Uninsured near-seniors struggling with health access and costs

Washington Uninsured patients ages 55-64, who typically are not yet eligible for Medicare, are experiencing significant difficulties accessing and affording health care, according to a report from the Kaiser Family Foundation. Even for people of that age who have insurance, paying medical bills and obtaining needed care can pose a challenge.

More than 40% of uninsured adults in the “near-senior” age bracket reported having unmet medical needs or delaying care, and they cited cost barriers as the biggest factor, according to the study. The foundation based its conclusions on data from the 2010 Health Tracking Household Survey and earlier surveys by the Center for Studying Health System Change.

Almost a third of these aging patients without insurance said they had problems affording prescription drugs they needed. Three in 10 uninsured near-seniors lived in families reporting problems paying medical bills.

On average, uninsured 55- to 64-year-olds have lower incomes and are in poorer health than those with commercial insurance, and a disproportionate share of the uninsured are Hispanic adults. They also have lower average incomes than seniors on Medicare, “with a substantially higher portion living on incomes below 300% of poverty,” the study stated.

Wanda Filer, MD, a family physician who works in a large, federally qualified health center in York, Pa., said she sees these types of patients all the time. “These are people who have forgone care because they don’t know how they could pay for it, and they’ve come to a point where they come into trouble and need some help, or they’re people who have been discharged from other practices. In our area, it tends to be large medical group practices that are owned by health systems.”

The patients receive letters saying they’re being discharged because of inability to pay, “and they’re looking for a new primary care source, and they come to us because we’re a federally qualified health center,” said Dr. Filer, who serves on the board of directors of the American Academy of Family Physicians.

Dr. Filer said people in this age bracket may be uninsured for several reasons, including losing a job because of illness. “I don’t think it’s necessarily told to them that’s why they lost their jobs. & I’ve heard the story so many times, that because of their medical issues and deteriorating attendance and performance and need to be out to get care, they’re often let go.”

Other uninsured near-seniors are self-employed and put off seeking health care when they were younger and healthier, Dr. Filer said. That becomes more difficult once an individual gets older and costly medical needs begin to mount.

Richard Madden, MD, an AAFP board member in Belen, N.M., said he tries to work with uninsured patients in this age group by keeping in touch, handling issues by phone and setting up sliding-scale or nominal payments based on income, a process that is done through the health system to which he belongs.

“Some of these people are looking for jobs, so the hope is they’ll get something with insurance” that’s affordable, Dr. Madden said.

Aging seniors without insurance face particular difficulties getting comprehensive health insurance in the individual market because their age and health status can mean high, unaffordable premiums, the study said. The report’s authors suggested that these populations could benefit from insurance market changes in the Affordable Care Act, or through proposals such as raising the Medicare eligibility age to make the pre-Medicare pool bigger.

“This is exactly the target group” for the health insurance exchanges under the ACA, said J.B. Silvers, PhD, a professor of health care finance and professor of banking and finance at Case Western Reserve University in Cleveland. “After risk adjustment, the insurance companies can offer community rates and stay solvent. After subsidies, the pre-65 [age group] can afford it. Both win, and providers avoid bad debt.”

Medicare seniors appear to be faring somewhat better than the pre-65 populations. Access to care overall “has remained relatively unchanged over time for seniors on Medicare but has eroded for insured and uninsured adults,” the study stated. Medicare seniors reported problems accessing care at a significantly lower rate than uninsured near-seniors and at a similar rate to near-seniors with private insurance, after controlling for differences in demographics and health status.

The addition of a Medicare drug benefit in 2006 has “muted the effects of rising costs for prescription drugs for seniors between 2003 and 2010 relative to adults aged 55 to 64 with private insurance,” the study said. Nevertheless, problems paying medical bills have increased for Medicare seniors and insured adults in their late 50s and early 60s.

The portion of privately insured, aging adults who had trouble paying medical bills increased from 10% in 2003 to 15% in 2010, the study said. In addition, the share of Medicare seniors struggling to pay bills has grown from 7% to 10% during the same period. Medicare seniors who lacked supplemental coverage, had lower incomes or were African-American had more problems accessing and affording care than other Medicare seniors.