look-back period. Adjusted differences were estimated from regression discontinuity models that included different linear controls for age before and after age 65, the survey year, and whether the person was working. *p <010 *p <005 ***p <001 ***p <0.001 implementation. Although more continuity in access and affordability around the threshold of age sixty-five might be expected after 2014, several results nevertheless showed meaningful improvements when Medicare eligibility was reached in the post-2014 period. Medicare ap- pears to be playing a continuing role in improv- ing access to care and affordability even after the coverage expansions under the ACA. Results from both MEPS-HC and the NHIS were quite consistent. One apparent exception was smaller changes in whether respondents were unable to get (or delayed getting) necessary care because of the cost (MEPS-HC) compared with those needing medical care but not getting it because they could not afford it (NHIS). How- ever, the MEPS-HC results are based on follow- up questions administered only to those who reported having an access problem, whereas the NHIS asked all adult respondents about affordability as a barrier. The broader scope of the NHIS question and the alternative choices presented to MEPS-HC respondents explain the lower prevalence of the outcomes in the MEPS- HC data. Hispanic -5.5m -0.5 -0.9 -0.5 22 -0.6 Previous efforts to assess access and afford- ability for Medicare beneficiaries either did not carefully control for differing population characteristics or considered only a limited set of measures. The only previous study to control -1.7 -22 -3.4 -3.1 -34 -5.0 -3.1 -26 -3.1* -1.3*** for population characteristics used data for 1997-2003 that predated major, recent changes to health care." That study showed a reduction in those saying that they delayed care (25.0 per cent) or could not get care (26.5 percent) be cause of the cost. The comparable reductions in this study were 45.3 percent and 46.0 percent, respectively. Since 2003, the growth in health care spending and the reductions in the gener- osity of private health insurance may help ex- plain the larger improvements found in this study. This study found no evidence of deteriorating access or affordability at the Medicare eligibility age. In particular, because Medicare payment rates are often below those set by private payers, it would not be surprising to have found a wors- ening of access on measures dealing with wheth- er doctors accepted Medicare as insurance, whether respondents had trouble finding a doc- tor, or whether waiting times were too long. None of the provider-side access measures stud- ied in this article showed any decline in access to providers after beneficiaries became Medicare eligible, either overall or for any of the studied subgroups. More broadly, because health needs increase with age, one could reasonably expect deteriorating access to care over the life cycle because there are more opportunities to experi- ence interruptions in or impediments to seeing providers. Similarly, because many seniors expe- rience reductions in income, it is conceivable that health care would be viewed as less afford- able with age. The findings in this article suggest access and affordability improvements after age sixty-five, hinting at the potentially large effect of Medicare in improving these measures at an age when the demand for care increases and the abil ity to pay for care falls. Access to care improved slightly more for peo- ple without a college degree compared with those with a degree, and affordability measures showed stronger improvements for non-Hispan- ic Whites and Hispanics compared with non- Hispanic Blacks. Improvements in access to care for people without a college degree are likely linked to their larger increases in coverage after becoming Medicare eligible, as well as to possi- bly less generous or less comprehensive cover- age beforehand. When looked at by race and ethnicity, the smaller improvements on afford- ability measures for non-Hispanic Blacks com- pared with non-Hispanic Whites may be a reflec- tion of their higher pre-sixty-five enrollment in Medicaid, which requires minimal cost sharing and thus allows less room for improvement when one enrolls in Medicare. Compared with other groups, the improvements in affordability for Hispanics are consistent with the large in- crease in coverage at age sixty-five. Some people may forgo care in expectation of becoming eligible for Medicare. However, some of the key results in this study were for measures assessing the difficulty of obtaining care that was deemed necessary or needed, which, at least in the respondents' own estimation, is not easily delayed. Moreover, in the two years before at- tainment of age sixty-five there were no sudden discontinuities in the outcomes suggesting worsening of access at ages sixty-three or six- ty-four (exhibits 1 and 2), which would be pres- ent if people were stinting on care just before turning sixty-five. All of these results compare access and afford- ability measures for the near-elderly population with those for the elderly. However, compared with younger populations, a higher proportion of the near-elderly are covered by private insur- ance, and a smaller share are uninsured. The near-elderly also have greater health needs than middle-aged people. These attributes may influ- ence whether and how the effects presented here may generalize outside of the samples used in this analysis. The relatively high needs of the near-elderly may have contributed in ways that would not generalize to younger cohorts. Medicare is a program with both public fee-for- service and private managed care (Medicare Ad- vantage) elements, and upon turning age sixty- five, people can choose one of these plans. Some of the estimates presented here may have been a result of people who enrolled in one segment rather than the other, although these effects are not easily disentangled. For instance, the modest decline in problems affording dental cov- erage may be a result of people enrolling in Medi- care Advantage plans with dental coverage, which is not covered in the traditional Medicare benefit package. Medicare has provided coverage to elderly US residents for more than five decades. The broad- based program now covers more than 60 million people, the majority of whom have chronic con- ditions and some of whom are disabled, institu- tionalized, or both. Understanding access and affordability issues is of paramount importance in a health system that is commonly described as fragmented and inequitable. The size and needs of the Medicare population underscore the par- ticular importance of studying people's access to providers and their perceptions of affordability in this setting. For many years now, policy makers have been engaged in a debate about whether to change the age of eligibility for Medicare or more generally expand Medicare coverage. Among the issues is how a newly expanded Medicare might affect access and affordability for prospective enroll- ees. Although answers to those questions are inherently uncertain and require considerations of the supply side of health care, a first step toward understanding lies in a rigorous assess ment of Medicare's impact on the care received and the ability to pay for care for its current enrollees. This analysis showed a substantial im- pact of Medicare in terms of improving both access to care and affordability of care across a range of measures. The results suggest that Medicare expansions can have positive benefits for enrollees compared with their insurance sta- tus before turning age sixty-five without any ob- The author appreciates the helpful comments from Thomas Selden, Sandra Decker, and Joel Cohen from the Agency servable disadvantages. Given the methods used in this study, the likelihood that these benefits would accrue to new enrollees is dependent on the nature of the Medicare expansion. This study has direct relevance for proposals that would incrementally lower the age of eligibility for Medicare. Although more substantial expan- sions of coverage could have similar benefits, the uncertainty surrounding how those expan- sions might change the entire health system grows as the size of the proposed expansion in- creases. for Healthcare Research and Quality (AHRQ). The views expressed in this article are those of the author, and no official endorsement by the Department of Health and Human Services or AHRQ is intended or should be inferred. Answer the following questions based on the reading "The impact of Medicare on Access to And Affordability of Health Care". All the questions can be answered with the information available in the reading in combination with lecture material. 1- According to this reading, is this statement true or false? [0.5 point] When a person is insured (i.e., has health insurance), this means this person has no accessibility issues regarding healthcare anymore. Explain. 2- From a policy perspective, why does the author think that is it important to look at the impact of Medicare on accessibility to healthcare and affordable coverage? [1 point] 3- Are comparisons between Medicare recipient's accessibility and accessibility of the privately insured an accurate approach to use to address the research question of this paper? [Hint: Think of counterfactuals and what is being compared] [1 point] 4- How does the author propose to solve the issue raised in Question 3? Do you think the proposed solution is a good approach regarding how to look at the causal impact of Medicare? Explain. [1 point] 5- In the solution proposed in Q4 what is the author exactly testing? (You can think of the causal effect to answer the question)? [0.5 point] By Paul D. Jacobs The Impact Of Medicare On Access To And Affordability Of Health Care ABSTRACT Medicare pays for roughly one in four physician visits in the United States, yet a rigorous understanding of how Medicare currently affects access to and affordability of care for its enrollees is unavailable. Using data from the Medical Expenditure Panel Survey-Household Component and the National Health Interview Survey, I tested for changes in access to care and affordability around age sixty-five, when most people gain eligibility for Medicare. I found that Medicare eligibility is associated with a 1.5-percentage-point reduction in reports of being unable to get necessary care (a 50.9 percent reduction compared with the percentage at age sixty-four) and a 4.1-percentage-point (45.3 percent) reduction in not being able to get needed care because of the cost. Recently, policy makers have proposed various ways of extending Medicare coverage. These results suggest that incremental Medicare expansions could have positive access and affordability benefits for enrollees compared with the insurance options available to them before they turn sixty-five. T he Medicare program pays for roughly one of every four physician visits in the United States, and in 2019 it covered roughly 60 million people. The program has also long enjoyed favorable public opinion among both seniors and the nonelderly. Yet although its scope is broad and opinion among beneficia ries is favorable, a rigorous understanding of how Medicare currently affects access to health care for its enrollees is not available. The greater health needs and lower income of its primarily elderly and disabled population, as well as the high cost of health care, underscore the impor- tance of assessing how Medicare beneficiaries perceive the affordability of their care. Perhaps as a result of the program's populari- ty, policy makers have proposed extending Medicare coverage by incrementally reducing the age of eligibility, offering a "buy-in" option, or offering Medicare to a wider swath of the American public, possibly by expanding cover- age to the entire US population. Alternatively, as a means of reducing federal obligations for health spending, some have proposed increasing the age of eligibility for Medicare. As a conse- quence, a more thorough understanding of the impacts of Medicare on health care access and affordability is important for evaluating the vari- ous proposals for changing who is covered under the program. Medicare can influence access to care or per- ceptions of affordability through a variety of channels. Medicare covers a different set of ser- vices than private insurance, and in the case of routine dental care, for example, the traditional Medicare fee-for-service program does not pro- vide any coverage. As a result, people who newly enroll in Medicare may experience access or affordability issues for dental or other non- covered services. Alternatively, the increasing prevalence of high-deductible health plans and other increases in cost sharing among private plans could increase the perceived affordability of Medicare. For people with limited or no health coverage before age sixty-five, access to care and perceived affordability may well improve on en- rolling in Medicare. Understanding access and affordability issues is critical for Medicare's high-need and low- income population, yet a gap exists in what we know about Medicare's current role in providing accessible care and affordable coverage. Re- search broadly shows that access to care not only is an outcome of whether someone has coverage but also depends on their type of health insur- ance. And although research consistently sug- gests that Medicare provides roughly compara- ble access compared with private insurance, previous efforts have generally relied on simple comparisons between people with different types of insurance. For instance, Medicare ben- eficiaries report that their access to care is com- parable to or better than that of people with private insurance," beneficiaries are able to find a new doctor without a problem,' and physicians accept new beneficiaries at roughly the same rate as they do patients with private insurance." How- ever, a fundamental shortcoming with this line of inquiry is that the populations being com- pared are inherently different. More rigorous analyses of Medicare have been conducted assessing discontinuities using the age of eligibility. These studies have documented changes in mortality at age sixty-five as well as changes in the receipt of care, including mam- mography and rehabilitation. Only one study to date has rigorously assessed changes in ac- cess-to-care measures for Medicare enrollees.2 However, these authors studied only two access measures (whether people delayed care or did not get care because of cost in the past year) and used data that are now nearly two decades old. In this study I used more recent data and a regression discontinuity design to test for changes in multiple measures of access and affordability just before and just after the attain- ment of age sixty-five, when most people gain Medicare eligibility. This design exploited the fact that only a small share of the near-elderly US population is enrolled in Medicare and a large majority of people obtain Medicare as their primary source of coverage at age sixty-five. Study Data And Methods POPULATION I examined measures of access to and affordability of care using data from both the 2008-17 Medical Expenditure Panel Survey- Household Component (MEPS-HC) and the 2008-18 National Health Interview Survey (NHIS). The primary sample was limited to respondents ages 57-72, excluding people age 65 at the time of the interview because survey questions on access to care and affordability typ- ically cover the previous twelve months. ACCESS OUTCOMES Using MEPS-HC data, I as- sessed the percentage-point change at age sixty- five in whether people had a usual source of care, had a routine checkup in the past year, delayed getting necessary medical care in the past year, and were unable to get necessary care in the past year. Using data from the NHIS Sample Adult file, I examined changes in the following re- ported experiences (all in the past twelve months): people were told by a doctor's office that they would not accept the person as a new patient, they were told by a doctor's office that they did not accept the person's health coverage, they could not get an appointment soon enough, they waited too long in the doctor's office, and they had trouble finding a doctor who would see them. AFFORDABILITY OUTCOMES To assess percep- tions of affordability, I examined whether people were unable to get or delayed getting necessary medical care because of the cost in the past twelve months (MEPS-HC) and questions asking whether people did not get care in the past twelve months because they could not afford it for five types of care (NHIS Sample Adult file): general medical care, prescription medicines, dental care, specialist care, and follow-up." COVERAGE In supplemental analyses I used MEPS-HC data to assess changes at age sixty-five in whether people had any health insurance cov- erage at the time of the survey (see the online appendix)." ANALYSIS Results were expressed as percent- age-point differences in those reporting issues accessing or affording care before and after the age of Medicare eligibility. In addition, to show the relative importance of these changes, results were calculated as the percentage change in the outcomes compared with means for the sixty- four-year-old population in my sample. I also calculated results by educational attainment and race/ethnicity. Results were also calculated for survey years before and after the implemen- tation of the Affordable Care Act (ACA) to test whether increases in insurance coverage for the nonelderly population minimized potential changes arising from newly obtaining coverage at the threshold of age sixty-five. Using a regression discontinuity design, I test- ed for discontinuous changes in measures of ac- cess to care and affordability of coverage before and after reaching age sixty-five. This design ex- ploited the fact that only 6-11 percent of the near- elderly US population (ages 57-64) are enrolled in Medicare, whereas 81 percent are enrolled in Medicare as their primary source of coverage upon turning age 65." A number of previous studies have used the age of Medicare eligibility to assess the program's impact on health, health spending, and care-related outcomes. Because people cannot control their age or the age cutoff for Medicare, differences in outcomes at the eli- gibility age can be attributed to the effects of the program and not underlying differences in the groups being compared. 10.12.17 Adjusted results were derived from ordinary least squares regressions with different linear age trends before and after age sixty-five. Regres- sions controlled for the survey year and whether the person was working. The sensitivity of the results to using quadratic age trends is in the appendix." All regressions used MEPS-HC and NHIS sampling weights, and standard errors were adjusted for clustering by year of age. Re- sults with standard errors adjusted for complex survey design were not appreciably different. LIMITATIONS A concern with this analysis may be that people retire at age sixty-five because of eligibility for Medicare, and changes in work status could influence the outcomes. However, the full retirement age for Social Security eligi- bility has increased over time. This change, cou- pled with reduced availability of employer- provided pensions and higher educational attainment of older workers, appears to have increased labor-force participation among older workers and led to relatively stable participation around age sixty-five." As a precaution, all mod- els controlled for whether the person was work- ing. In addition, in supplemental analyses I con- firmed that both working status and Medicaid EXHIBIT 1 coverage did not show significant discontinu- ities at age sixty-five (see the appendix)." Anoth- er concern is that regression discontinuity esti- mates could be sensitive to the age range used to form the sample. In the appendix I show that key results are not sensitive to different ranges." I 57 58 59 60 61 Study Results UNADJUSTED RESULTS Unadjusted, the percent- age of people in the US ages 57-72 who did not have a usual source of health care declined with age during the sample period (exhibit 1). Exhib- it 1 suggests a consistent decline in the percent- age without a usual source of care by age from about 15.0 percent at age fifty-seven to 6.3 per- cent at age seventy-two. The break in the two lines suggests an abrupt change in those report- ing no usual source of care from 11.9 percent at age sixty-four to 8.9 percent at age sixty-five and 7.9 percent at age sixty-six. Based on the trend for all ages in the sample, we would expect a 1.2- percentage-point decline from age sixty-four to age sixty-six. Instead, the percentage without a usual source of care fell 4.0 percentage points (from 11.9 to 7.9 percent). Unadjusted NHIS data show that 6.3 percent of respondents age sixty-four reported problems obtaining needed medical care because of its cost, compared with 3.7 percent for those age sixty-six (exhibit 2). Based on the trend, afford- ability as a barrier to care would be expected to decline 0.8 percentage points from age sixty-four to age sixty-six; the actual decline of 2.6 percent- age points was more than threefold larger. ACCESS TO CARE AND COVERAGE Sample respondents were 2.6 percentage points less Percent of people in the US without a usual source of care, by age, 2008-17 16% - 14% - 12% - 10% - 8% - 6% - 4% - 2% - 0%- 65 Age (years) 66 67 69 70 71 72 Sounce Author's analysis of data for 2008-17 from the Medical Expenditure Panel Survey-Household Component. NOTES Lines are derived from a regression allowing different linear trends for age before and after age sixty-five. Sample included people ages 57-72. EXHIBIT 2 Percent of people in the US who needed but did not get medical care in the past year because they could not afford it, by age, 2008-18 9%- 8% - 7% - 6%- 5%- 4%- 3%- 2%- 1%- 0%- 1 57 58 59 EXHIBIT 3 60 61 Sounce Author's analysis of data for 2008-18 from the National Health Interview Survey NOTES Lines are derived from a regression allowing different linear trends for age before and after age sixty-five. Sample included people ages 57-72. likely to lack a usual source of care after becom- ing Medicare eligible (p=0.002) compared with younger respondents (exhibit 3). At age sixty- six, respondents were also less likely to be unable I 62 63 Access and affordability measures ACCESS TO CARE No usual source of care No check-up in past year 6 65 Age (years) Doctor does not accept new patients Doctor does not accept insurance Unadjusted and adjusted measures of access to and affordability of care before and after reaching Medicare eligibility age, 2008-18 Unadjusted Adjusted Difference (percentage Difference points) (96) Could not get appointment soon enough Wait too long for appointment Trouble finding doctor Unable to get necessary care Not easy to get needed care AFFORDABILITY OF CARE Medical care needed, not gotten because of cost Medical care needed, delayed because of cast Could not afford dental care Could not afford prescription drugs Could not afford specialist care Could not afford follow-up care Unable to get or delayed necessary care because of cost I I I 66 67 68 69 70 71 72 to get necessary care (1.5 percentage points; p <0.001) and less likely to not find it easy to get needed care (2.3 percentage points; p <0.001). Across the access measures, percent- Source NHIS NHIS NHIS NHIS NHIS MEPS-HC 11.9 MEPS-HC 27.3 Age 64 (%) NHIS NHIS NHIS NHIS NHIS NHIS MEPS-HC 2.7 3.8 5.7 4.1 2.7 MEPS-HC 3.0 MEPS-HC 6.7 6.3 9.1 11.1 6.7 10 m- 16 43= ANMO 42 3.3 1.0 Age 66 7.9 24.3 22 3.1 6.1 4.4 25 1.5 3.6 556 3.7 5.5 9.5 5.8 24 21 0.2 Difference (percentage points) -40 -3.0 -0.5 -0.7 0.4 0.3 -02 -15 -3.1 -2.6 -3.6 -1.7 -09 -18 -12 -0.7 -26 -1.9 0.1 -0.3 0.5 0.5 -0.5 -1.5*** -23 -29 -1.4" -0.5 -21 -1.7*** -0.7*** -22.1 -6.8 22 -8.8 8.0 13.4 -16.8 -50.9 -34.7 -46.0 -45.3 -128 -7.4 -50.9 -51.8 -75.4 age-point reductions ranged from 1 to 3 perdut This study found no age but represented fairly sizable tions in the percentage of people with an access evidence of issue. There was a 22.1 percent (2.6-percentage- point) reduction in people without a usual deteriorating access source of care after age sixty-five and a 50.9 per- cent (1.5-percentage-point) reduction in those or affordability at the saying they were to necessary care. As shown in the appendix, the results were very similar when I included those age sixty-five." Medicare eligibility age. As displayed in appendix exhibit 3, there was a 14.9-percentage-point increase in having any source of health insurance coverage at the Medi- care eligibility age." AFFORDABILITY From the NHIS data, the Medi- care eligibility age was associated with a 2.9- percentage-point reduction in those who said they could not get care because of cost and a 4.1-percentage-point reduction in those saying they delayed care because of the cost (exhibit 3). By type of care, there were significant reduc- tions in the percentage saying they could not afford dental care (1.4 percentage points; p=0.027), specialist care (2.1 percentage points; p <0.001), and follow-up care (1.7 per centage points; p <0.001). From the MEPS-HC data, the percentage saying they were unable to get or were delayed in getting necessary care because of the cost fell 0.7 percentage points (p <0.001) at age sixty-six. Reductions in afford- ability issues represented fairly large effects when expressed as a percentage of those with problems before reaching age sixty-five. Com- pared with people age sixty-four, 46.0 percent fewer (2.9 percentage points) people age sixty- six said they could not get care because of the cost and the number of people saying they could not afford follow-up care fell by 51.8 percent (1.7 percentage points). BEFORE AND AFTER ACA IMPLEMENTATION As displayed in appendix exhibit 1, the percentage change in having a usual source of care was iden- tical when limiting the sample to the years before or after the 2014 implementation of the ACA (-2.6 percentage points)." Estimates for all changes in access and affordability were not sta- tistically different before and after ACA imple- mentation. Access and affordability improved upon the attainment of Medicare eligibility after ACA implementation, including reductions in those without a checkup in the last year and in not getting needed medical care because of cost. Appendix exhibit 3 suggests that although the increase in insurance coverage at the age of Medicare eligibility was larger before 2014 (17.5 percentage points), there was nevertheless a substantial increase after ACA implementation (11.7 percentage points)." SOCIOECONOMIC STATUS Several access mea- sures improved more for people without a col- lege degree than for those with a college degree, whereas other changes were statistically indis- tinguishal The percentage without a check-up fell by 3.9 percentage points (p <0.01) for those without a college degree compared with no sta- tistically significant change for those with a col- lege degree (exhibit 4). (Results by socioeco- nomic status, including comparisons to means at age sixty-four, are in the appendix.)" Afford- ability measures for people without a college. degree improved more than for those with a de- gree. Those without a college degree saw a larger decline upon becoming eligible for Medicare in not getting medical care (-2.7 percentage points) or delaying medical care because of the cost (-3.9 percentage points) than those with a degree (-1.3 and -1.7 percentage points, respec- tively). By race and ethnicity, people identifying as Hispanic and non-Hispanic White appeared to gain more from Medicare eligibility than people identifying as non-Hispanic Black. For example, the changes in those without a usual source of care upon reaching the Medicare eligibility age were -2.4 and -5.5 percentage points (p <0.05 for both) for non-Hispanic Whites and His- panics, respectively, compared with no statisti- cally significant change for non-Hispanic Blacks (p>0.10). Improvement in the percentages saying that care was unaffordable also appeared to accrue to non-Hispanic Whites and Hispanics more so than to non-Hispanic Blacks. The percentage of people saying care was delayed because of the cost declined by 3.4 percentage points both for non-Hispanic Whites and for Hispanics (p <0.01 for both) compared with a decline of 1.7 percentage points (p <0.10) for non-Hispan- ic Blacks. Similarly, there were significant de- clines for both non-Hispanic Whites and His- panics in the percentage saying that they could not afford dental or follow-up care, whereas the EXHIBIT 4 Percentage-point changes in adjusted measures of access to and affordability of care before and after attainment of Medicare eligibility age, by educational attainment and race/ethnicity, 2008-18 Access and affordability measures ACCESS TO CARE No usual source of care No check-up in last year Doctor does not accept new patients Doctor does not accept insurance Could not get appointment soon enough Wait too long for appointment Trouble finding doctor Unable to get necessary care Not easy to get needed care AFFORDABILITY OF CARE Medical care needed not gotten because of cost Medical care needed but delayed because of cost Could not afford dental care Could not afford prescription drugs Could not afford specialist care Could not afford follow-up care Unable or delayed necessary care because of cost changes for non-Hispanic Blacks were not statis- tically significant. Appendix exhibit 3 shows that increases in insurance coverage were large for Hispanics (28.5 percentage points) and non-Hispanic Blacks (17.1 percentage points) compared with non-Hispanic Whites (13.1 percentage points)." (Source of coverage also differed by race, with 15.2 percent of non-Hispanic Blacks enrolled in Medicaid at age sixty-four versus 5.1 percent for non-Hispanic Whites.) 5 No college degree Discussion In this article I use potential discontinuities at age sixty-five to identify the impact of near- universal Medicare eligibility on a wide range of access and affordability measures, finding that many of these measures improved after at tainment of the Medicare eligibility age. In some cases, access and affordability improved for a substantial portion of those age sixty-four who reported access issues: The number reporting that they were unable to get necessary care fell by 1.5 percentage points (50.9 percent), and the number saying that they needed medical care but could not get it because of the cost fell by 2.9 percentage points (46.0 percent). Supplemental analyses showed that the esti- mates were not different before versus after ACA -1.9 -3.9*** -0.3 -0.8 0.5 0.3 -0.5 -1.8 -2.1** -2.7 -3.9**** -18** -0.5 -2.2*** -1.8*** -0.9*** College degree 21 0.0 0.4 0.6 0.5 -0.4 -0.8 -2.8 -1.3**** -1.7*** -1.0 0.3 -1.1" -1.0 White, non- Hispanic -2.4** -2.0 -0.1 -03 0.5 0.5 -0.4 -1.5 -27 -2.4**** -3.4**** -1.6*** 0.0 -1.8 -1.7 -0.8**** Black, non- Hispanic -2.0 -25 0.0 -0.7 0.4 0.9 -0.7 -15* 1.1 -0.8 -1.7* 12 -07 -1.6 0.8 -0.6 Sounce Author's analysis of data for 2008-17 from the Medical Expenditure Panel Survey-Household Component and for 2008-18 from the National Health Interview Survey. WOTEs Sample included people ages 57-64 and ages 66-72. People age 65 were excluded because most questions had a one-year look-back period. Adjusted differences were estimated from regression discontinuity models that included different linear controls for age before and after age 65, the survey year, and whether the person was working. *p <010 *p <005 ***p <001 ***p <0.001 implementation. Although more continuity in access and affordability around the threshold of age sixty-five might be expected after 2014, several results nevertheless showed meaningful improvements when Medicare eligibility was reached in the post-2014 period. Medicare ap- pears to be playing a continuing role in improv- ing access to care and affordability even after the coverage expansions under the ACA. Results from both MEPS-HC and the NHIS were quite consistent. One apparent exception was smaller changes in whether respondents were unable to get (or delayed getting) necessary care because of the cost (MEPS-HC) compared with those needing medical care but not getting it because they could not afford it (NHIS). How- ever, the MEPS-HC results are based on follow- up questions administered only to those who reported having an access problem, whereas the NHIS asked all adult respondents about affordability as a barrier. The broader scope of the NHIS question and the alternative choices presented to MEPS-HC respondents explain the lower prevalence of the outcomes in the MEPS- HC data. Hispanic -5.5m -0.5 -0.9 -0.5 22 -0.6 Previous efforts to assess access and afford- ability for Medicare beneficiaries either did not carefully control for differing population characteristics or considered only a limited set of measures. The only previous study to control -1.7 -22 -3.4 -3.1 -34 -5.0 -3.1 -26 -3.1* -1.3*** for population characteristics used data for 1997-2003 that predated major, recent changes to health care." That study showed a reduction in those saying that they delayed care (25.0 per cent) or could not get care (26.5 percent) be cause of the cost. The comparable reductions in this study were 45.3 percent and 46.0 percent, respectively. Since 2003, the growth in health care spending and the reductions in the gener- osity of private health insurance may help ex- plain the larger improvements found in this study. This study found no evidence of deteriorating access or affordability at the Medicare eligibility age. In particular, because Medicare payment rates are often below those set by private payers, it would not be surprising to have found a wors- ening of access on measures dealing with wheth- er doctors accepted Medicare as insurance, whether respondents had trouble finding a doc- tor, or whether waiting times were too long. None of the provider-side access measures stud- ied in this article showed any decline in access to providers after beneficiaries became Medicare eligible, either overall or for any of the studied subgroups. More broadly, because health needs increase with age, one could reasonably expect deteriorating access to care over the life cycle because there are more opportunities to experi- ence interruptions in or impediments to seeing providers. Similarly, because many seniors expe- rience reductions in income, it is conceivable that health care would be viewed as less afford- able with age. The findings in this article suggest access and affordability improvements after age sixty-five, hinting at the potentially large effect of Medicare in improving these measures at an age when the demand for care increases and the abil ity to pay for care falls. Access to care improved slightly more for peo- ple without a college degree compared with those with a degree, and affordability measures showed stronger improvements for non-Hispan- ic Whites and Hispanics compared with non- Hispanic Blacks. Improvements in access to care for people without a college degree are likely linked to their larger increases in coverage after becoming Medicare eligible, as well as to possi- bly less generous or less comprehensive cover- age beforehand. When looked at by race and ethnicity, the smaller improvements on afford- ability measures for non-Hispanic Blacks com- pared with non-Hispanic Whites may be a reflec- tion of their higher pre-sixty-five enrollment in Medicaid, which requires minimal cost sharing and thus allows less room for improvement when one enrolls in Medicare. Compared with other groups, the improvements in affordability for Hispanics are consistent with the large in- crease in coverage at age sixty-five. Some people may forgo care in expectation of becoming eligible for Medicare. However, some of the key results in this study were for measures assessing the difficulty of obtaining care that was deemed necessary or needed, which, at least in the respondents' own estimation, is not easily delayed. Moreover, in the two years before at- tainment of age sixty-five there were no sudden discontinuities in the outcomes suggesting worsening of access at ages sixty-three or six- ty-four (exhibits 1 and 2), which would be pres- ent if people were stinting on care just before turning sixty-five. All of these results compare access and afford- ability measures for the near-elderly population with those for the elderly. However, compared with younger populations, a higher proportion of the near-elderly are covered by private insur- ance, and a smaller share are uninsured. The near-elderly also have greater health needs than middle-aged people. These attributes may influ- ence whether and how the effects presented here may generalize outside of the samples used in this analysis. The relatively high needs of the near-elderly may have contributed in ways that would not generalize to younger cohorts. Medicare is a program with both public fee-for- service and private managed care (Medicare Ad- vantage) elements, and upon turning age sixty- five, people can choose one of these plans. Some of the estimates presented here may have been a result of people who enrolled in one segment rather than the other, although these effects are not easily disentangled. For instance, the modest decline in problems affording dental cov- erage may be a result of people enrolling in Medi- care Advantage plans with dental coverage, which is not covered in the traditional Medicare benefit package. Medicare has provided coverage to elderly US residents for more than five decades. The broad- based program now covers more than 60 million people, the majority of whom have chronic con- ditions and some of whom are disabled, institu- tionalized, or both. Understanding access and affordability issues is of paramount importance in a health system that is commonly described as fragmented and inequitable. The size and needs of the Medicare population underscore the par- ticular importance of studying people's access to providers and their perceptions of affordability in this setting. For many years now, policy makers have been engaged in a debate about whether to change the age of eligibility for Medicare or more generally expand Medicare coverage. Among the issues is how a newly expanded Medicare might affect access and affordability for prospective enroll- ees. Although answers to those questions are inherently uncertain and require considerations of the supply side of health care, a first step toward understanding lies in a rigorous assess ment of Medicare's impact on the care received and the ability to pay for care for its current enrollees. This analysis showed a substantial im- pact of Medicare in terms of improving both access to care and affordability of care across a range of measures. The results suggest that Medicare expansions can have positive benefits for enrollees compared with their insurance sta- tus before turning age sixty-five without any ob- The author appreciates the helpful comments from Thomas Selden, Sandra Decker, and Joel Cohen from the Agency servable disadvantages. Given the methods used in this study, the likelihood that these benefits would accrue to new enrollees is dependent on the nature of the Medicare expansion. This study has direct relevance for proposals that would incrementally lower the age of eligibility for Medicare. Although more substantial expan- sions of coverage could have similar benefits, the uncertainty surrounding how those expan- sions might change the entire health system grows as the size of the proposed expansion in- creases. for Healthcare Research and Quality (AHRQ). The views expressed in this article are those of the author, and no official endorsement by the Department of Health and Human Services or AHRQ is intended or should be inferred.
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