Insurance Disruption due to Spousal Medicare Transitions: Implications for Access to Care and Health Care Utilization for Women Approaching Age 65

Health insurance plays a critical role in health care use among near-elderly adults (ages 55–64). People approaching the age of Medicare eligibility are more likely to experience illnesses requiring medical care (Brennan 2000; Holahan 2004; McWilliams et al. 2004) and face increased medical expenditures relative to people in younger cohorts (Holahan 2004). Although prior research has shown that the near-elderly are less likely than younger cohorts to be uninsured (Morrisey and Jensen 2001; Holahan 2004), more than one in five near-elderly adults change their insurance in a given year (Sloan and Conover 1998). These insurance disruptions strike this population at a vulnerable time; the near-elderly represent the oldest age group without universal health care coverage and have a high likelihood of poorer health and morbidity (Jensen 1992; Sloan and Conover 1998; Brennan 2000). There is reason to believe that the consequences associated with insurance disruptions may disproportionately burden near-elderly women. Over one-third of women in this age range are listed as a dependent on their husbands' employer-sponsored health insurance policies (Short 1998; McCormack et al. 2002). This is critical given that fewer employers are offering retiree health benefits (Morrisey and Jensen 2001; Iglehart 2002; McCormack et al. 2002), and fewer still are offering health benefits that continue to cover a spouse once employment has ended (Johnson, Davidoff, and Moon 2002). Given most women in this age range will not be Medicare eligible themselves because they are not yet 65 (Sloan and Conover 1998; Brennan 2000) coupled with the fact that women in this age range are more likely to be married to men who are older than they are (Oppenheimer 1988; Mutschler 2001; Wisconsin Department of Health and Family Services, Division of Health Care Financing, and Bureau of Health Information 2004), it appears that near-elderly women represent a group that is at increased risk of health insurance coverage disruptions. Further, while previous research has found evidence that a husband's near universal transition to Medicare at age 65 contributes to insurance disruptions for his near-elderly wife (Mutschler 2001), the consequences of such a disruption on perceived access to care, health care utilization, and health status are unknown. The fact that over the next 20 years the number of women in the 55–64 year age group will increase by over 5.5 million (Purcell 2005) and that women are more likely than men to have higher health care expenses and utilize more health care services (Patchias and Waxman 2007) underscores the importance of examining the consequences of insurance change on a rapidly growing population of near-elderly women who are likely to experience these changes. Studies examining the impact of health insurance disruptions on health care use and health outcomes have demonstrated conflicting findings, a likely result of methodological problems. Studies have found health insurance changes in the general population to be associated with a higher risk of avoidable hospitalizations (Franks, Cameron, and Bertakis 2003), emergency room (ER) visits (Kasper, Giovannini, and Hoffman 2000), and a lower likelihood of visiting a physician (Burstin et al. 1998; Kasper, Giovannini, and Hoffman 2000; Weber et al. 2005). Other studies have found insurance changes to be associated with an increased likelihood of physician office visits (Flocke, Stange, and Zyzanski 1997; Franks, Cameron, and Bertakis 2003), a finding that seemingly conflicts with previous research. The majority of research that has examined the impact of insurance disruptions on health care utilization and health outcomes, however, utilizes insurance change as an explanatory variable in a multivariable model with statistical control as the primary approach to adjust for confounding factors (Flocke, Stange, and Zyzanski 1997; Burstin et al. 1998; Kasper, Giovannini, and Hoffman 2000; Franks, Cameron, and Bertakis 2003). Yet prior research has shown that nearly 60 percent of insurance changes are brought about by personal choice, including for example, a desire to change insurance policies due to between-plan differences (Cunningham and Kohn 2000). It is likely that many of the factors associated with the decision to change insurance plans are unidentified and/or unmeasured. To the extent these same unobserved factors are associated with perceived access to care, health care utilization, or health status, the relationship between insurance disruption and these outcomes is confounded and the estimates of effect are biased. In addition, the majority of studies that have examined the impact of insurance disruptions have emphasized general, as opposed to near-elderly populations. The few studies of the near-elderly have been limited to the effect of gaps in or loss of insurance coverage on health care utilization and health outcomes (Baker et al. 2001; Sudano and Baker 2003; McWilliams et al. 2004), and not on the impact of insurance change on these same outcomes or on perceived access to care. This is a significant gap in the literature given the high percentage of the near-elderly that are likely to experience insurance changes at a time when they are also more likely to have chronic conditions requiring consistent access to medical care. The purpose of the current investigation is to assess the extent to which a husband's transition to Medicare at age 65 leads to insurance disruptions for his wife that impact her perceived access to care, health care utilization, and health status. Disruption was defined as a change in insurance plan within the previous year. An instrumental variable (IV) analysis was used to provide unbiased estimates of the effect of insurance disruption on outcomes, isolating the insurance disruption effect to the women who experienced the disruption because of their husbands' Medicare transitions (Greene 1997). We compare our findings with the traditional multivariable approach. Our analysis addresses important gaps in the research literature including the consequences of insurance change in the near-elderly population and the methodological limitations of previous studies.