Those Who Lacked Insurance Are More Expensive When They Qualify For Medicare

Annals of Internal Medicine reports in the December 1 issue (now on the web) those with prolonged periods of uninsurance in late middle age have substantially higher Medicare costs when they become eligible for Medicare at age 65.    The researchers interviewed individuals in the early 1990s, and tracked most of them down after they turned 65 and ascertained insurance coverage history. They then procured and analyzed Medicare claims for each study subject.

The uninsured were, predictable, different than those with continuous insurance even at the start of the observation period. They were less white, had lower educational levels, had lower incomes and were more likely unemployed. They were less likely to be married, had more functional impairments, were more likely active smokers, and were more likely diabetics.   When this group turned 65, those with previous periods of uninsurance had more hospitalizations than those with continuous insurance, especially for cardiac disease and diabetes and joint replacement.

The authors calculate that while providing insurance for such enrollees would be expensive (almost $200 billion for four years that they were uninsured on average), the savings in Medicare from having these people insured prior to turning 65 might fund half of this cost. 

That’s optimistic. In fact, the group lacking insurance had such fundamental differences from the insured group at the outset that merely giving them insurance wouldn’t likely make their future medical costs equivalent.

Still, the authors demonstrate that the needs of those with periods of continuous uninsurance are real and large.  Those lacking insurance didn’t get treatment for their diabetes – and thus had more hospitalizations after they finally became eligible for insurance. The uninsured lived with the pain of “bone on bone” joints, and suffered unnecessary disability.

I am skeptical of the authors' conclusion that we could fund half of the cost of insuring these patients  from future Medicare savings.  I’m certain that the personal and societal cost of this delayed care is a substantial moral issue, and one of the reasons we miss many opportunities to deliver optimal care to Americans.