MHA 550 Trident University Medicare Coverage Affordability and Access Essay

GE NER ATIO NS – Journal of the American Society on AgingBy Juliette Cubanski and Cristina Boccuti
Medicare Coverage,
Affordability, and Access
Gaps remain in Medicare’s coverage and accessibility
for low- to moderate-income older adults.
F
or fifty years, Medicare has been a bedrock
of economic and health security for older
Americans, providing access to essential medical
benefits that address many acute, chronic, and
preventive health service needs. Prior to its
enactment in 1965, only slightly more than half
of all older adults had insurance to help pay for
hospital care (Gornick et al., 1996). Many were
unable to obtain health insurance either because
they could not afford the premiums or because
they were denied coverage based on age or preexisting health conditions. Because of Medicare,
millions of older Americans and people with
disabilities no longer have to worry about being
uninsured for their medical care needs.
In important ways, however, Medicare
coverage is not comprehensive, and, due in part
to Medicare’s premiums, deductibles, and costsharing requirements, paying for Medicare
and Medicare-covered services can represent a
financial challenge, particularly for people with
low and moderate incomes. The combination of
coverage gaps and affordability concerns can
lead to access problems that some on Medicare
struggle to overcome.
This article will review the state of Medicare
coverage, affordability, and access, examine ways
in which Medicare falls short, and discuss the
implications. Findings are based upon previously
published research and new analysis of the Medi-
26 | Summer 2015 • Vol. 39 . No. 2
care Current Beneficiary Survey 2012 Access
to Care file, a nationally representative survey
of Medicare beneficiaries conducted by the
Centers for Medicare & Medicaid Services
(CMS) (Centers for Medicare & Medicaid
Services, n.d.).
Overview of Medicare Coverage
Medicare benefits are covered under three
parts—Part A, Part B, and Part D—and beneficiaries can access Medicare benefits through two
programs—traditional Medicare and Medicare
Advantage. Part A benefits include inpatient care
provided in hospitals, short-term stays in skilled
nursing facilities, hospice care, and post-acute
home healthcare. Part B benefits include outpatient services, including outpatient hospital care,
physician visits, and preventive services (such as
mammography and colorectal screening). Other
Part B outpatient benefits include laboratory
services and diagnostic tests, durable medical
equipment (such as wheelchairs and oxygen),
outpatient mental health care, and some home
health visits. Part D covers a voluntary outpatient prescription drug benefit delivered through
private plans that contract with Medicare,
including stand-alone prescription drug plans
(PDP) or Medicare Advantage drug plans.
Beneficiaries can access parts A and B
benefits through the traditional Medicare
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Pages 26–34
Medicare at 50 Years
program, which pays for care delivered by medi- mise social functioning and hinder quality of life
cal providers such as doctors and hospitals on a
(Crews and Campbell, 2004).
fee-for-service basis, and can enroll in a standResearch suggests that seven in ten older
alone Part D plan for drug coverage. As an aladults will require LTSS at some point in their
ternative to traditional Medicare, beneficiaries
lives (Stevenson et al., 2010). Averaging more
can enroll in a private Medicare Advantage plan, than $90,000 for a year of nursing home care
such as a health maintenance organization
in a private room and more than $20,000 for
(HMO) or preferred provider organization
annual home health care (MetLife Mature
(PPO), for all Medicare-covered Part A and Part Market Institute, 2012), few people on Medicare
B benefits, and, typically, Part D benefits. Enroll- have the financial resources to afford either the
ment in Medicare Advantage plans has grown
high cost of custodial LTSS or the lower cost of
over time, with nearly 16 million beneficireceiving skilled care at home. Beneficiaries with
aries (30 percent of all beneficiaries) in
a Medicare Advantage plan in 2014
There were nearly 16 million beneficiaries
(Jacobson et al., 2014).
While benefits covered by Medicare (30 percent of all beneficiaries) in a
are the same for enrollees in traditional
Medicare Advantage Plan in 2014.
Medicare and Medicare Advantage
plans, issues related to gaps in coverage,
very low incomes, or who spend down their
affordability, and provider access are differsavings to pay for medical and long-term care,
ent for these populations, and are discussed
may qualify for LTSS coverage through their
separately below.
state Medicaid program. Medicaid is not available to everyone on Medicare who needs longGaps in Medicare Coverage
term care, however, depending upon state
Traditional Medicare does not cover some
policy choices with regard to Medicaid coverservices that could greatly benefit many older
age of older adults and people with disabilities
adults and people with permanent disabilities,
(Young et al., 2013). Consequently, most people
including long-term services and supports
living in the community who need LTSS rely on
(LTSS), dental services, eyeglasses, and hearing
informal, unpaid caregivers, including family
aids. Beneficiaries in Medicare who need these
and friends (The SCAN Foundation, 2013), but
services must pay the full cost out of their own
providing this care can have negative health and
pockets unless they have other sources of covfinancial effects on caregivers themselves
erage. Those with low incomes may qualify for
(Feinberg et al., 2011).
Medicaid coverage of these services.
Because traditional Medicare does not cover Medicare’s Affordability
dental services, eyeglasses, and hearing aids,
In addition to Medicare’s other sources of
some beneficiaries may not be able to afford
financing (primarily general revenues and paythem, which may adversely affect their overall
roll taxes), beneficiaries pay for Medicare coverhealth. Oral health care is closely correlated with age in the form of premiums and cost-sharing
health and well-being, and lacking adequate or
requirements. Part A benefits are subject to a
appropriate oral health care can exacerbate
deductible ($1,260 per benefit period in 2015)
health problems or create new ones (Kaiser
and a daily copayment for hospital and skilled
Family Foundation, 2012). While age-related
nursing facility stays. Beneficiaries pay a monthchanges in hearing and vision may be a normal
ly premium for Part B benefits ($104.90 in 2015),
part of aging, sensory impairments can compro- which are subject to a deductible ($147 in 2015)
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
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Summer 2015 • Vol. 39 . No. 2 | 27
GE NER ATIO NS – Journal of the American Society on Aging
and 20 percent co-insurance (most preventive
services are covered at no charge). Beneficiaries
with annual incomes that are more than $85,000
per individual or $170,000 per couple pay a
higher, income-related premium reflecting a
larger share of total Part B spending. Part D plan
enrollees pay monthly premiums (averaging
$38.83 for PDPs in 2015 [Hoadley, 2014]) and
cost-sharing for prescriptions (varying widely
by plan), with additional financial assistance for
beneficiaries with low incomes and modest assets. Similar to Part B, higher income enrollees
pay a larger share of the cost of Part D coverage.
Part D enrollees also may be subject to higher
costs in the drug benefit’s coverage gap (the socalled donut hole). In 2015, beneficiaries with
prescription drug spending exceeding $2,960
pay 45 percent of the cost for brand-name drugs
and 65 percent of the cost of generics until they
Pages 26–34
reach the catastrophic coverage limit ($4,700
in out-of-pocket costs in 2015). As a result of a
provision in the Affordable Care Act, the coverage gap is gradually closing by 2020, when beneficiaries will pay no more than 25 percent of their
drug costs in the gap.
While traditional Medicare limits the amount
that physicians and other providers may charge
beneficiaries, it lacks the key financial protection
of a limit on beneficiaries’ annual out-of-pocket
spending. Catastrophic coverage for very high
medical bills is a common feature of private commercial plans and is required for plans offered in the Health Insurance Marketplace and in
Medicare Advantage. Research shows that adding a $5,000 out-of-pocket limit to Medicare
would protect a small share (6.5 percent) of
beneficiaries against catastrophic expenses in
any given year, but nearly one-third of beneficia-
Figure 1.
28 | Summer 2015 • Vol. 39 . No. 2
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Medicare at 50 Years
Pages 26–34
Figure 2.
ries would reach the limit in one or more years
over a ten-year period (Kaiser Family Foundation/MedPAC, 2013).
In response to traditional Medicare’s benefit
gaps, cost-sharing requirements, and lack of an
out-of-pocket limit that can leave beneficiaries
at financial risk for costly medical and longterm-care bills, many beneficiaries in traditional Medicare have supplemental insurance to
help pay expenses for Medicare-covered services. Those with low incomes may qualify for
Medicaid coverage, which provides some benefits that Medicare does not and helps with the
cost of Medicare premiums and cost-sharing.
Beneficiaries with incomes or assets above
Medicaid eligibility limits may be able to obtain
private supplemental coverage, such as Medigap or employer-sponsored retiree health
benefits, but premiums for these policies can
add hundreds or thousands of dollars to annual
out-of-pocket costs.
Taking these premium and non-premium
expenses into account, many beneficiaries face
significant out-of-pocket costs to meet their
medical and long-term-care needs. Health
expenses accounted for 14 percent of Medicare
household budgets in 2012, nearly three times
the share of spending on healthcare in nonMedicare households (Cubanski et al., 2014a).
In 2010, Medicare beneficiaries spent $4,745
out-of-pocket for healthcare, on average, including $2,000 in premiums and $2,746 for medical
and long-term-care services (Cubanski et al.,
2014b) (see Figure 1, page 28).
As might be expected, beneficiaries in poorer
health, who typically need and use more medical
and long-term-care services, have higher than
average out-of-pocket costs. Out-of-pocket spend-
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Summer 2015 • Vol. 39 . No. 2 | 29
GE NER ATIO NS – Journal of the American Society on Aging
Pages 26–34
ing on services by beneficiaries in poor selfreported health averaged nearly two and a half
times more than among beneficiaries who said
they were in excellent health ($4,246 vs. $1,797,
respectively, in 2010). Out-of-pocket spending
on services is as large among those with low and
modest incomes as it is among those with higher
incomes, suggesting a greater burden among
beneficiaries with the fewest resources (see
Figure 2, page 29). Out-of-pocket spending also
rises with age among beneficiaries ages 65 and
older, and is higher for women than for men,
especially among those ages 85 and older.
including having a usual source of care, obtaining medical care when needed, ability to schedule timely appointments, and finding new
physicians when needed. Yet there is some
evidence of access problems among certain
demographic subgroups.
One key indicator of access to care is the share
of people reporting they have a usual source of
care for when they are sick or seeking medical
advice, such as a doctor’s office or clinic. In 2012,
the vast majority of Medicare beneficiaries
(95 percent) reported having a usual source of
care, a rate higher than younger adults with
private insurance (90 percent), as reported in the
National Health Interview Survey (CDC, n.d.).
When scheduling doctor appointments or looking
for new physicians, most older adults in Medicare
report easy access and are as likely as privately
insured adults ages 50 to 64 to report problems
Access to Care
Medicare beneficiaries generally enjoy broad
access to physicians, hospitals, and other
providers, and report relatively low rates of
problems across a number of access measures,
Figure 3.
30 | Summer 2015 • Vol. 39 . No. 2
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Pages 26–34
Medicare at 50 Years
(Medicare Payment Advisory Commission, 2013).
For both these populations, however, access to
primary care doctors is generally somewhat
worse than access to specialists. Among the small
share of adults ages 65 and older on Medicare
(7 percent) who said that they looked for a new
primary care physician in 2013, 28 percent
reported a problem finding one—equating to
about 2 percent of all older adults in Medicare.
of pills (Osborn et al., 2014). This finding suggests that while Medicare coverage is nearly
universal among older adults, out-of-pocket
expenses are troublesome for one in five—either
because of Medicare’s benefit gaps or difficulties
meeting Medicare’s cost-sharing requirements.
Access indicators generally look positive
when viewed from the perspective of Medicare
providers. The majority of office-based physicians (91 percent) report accepting new
Medicare patients (Boccuti et al., 2013).
Premiums for private supplemental
As for other types of insurance, the
coverage can add hundreds or thousands
same proportion of physicians (91 percent) report accepting new patients with
of dollars to annual out-of-pocket costs.
private non-capitated insurance (such
While a relatively small share of Medicare
as PPOs), but a smaller share says they accept
beneficiaries report experiencing problems
new patients with private capitated insurance
obtaining needed medical care, the share re(such as HMOs) (72 percent), with Medicaid
porting such problems has increased modestly
(71 percent), or without insurance (47 percent).
in the past ten years. About 6 percent of benefiNearly all physicians and other health profesciaries reported trouble getting healthcare in
sionals (96 percent) who bill Medicare are
2012 (up from 3.5 percent in 2002), 11 percent of “participating providers,” meaning that for their
beneficiaries said they delayed seeking medical
Medicare patients, they agree to accept Medicare because of cost (up from 6.5 percent), and
care’s fee-schedule rate as full payment and will
11.4 percent reported not seeing a doctor about
not charge higher fees for Medicare-covered
an existing health problem (up from 7.4 percent) services. As a result, most beneficiaries encoun(see Figure 3, page 30).
ter predictable expenses when seeing their phyCertain beneficiary subgroups report access
sician. A small share of physicians (less than
problems more frequently than others, particu4 percent) who bill Medicare do not have these
larly those who typically need more healthcare
agreements and may charge higher fees (“balservices because of medical problems. For
ance bill”) up to a specified maximum for Mediinstance, 17 percent of Medicare beneficiaries
care-covered services. Less than 1 percent has
with disabilities who are younger than age 65
elected to “opt out” of Medicare, instead conexperienced trouble accessing needed care,
tracting privately with all of their Medicare
compared to just 4 percent of beneficiaries ages
patients (Boccuti, 2014).
65 and older. Beneficiaries who are in fair or
poor health, are non-white, or have lower
Coverage under Medicare Advantage
incomes are also at higher risk for having
Beneficiaries enrolled in Medicare Advantage
problems accessing healthcare, or delaying care
plans face a different set of coverage, affordabecause of cost. Other survey research finds that bility, and access issues compared to their
19 percent of Americans ages 65 and older report counterparts in traditional Medicare. Medicare
experiencing at least one cost-related problem
Advantage plans are required to provide all
accessing healthcare during the year—not seeing Medicare-covered benefits, but are allowed to
a doctor, not seeking recommended medical
vary benefit design and cost-sharing charged
tests, or not filling prescriptions or skipping doses for services, as long as the core benefit package
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
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Summer 2015 • Vol. 39 . No. 2 | 31
GE NER ATIO NS – Journal of the American Society on Aging
(excluding the value of supplemental benefits) is
equal in value to traditional Medicare. Medicare
Advantage plans also may offer extra benefits
not covered under traditional Medicare, such as
dental services, eyeglasses, or hearing exams.
For this reason, some benefit gaps in traditional
Medicare may not apply to all Medicare Advantage enrollees. Medicare Advantage plans also
charge varied amounts for Medicare-covered
services—typically flat cost-sharing amounts
rather than co-insurance—and all Medicare
Advantage plans are required to have an out-ofpocket limit (no more than $6,700 in 2015). For
these reasons, people with Medicare Advantage
do not equally share the potential financial liability traditional Medicare beneficiaries experience
with catastrophic medical expenses.
Less than 1 percent of physicians
has elected to “opt out” of Medicare,
instead contracting privately with
all of their Medicare patients.
Cost burdens may still be a concern for Medicare Advantage enrollees, however. Beneficiaries
enrolled in Medicare Advantage typically pay
monthly premiums for additional benefits
covered by their plan in addition to the Part B
premium. In 2015, enrollees will pay, on average,
$41 per month in Medicare Advantage premiums
(Jacobson et al., 2014). While recent data on outof-pocket spending for Medicare Advantage
enrollees are not available, evidence from 2015
shows that plans are increasing costs in the form
of higher deductibles and out-of-pocket limits
(Jacobson et al., 2014), which will translate to
higher costs for enrollees.
In terms of access and quality of care, a
recent review shows that evidence on the
performance of Medicare Advantage plans
compared to traditional Medicare is lacking,
limited, or outdated (Gold and Casillas, 2014).
Older evidence shows Medicare HMOs have
32 | Summer 2015 • Vol. 39 . No. 2
Pages 26–34
provided better access to preventive services and
have lower rates of potentially avoidable hospital
admissions. Beneficiary ratings of quality and
access, however, are more favorable for traditional Medicare than for Medicare Advantage.
Medicare Advantage enrollees may face more
limited choices of providers than traditional
Medicare beneficiaries. Most Medicare Advantage plans contract with providers to participate in their networks; enrollees generally are
required to seek care from network providers or
pay higher costs to see non-network providers.
On a national level, beneficiaries in Medicare
Advantage and traditional Medicare report that
they are able to schedule timely appointments
at similar rates (Boccuti et al., 2013). Recently,
however, there has been concern about some
Medicare Advantage plans curtailing provider
networks and terminating providers during the
year, which could affect beneficiaries’ access to
their preferred physicians (Jaffe, 2014). Current
rules allow plans to make such changes midyear, but beneficiaries who lose access to their
providers as a result are unable to change plans
until the next open enrollment period.
Conclusion
While Medicare offers access to a wide array of
medical benefits, Medicare’s benefit gaps and
cost-sharing requirements leave beneficiaries at
risk of not getting or not being able to afford
needed care. Gaps in the traditional Medicare
benefit package include no coverage of LTSS,
dental services, eyeglasses, and hearing aids—
benefits that could be especially valuable for
an older population. Medicare’s out-of-pocket
spending burden is greater for some groups than
others, depending upon socioeconomic factors,
health status, and medical needs. At the same
time, while access problems have not been
widely documented, small shares of beneficiaries encounter difficulty affording needed care
and finding a new physician.
In light of Medicare’s benefit gaps and costsharing requirements, most beneficiaries in tra-
Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
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Medicare at 50 Years
Pages 26–34
ditional Medicare have supplemental coverage
to help cover their costs for Medicare-covered
services. Alternatively, beneficiaries can enroll
in Medicare Advantage plans. The prevalence of
supplemental coverage, however, suggests that
Medicare coverage alone is not sufficient to protect beneficiaries from the high cost of care and
unpredictable medical expenses.
Overall, beneficiaries report high levels of
satisfaction with Medicare, the quality of care
they receive, and various features of their
Medicare coverage, such as the availability of
specialty care. Nonetheless, it is important not
to overlook the existence of Medicare’s gaps,
cost burdens, and access barriers, particularly
as those beneficiaries who may be hardest hit
are among those with the greatest needs. Improving coverage and enhancing financial protections—whether by adding benefits such
as dental coverage, adding an out-of-pocket
spending limit, or providing additional financial protections for low-income beneficiaries—
could bring renewed vitality to Medicare for
the next fifty years.
Acknowledgment
The authors thank Giselle Casillas and Anthony
Damico for data programming assistance in the
preparation of this article.
Juliette Cubanski, Ph.D., M.P.P., M.P.H., is associate
director of the Program on Medicare Policy at the
Kaiser Family Foundation in Menlo Park, California.
She can be contacted at jcubanski@kff.org. Cristina
Boccuti, M.P.P., is senior associate in the Program
on Medicare Policy at the Kaiser Family Foundation
in Washington, D.C. She can be contacted at
cboccuti@kff.org.
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
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visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
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