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Physical and/or Cognitive Impairment, Out-of-Pocket Spending, and Medicaid Entry among Older Adults


While Medicare provides health insurance coverage for those over 65 years of age, many still are underinsured, experiencing substantial out-of-pocket costs for covered and non-covered services as a proportion of their income. Using the Health and Retirement Study (HRS), this study found that being underinsured is a significant predictor of entering into Medicaid coverage over a 16-year period. The rate of entering Medicaid was almost twice as high for those who were underinsured and with physical and/or cognitive impairment than those who were not, while supplemental health insurance reduced the rate of entering Medicaid by 30 %. Providing more comprehensive coverage through the traditional Medicare program, including a ceiling on out-of-pocket expenditures or targeted support for those with physical or cognitive impairment, could postpone becoming covered by Medicaid and yield savings in Medicaid.

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  1. Paradise J. Medicaid Moving Forward. Kaiser Fam Found Issue Br. 2015. Available at: May 2016.

  2. Komisar HL, Feder J. Transforming care for medicare beneficiaries with chronic conditions and long-term care needs: coordinating care across all services. Washington, DC: Georgetown University; 2011.

  3. Schoen C, Buttorff C, Andersen M, Davis K. Policy options to expand medicare’s low-income provisions to improve access and affordability. Health Aff. 2015; 34(12): 2086–94.

    Article  Google Scholar 

  4. Wiener JM, Anderson WL, Khatutsky G, Kaganova Y, O’Keeffe J. Medicaid spend down: new estimates and implications for long-term services and supports financing reform. Washington, DC: RTI International; 2013.

  5. Brown JR, Finkelstein A. The interaction of public and private insurance: medicaid and the long-term care insurance market. Am Econ Rev. 2004; 98(3): 1083–1102.

  6. Chien S, Campbell N, Chan C, et al. RAND HRS data documentation, version O. Washington, DC; 2015. Accessed May 2015.

  7. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. J Am Med Assoc. 1963; 185(12): 914–9.

    Article  CAS  Google Scholar 

  8. Crimmins EM, Kim JK, Langa KM, Weir DR. Assessment of cognition using surveys and neuropsychological assessment: the health and retirement study and the aging, demographics, and memory study. J Gerontol Ser B Psychol Sci Soc Sci. 2011; 66B(Supplement 1): i162–71.

    Article  Google Scholar 

  9. Langa KM, Plassman BL, Wallace RB, et al. The aging, demographics, and memory study: study design and methods. Neuroepidemiology. 2005; 25(4): 181–91.

    Article  PubMed  Google Scholar 

  10. Ofstedal MB, Fisher GG, Herzog AR. Documentation of cognitive functioning measures in the health and retirement study. Ann Arbor, MI: University of Michigan; 2005. p. 10.

  11. Schoen C, Doty MM, Collins SR, Holmgren AL. Insured but not protected: how many adults are underinsured? Health Aff. 2005; 24: W5.

  12. Collins SR, Gunja M, Doty MM, Buetel S. How high is America’s health care cost burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July-August 2015. Issue Brief (Commonw Fund). 2015; 32: 1–15.

  13. Hurd MD, Rohwedder S. The level and risk of out-of-pocket health care spending. Michigan Retirement Research Center, Ann Arbor, MI, USA. 2009; p. 218.

  14. Zissimopoulos J, Goldman D, Lu Y. Medical expenditure measures in the health and retirement study. Forum Health Econ Policy. 2011; 14(3): 4. doi:10.2202/1558-9544.1267.

  15. Borella M, De Nardi M, French E. Rich, poor, singles, and couples. Who Receives Medicaid in old age and why? (No. w21873). National Bureau of Economic Research, Cambridge, MA, USA; 2016.

  16. Davis K, Willink A, Schoen C. Medicare help at home. Heal Aff Blog. 2016. Available at: April 2016.

  17. Gawande A. Being mortal: medicine and what matters in the end. Metropolitan Books, New York, NY, USA; 2014.

  18. Moon M, Hollin IL, Nicholas LH, Schoen C, Davis K. Serving older adults with complex care needs: a new benefit option for Medicare. Issue Brief (Commonw Fund). 2015; 23: 1–11.

  19. Szanton SL, Samuel L, Wolff JL, Thorpe RJ, Mohamoud S, Betley C. Public benefits reduce risk for nursing home entry among Maryland’s dual eligible older adults. In: Academy Health Annual Research Meeting. Academy Health, Minneapolis MN; 2015.

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This work was made possible by funding from the Commonwealth Fund (20160346).

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Correspondence to Amber Willink.

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Willink, A., Davis, K., Schoen, C. et al. Physical and/or Cognitive Impairment, Out-of-Pocket Spending, and Medicaid Entry among Older Adults. J Urban Health 93, 840–850 (2016).

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