Does Medicare actually provide universal, affordable healthcare?

Debra Smith holds her medical bills in her living room on Thursday, Oct. 7, 2021, in Spring Hill, Tenn. Smith figures she has around $10,000 in unpaid medical bills from a string of hospital stays over the past year, even though she has coverage through Medicare. She hasn’t been able to make much progress paying them off. AP Photo/Mark Zaleski

Enrolling in Medicare doesn’t eliminate the burden of medical expenses for some, according to a new study led by Jeanne Madden, associate professor of pharmacy and health systems sciences at Northeastern.

More than one in 10 Medicare recipients surveyed reported having problems paying medical bills, and about the same proportion reported having delayed care due to worries about cost. Many of the people who reported those concerns had lower incomes, worse health, or were eligible for Medicare due to long-term disability.

“There’s this serious concentration of unaffordability among people who don’t have money or who have very high healthcare needs,” Madden says. “Most people know that Medicare is good insurance and it’s this safety net for these groups, and we tend to think that they’re sort of taken care of … It’s considered a universal program. But that doesn’t make it equitable.”

Jeanne Madden, associate professor of pharmacy and health systems sciences in the School of Pharmacy, Bouvé College of Health Sciences, at Northeastern University. Photo by Matthew Modoono/Northeastern University

In the study, Madden and her colleagues found that enrollees over the age of 65 with an annual income between $15,000 and $25,000 a year were twice as likely to delay care than those with incomes greater than $50,000. The same group of Medicare enrollees was also three times as likely to report having trouble paying medical bills as their higher-income counterparts. 

Chronic health conditions also increased the likelihood that enrollees would report trouble paying medical bills. Older adults surveyed with four to 10 chronic conditions were more than twice as likely to report problems with paying bills as those with one or no conditions.

What it comes down to, Madden says, is the out-of-pocket costs incurred that are not covered by the insurance policies. For someone who has chronic conditions that require more frequent care, those costs can add up quickly. And for patients who don’t have a lot of financial flexibility due to a lower income, those costs can force tough choices. 

“There are ramifications for the rest of your life,” Madden says. “If you’re choosing to take care of your health financially, it means you have less [money] left over for other things like food, housing, and heat.” (Madden’s previous research found that roughly one in 10 older Medicare recipients struggle to afford food, and four in ten people younger than 65 who qualify for Medicare because of a long-term disability also don’t have enough to eat.)

Or, she adds, you might go into debt to cover the out-of-pocket expenses of medical procedures and incur further costs over time. “When you’re a very sick, vulnerable person with not a lot of room to move in your income, you can really find yourself in a big pinch.”

The study data comes from before the pandemic, from a 2018 survey of about 15,000 Medicare enrollees conducted annually by the U.S. Centers for Medicare & Medicaid Services. That was the first year that these questions about affordability were added to the annual interviews.  After that federal agency made their data available to researchers like Madden, her team analyzed the answers to survey questions focused on Medicare recipients’ experiences in the year 2017. Madden and her colleagues published a paper last month in the Journal of the American Medical Association Health Forum.

“It’s helpful to have this in an annual survey because now we have a baseline picture of what it looks like and we can be tracking it over time to see whether it changes,” Madden says. This data could help inform legislation to improve healthcare, she says, and monitor if changes to healthcare policy improve the affordability of medical care.

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