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PubMed2000

The Medicare mix: efficient and inefficient combinations of social and private health insurance for U.S. elderly.

This paper explores two theories about the reason why the United States provides mixed public (Medicare) and private (Medigap) insurance for the elderly: that this represents an efficient combination of financing methods for a public good, or that it represents public provision of a private good for distributional reasons. It is argued that the first theory has more support than the second, but that the current configuration of Medicare and Medigap is not optimal. Two main problems are identified: the absence of coordination between public and private insurers, and the provision of overly generous coverage to the well off. Recent Medicare reforms have helped with the first problem, but the second remains to be solved.

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PubMed1987

Catastrophic health insurance for the elderly.

Recent proposals to provide catastrophic healthcare benefits to the elderly under Medicare are flawed by their compulsory nature of premium payments and the granting of a monopoly to the federal government to underwrite such coverage. Additionally, current Medicare policy provides an inherent subsidy to Medigap insurance reducing the incentive to purchase private catastrophic coverage. Other options include paying for such coverage by increasing copayments or increasing private Medigap coverage. The public policy implications of these proposals are discussed.

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PubMed1990

Older women's health and financial vulnerability: implications of the Medicare benefit structure.

Elderly women and men have different patterns of disease and utilize health services differently. This essay examines the extent to which Medicare covers the specific conditions and services associated with women and men. Elderly women experience higher rates of poverty than elderly men; consequently, elderly women are especially likely to be unable to pay high out-of-pocket costs for health care. Using a new method for simulating out-of-pocket costs, the Illness Episode Approach, the essay shows that Medicare provides better coverage for illnesses which predominate among men than for those which predominate among women. In addition, women on Medicare who supplement their basic coverage by purchasing a typical private insurance "Medigap" policy do not receive as much of an advantage from their purchases as do men. The calculations also show that the Medicare Catastrophic Coverage Act would have had little impact on the gender gap in financial vulnerability.

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PubMed2004

The interaction of partial public insurance programs and residual private insurance markets: evidence from the US Medicare program.

A ubiquitous form of government intervention in insurance markets is to provide compulsory, but partial, public insurance coverage and to allow voluntary purchases of supplementary private insurance. This paper investigates the effects of such programs on insurance coverage for the risks not covered by the public program, using the example of the US Medicare program. I find that Medicare does not have substantial effects-in either direction-on coverage in residual private insurance markets. In particular, there is no evidence that Medicare is associated with reductions in private insurance coverage for prescription drug expenditures, an expenditure risk not covered by Medicare. Medicare is, however, associated with a shift in the source of prescription drug coverage, from employer-provided coverage to Medicare HMOs.

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PubMed1992

Health care and consumer control: Pittsburgh's Town Meeting for Seniors.

Since 1988 two hospitals in Pittsburgh have conducted a semiannual Town Meeting for Seniors designed to provide community- based health education so that seniors can make informed decisions not only about medical care, but also about issues such as Medigap insurance, advance directives, and proper nutrition. Attendees have been predominantly white and middle class, reflecting the demographics of the surrounding area. The Town Meeting has been enthusiastically received by consumers and has led to the creation of several new community programs, including exercise classes, driver education classes, durable power of attorney workshops, and expanded insurance counseling services.

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PubMed1998

Ability to pay and the decision to medicate.

OBJECTIVES: It is widely recognized that ability to pay affects access to hospital and physician services. Much less is known about the economic determinants of prescription drug use, particularly among the elderly. The authors hypothesize that persons with higher incomes and better health insurance coverage are more likely to medicate common health problems than those with lower incomes and less comprehensive coverage. METHODS: A random sample of 4,066 elderly Pennsylvania Medicare beneficiaries were asked to complete a mail survey on health insurance, income, and medicine use for 23 common health problems. The relationship between ability to pay and medication decisions was analyzed using logistic and Poisson regression models with covariates for sociodemographic characteristics and health status. RESULTS: A strong and consistent relationship was found in the hypothesized direction. Other things being equal, elderly persons with Medicare supplementation were between 6% and 17% more likely to use prescription medicine to treat their health problems than are persons with Medicare coverage alone. The presence of prescription drug coverage significantly increased the odds of prescription treatment for 10 of the 22 conditions examined. The insurance effects were generally--but not exclusively--more pronounced for less serious compared with serious health problems. Income also was shown to have a strong independent effect on medication decisions. Elderly with annual incomes greater than $18,000 were 18% more likely to treat problems with prescription drugs than were persons with annual incomes less than $6,000. CONCLUSIONS: In sum, economic factors appeared to play an important role in medication decisions by the elderly. The magnitude of the impact was sufficiently high that it could have major negative consequences on the health of elderly persons who are poor and lack drug coverage.

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PubMed1997

Medicare: past, present and future.

The history of the Medicare program, including changes that have been enacted over the years in an effort to control spiraling costs, is reviewed. Medigap insurance and preventive medical care for the elderly are examined, as is the impact of Medicare coverage for the terminally ill. Trends indicate that the Medicare system as presently structured is not financially viable. The question is: what will replace it?

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PubMed1993

Prescription and nonprescription drug use among black and white community-residing elderly.

OBJECTIVES: To examine and compare concomitants of prescription and nonprescription drug use of Black and White community-dwelling elderly. METHODS: Information on prescription and nonprescription drug use, demographic and health characteristics, and use of health services was obtained from a probability-based sample of Black (n = 2152) and White (n = 1821) community-resident elderly in the Piedmont area of North Carolina. Descriptive statistics were calculated. Linear regression, in which sample weights and design effects were taken into account, was used for the final models. RESULTS: For prescription drug use, 37% and 32% of the variance was explained for Whites and Blacks, respectively (6% and 5% for nonprescription drugs). Health status and use of medical services were the strongest predictors of prescription drug use for both races (with Medigap insurance also important for Whites and Medicaid important for Blacks). Demographic characteristics and self-assessed health were significant factors in the use of nonprescription drugs. Race independently predicted use of both types of drugs but explained only a small proportion of the variance. CONCLUSIONS: Health status and use of health services are importantly related to prescription drug use. Non-prescription drug use is difficult to explain.

Black or African American↗
PubMed2003

State-based versus federal-based approaches to reducing the Medicare pharmaceutical coverage gap.

A state-based approach, such as the Immediate Helping Hand proposal put forward by the Bush administration, is likely to be less effective than a federal-based approach at reducing the Medicare pharmaceutical coverage gap. In addition, the voluntary nature of a state-based approach, coupled with variations across states in existing coverage benefits and the limited reach of state pharmacy assistance programs, would likely lead to a perpetuation of uneven coverage. This article argues in favor of adding a federal-based universal prescription drug benefit to Medicare on the grounds of both equity and empirical evidence. Adding a universal drug benefit to the currently existing Medicare program would extend application of the social insurance concept across hospital care, physician service, and prescription drug coverage components of Medicare. As a result, a more equitable distribution of prescription drug coverage would be promoted while mitigating the effects of selection risk.

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PubMed1998

Provide, provide: the economics of aging.

Most older persons face two potentially serious economic problems: (a) declining earning power and (b) declining health that can be partly offset by increased utilization of health care. The decline in earning power is largely attributable to physiological changes and to obsolescence of skills and knowledge. These adverse effects are exacerbated by public and private policies that reduce the incentives of older persons to continue work and increase the cost to employers of employing older workers. The problems of earnings replacement and health care payment are usually discussed separately, but there are several reasons why they should be considered together. First, there are often tradeoffs between the two. Money is money, and for most people there is never enough to go around. This is self-evident where private funds are concerned. Low-income elderly, for instance, frequently must choose between expensive prescription drugs and an adequate diet. For middle-income elderly, the choice may be between saving on medigap insurance or forgoing an airplane trip to a grandchild's graduation. Difficult choices are also inherent in the allocation of public funds. The same tax receipts that could be used to maintain or increase retirement benefits could be used to fund additional care, and vice versa. In discussing these tradeoffs, some analysts assert that people will gladly give up other goods and services for medical care that cures illness, relieves pain, or restores function. Others believe that some people would forgo some health insurance in order to maintain access to other goods and services. A second reason for looking at the two problems together is that they pose similar questions for public policy. How much should each generation provide for its own needs in old age, and how much should be provided by the generations that follow? How much provision should be voluntary, how much compulsory? How much intra-generational redistribution is appropriate after age 65? How well can private markets serve the elderly's desire for annuities and health insurance, and when are public programs more efficient? Finally, the problem of health care payment is approaching that of earning replacement in economic importance and, by 2020, will far exceed it. Declining health after age 65 results in substantial increase in use of prescription drugs, hospital admissions, repair or replacement of parts of the body, rehabilitation and physical therapy, and assistance with activities of daily living. New technologies offer great promise for offsetting the health problems of aging, but often at considerable expense. Overall, per capita expenditures for health care after age 65 are between three and four times as great as for those under 65. This presentation will focus primarily on the (thus far) inexorable increase in consumption of health care by older Americans. If this increase continues and if the government's share of the total remains unchanged, the tax burden on younger cohorts could become intolerable. Concomitantly, if the private share remains unchanged, the ability of the elderly to obtain other goods and services would be sharply diminished. Although the emphasis of the session will be on aggregate and average results, levels and trends in income inequality among the elderly will also be examined and compared with inequality at younger ages. The session will conclude with a discussion of changes that might avert the economic and social crises foreshadowed in the data.

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PubMedDate not supplied

Medicare prescription drugs: a benefit whose time has come.

The Federal Medicare program's biggest flaw is the lack of an outpatient benefit for prescription drugs. One of the hottest legislative debates this summer will be whether or not to add this important therapeutic benefit to the Medicare program. Congressional planners will be weighing the positions of numerous stakeholders, as well as the fiscal implications of such a measure. The most important stakeholders are the elderly and the disabled, who depend on these medications for therapeutic relief.

Ambulatory Care↗
PubMed2001

Coordination of health coverage for Medicare enrollees: a case study of HIV/AIDS.

When people with HIV/AIDS become eligible for Medicare, they find that it does not pay for a significant share of their health care needs. As enrollees seek supplemental health coverage (e.g., Medicaid, employer-sponsored and individually-purchased insurance, and premium payment programs), they find that though there are numerous potential benefit and insurance options, the rules are complex and often conflicting. The search for comprehensive health coverage is further complicated by the fact that each program is separately administered, with different eligibility requirements and application processes. Because each program and agency's staff knows little about other programs, they are often unable to help coordinate coverage. Respondents to the study believe that people with a serious chronic condition would benefit from reforms that make Medicare's benefits more comprehensive and its eligibility, coverage, and payment rules less complicated. They also said that enrollees need better access to Medicare information and enhanced mechanisms to coordinate Medicare with supplemental health coverage. Some HIV/AIDS organizations have developed benefits counseling programs that help their clients piece together a synthetic health coverage "system." These and other issues discussed in this Medicare Brief illustrate possible policy reforms that could help enrollees with HIV/AIDS and other serious chronic conditions.

Centers for Medicare and Medicaid Services, U.S.↗