J. Michael McWilliams, MD, PhD; Ellen Meara, PhD; Alan M. Zaslavsky, PhD; John Z. Ayanian, MD, MPP
Acknowledgment: The authors thank Stuart B. Mushlin, MD, for helpful comments on an earlier draft of this manuscript.
Grant Support: By the Commonwealth Fund (grant 20060485).
Potential Conflicts of Interest:Consultancies: E. Meara (Employment Policies Institute), J.Z. Ayanian (RTI International, Verisk Health). Expert testimony: J.Z. Ayanian (U.S. House of Representatives Ways and Means Committee). Grants received: J.Z. Ayanian (National Institute on Aging).
Reproducible Research Statement:Study protocol: See Methods and the Appendix. Statistical code: Available from Dr. McWilliams (e-mail, email@example.com); SAS code for constructing inverse-probability-of-treatment weights are also available in appendix of reference 32. Data set: Health and Retirement Study survey data are available at http://hrsonline.isr.umich.edu/index.php?p=data. Linked Medicare claims data are restricted, and use requires approval by the Health and Retirement Study and the Centers for Medicare & Medicaid Services.
Requests for Single Reprints: J. Michael McWilliams, MD, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. McWilliams, Meara, Zaslavsky, and Ayanian: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.
Author Contributions: Conception and design: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Analysis and interpretation of the data: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Drafting of the article: J.M. McWilliams, A.M. Zaslavsky.
Critical revision of the article for important intellectual content: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Final approval of the article: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Statistical expertise: J.M. McWilliams, E. Meara, A.M. Zaslavsky.
Obtaining of funding: J.M. McWilliams, J.Z. Ayanian.
Administrative, technical, or logistic support: J.M. McWilliams.
Collection and assembly of data: J.M. McWilliams.
McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Medicare Spending for Previously Uninsured Adults. Ann Intern Med. 2009;151:757-766. doi: 10.7326/0000605-200912010-00149
Download citation file:
Published: Ann Intern Med. 2009;151(11):757-766.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
University of Pennsylvania and National Center for Health Statistics
December 8, 2009
Would Insuring the Near-Elderly Reduce Medicare Spending Beginning at Age 65?
McWilliams and colleagues (1) find that Medicare spending is higher for the previously uninsured and use this finding to suggest that nearly half of the cost of expanding health insurance coverage to uninsured near- elderly adults might be offset by reduced spending once the age of 65 has been reached. We do not believe this research supports the notion of cost savings from insuring the uninsured, because a large fraction of higher Medicare expenditures observed for the previously uninsured cannot be avoided by insuring people earlier. As pointed out by Bhattacharya (2), this may be particularly true if poor health caused them to be uninsured rather than poor health resulting from lack of insurance.
McWilliams and colleagues are unable to adequately control for this reverse causation. This problem is exacerbated by including in their sample individuals from the Health and Retirement Study who acquired public insurance after 1992 but before turning age 65. (Of these, individuals who are ever uninsured before turning 65 are included in the "uninsured" sample.) Adults who transition to public insurance before age 65 are likely to have had a health event that led them to become eligible for public insurance. This health event may have also caused them to be uninsured prior to obtaining public coverage. For example, individuals who quality for Medicare prior to age 65 due to participation in Social Security Disability Insurance (SSDI) qualify only after a 24-month waiting period following SSDI entitlement. Since they must be too disabled to work in order to qualify for SSDI, a substantial fraction are uninsured during the waiting period. (3) According to our estimates using McWilliams' sample definitions, 25% of the "uninsured" but only 11% of the "insured" transitioned to public insurance before turning 65. Because the disabled are more likely to use health care services and because their health characteristics are not adequately captured in the control variables, the McWilliams estimate includes spending that could not be avoided by insuring the uninsured. Our calculations suggest that the McWilliams estimate of the difference in Medicare spending between the uninsured and insured would drop by 50% if those ever public insured before age 65 are dropped from the sample.
Unrealistic expectations about the cost of health reform could lead to early dissatisfaction with reform efforts and result in their curtailment. The costs of insuring the near-elderly uninsured are unlikely to be offset by significant reductions in Medicare spending after age 65.
1. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Medicare spending for previously uninsured adults. Ann Intern Med. 2009;151.
2. Bhattacharya J. Insuring the Near-Elderly: How Much Would Medicare Save? Ann Intern Med. 2009;151.
3. Riley GF. Health Insurance and Access to Care among Social Security Disability Insurance Beneficiaries during the Medicare Waiting Period. Inquiry. 2006. 43; 222-230.
Note: The views expressed in this letter reflect those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Healthcare Delivery and Policy.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only