The Mortality Effects of Health Insurance for the Near-Elderly Uninsured Jose Escarce David Geffen School of Medicine at UCLA and RAND Coauthors: Daniel Polsky, Jalpa Doshi, Susan Paddock, Liyi Cen, Jeannette Rogowski, Willard Manning Funding Source: NIA (R01 AG )

Background 46 Million Uninsured in the U.S. –18% of total non-elderly population –14.5% of near-elderly population Benefits of health insurance well documented –Access to health care and use of health care services –Health and mortality Hazard of mortality higher for the uninsured –Under-65 population: HR: 1.23 –Near-elderly population: HR: 1.43 Medicare shown to increase use of health care services at 65

Objective To determine whether there is a change in the hazard of mortality for the near-elderly uninsured when they acquire Medicare at age 65.

Health and Retirement Study (HRS) A panel study of a nationally representative sample of people born between and their spouses –Ages 51 to 61 in 1992 –1992 through 2004 waves Study sample: Subjects alive and interviewed at age 59/60 and in birth cohorts (N=4,860) –Avoids left-censoring bias –Avoids attributing effect to cohorts

Sample Design

Graphical Representation of Research Design

Empirical Approach To implement research design: –Use Cox proportional hazards model to estimate hazard ratio for the uninsured relative to the insured, both before age 65 and after age 65 (i.e., after Medicare enrollment) –Assess change in hazard ratio after age 65 compared with before age 65

Cox Regression Model Outcome variable: Days until death or censored Key Explanatory variables: –Uninsured at 59/60 –Uninsured at 59/60*Medicare enrollment Insured—85.5%Uninsured—14.5% Control Variables: –Model 1: Age, sex, race, education, region, self-rated general health at baseline –Model 2: Model 1 plus income, assets, employment status, baseline comorbidities, baseline ADLs, body mass index, alcohol use, smoking

Selected Baseline Characteristics

Survival Curves by Insurance Status

Hazard Ratio for Mortality: Uninsured Versus Insured Unadjusted HR Model 1 HR Model 2 HR Uninsured vs. Insured (before 65) 1.92**1.45*1.25 Uninsured vs. Insured (after 65) 1.86**1.41*1.32 * p<.05, ** p<.01

Sensitivity Analyses Turn Medicare indicator “on” at age 65.5, 66, or 66.5 instead of 65 (to capture lagged effects of Medicare on mortality) Use time-varying health status measures as explanatory variables Results: No change in findings

Conclusions People who are uninsured in late middle age have higher mortality rates than their insured counterparts This difference in mortality rates is partly explained by other characteristics of the two groups The magnitude of the difference between the two groups is unchanged after the uninsured enroll in Medicare at age 65 –This finding is robust to a wide range of sensitivity analyses

Implications For people who are uninsured in late middle age, Medicare may come too late to make a difference in their health and mortality trajectories Whether those trajectories can be modified through earlier receipt of insurance is a crucial question –The insured and uninsured in late middle age differ on a range of personal characteristics that are correlated with health

Sample Design

Background Medicare increases use of health care services at 65 –Preventive services –Doctor visits and hospital admissions –Greater increases in health care service use among the previously uninsured Effect of Medicare on health –Enactment of Medicare No aggregate impact on mortality Reduction in mortality –Medicare at 65 for the uninsured No significant improvement in health status relative to the insured

Uninsured Hazard of Mortality from Cox Proportional Hazard Model