Medicare Beneficiaries Under 65 Without Supplemental Coverage Face Significant Care Barriers

• Medicare beneficiaries younger than 65 years without supplemental coverage experience higher rates of cost-related medication nonadherence and delayed care compared to those with additional protection.
• Enrollment in Medicare Advantage or traditional Medicare with supplemental coverage was associated with better access to care for non-dual-eligible beneficiaries under 65.
• Dual-eligible beneficiaries (those with both Medicare and Medicaid) reported minimal differences in financial and access barriers regardless of their Medicare coverage type.

A recent study published in the American Journal of Managed Care reveals that Medicare beneficiaries under age 65 who lack supplemental coverage face significant barriers to accessing healthcare, highlighting important disparities within this vulnerable population.

The research, led by Emma Achola-Kothari, PhD, and colleagues at Vanderbilt University School of Medicine, examined how different Medicare coverage types affect reported barriers to care among beneficiaries aged 50-64 years who qualify for Medicare due to long-term disabilities or specific conditions like end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).

Financial and Access Barriers Vary by Coverage Type

Using data from the Health and Retirement Study spanning 2012-2020, researchers analyzed self-reported outcomes from 3,249 Medicare beneficiaries under 65 years old. The study compared experiences across different coverage types, including traditional Medicare (TM) without supplemental coverage, TM with supplemental coverage, and Medicare Advantage (MA).

For non-dual-eligible beneficiaries (those without Medicaid), the findings were striking. Those enrolled in traditional Medicare without supplemental coverage reported significantly higher rates of:

• Cost-related medication nonadherence (30.2%)
• Delayed care due to costs (24.2%)
• No usual source of care (18.2%)
• Trouble finding a doctor (7.7%)

In contrast, beneficiaries with TM plus supplemental coverage experienced a 7.5 percentage point reduction in cost-related medication nonadherence and a 9.8 percentage point reduction in delayed care due to costs compared to those without supplemental coverage.

"Enrollment in Medicare coverage without out-of-pocket protections was associated with a higher likelihood of reporting cost and access barriers to care for beneficiaries aged 50 to 64 years," the researchers noted.

Medicare Advantage Shows Mixed Results

Medicare Advantage enrollment was associated with some improvements for non-dual-eligible beneficiaries, including a 4.2 percentage point reduction in delayed care due to costs and a 5.2 percentage point reduction in having no usual source of care compared to traditional Medicare without supplemental coverage.

However, the study's sensitivity analysis revealed that dual-eligible beneficiaries who switched from traditional Medicare to Medicare Advantage were 5.1 percentage points more likely to report trouble finding a doctor, suggesting that MA networks may present access challenges for some beneficiaries.

Dual-Eligible Beneficiaries Face Different Challenges

For dual-eligible beneficiaries (those with both Medicare and Medicaid), the study found minimal differences in financial barriers between coverage types. This likely reflects the additional financial protections provided by Medicaid, which covers most out-of-pocket costs.

"Beneficiaries with Medicaid experienced minimal financial and access differences by coverage type," the researchers reported, though they noted that MA enrollees were less likely to report having no usual source of care compared to those in traditional Medicare.

A Vulnerable Population with Limited Options

The study highlights the unique challenges faced by Medicare beneficiaries under 65, who represent about 13.1% of the Medicare population but account for 17.8% of Medicare spending. These beneficiaries typically have complex medical needs, lower incomes, and face significant barriers to obtaining supplemental coverage.

Unlike older Medicare beneficiaries, those under 65 largely do not qualify for federal guaranteed issue protections for Medigap plans and can be denied coverage or charged prohibitively high premiums depending on state regulations.

"Our results highlight how important protections from high out-of-pocket costs are for beneficiaries who largely cannot work and generally have lower incomes relative to the older Medicare population," the researchers emphasized. In 2023, the median household income for beneficiaries under 65 was just $23,900, with approximately 25% living on annual incomes less than $15,000.

Policy Implications

The researchers suggest several policy approaches to address these disparities, including:

1. Extending community rating and guaranteed issue requirements for supplemental coverage to Medicare beneficiaries under 65 at the state or federal level
2. Reforming traditional Medicare's cost-sharing structure to reduce financial burden and lessen the need for supplemental coverage
3. Addressing potential network adequacy issues in Medicare Advantage plans, particularly for dual-eligible beneficiaries

"Our study findings highlight the need for continued focus on these beneficiaries' experiences within the Medicare program," concluded Achola-Kothari and colleagues.

The research underscores the importance of ensuring that all Medicare beneficiaries, regardless of age or disability status, have access to affordable, comprehensive healthcare coverage that meets their unique needs.