Striking health inequities between dually enrolled and nondually enrolled older Medicare beneficiaries

In the United States, income inequality has steadily increased over the last several decades. Given widening inequities, health care leaders have been concerned about the health outcomes of older Americans who experience poverty, particularly because prior studies have shown a strong link between socioeconomic status and health.

In a new study published today in JAMA, a team of researchers led by Rishi Wadhera, MD, MPP, MPhil, an investigator in the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center (BIDMC), evaluated how health outcomes for low-income older adults who are dually enrolled in both Medicare and Medicaid have changed since the early 2000s, and whether disparities have narrowed or widened over time compared with more affluent older adults who are solely enrolled in Medicare.

The study included more than 71 million older adults insured by Medicare from 2004 and 2017. The researchers evaluated the change in annual death rates, hospitalization rates, and hospitalization-related deaths for the subset of this population that is also dually enrolled in Medicaid due to poverty. Wadhera and colleagues also assessed whether health outcomes for this low-income population have improved or worsened compared with more affluent older adults only enrolled in Medicare.

We found that annual death rates were more than two-fold higher for low-income older adults who were dually enrolled in Medicare and Medicaid compared with their more affluent, non-dually enrolled counterparts. In addition, annual hospitalization rates among dually-enrolled adults were almost double that of non-dually enrolled adults, and 30-day and one-year death rates after hospitalization were also higher for this low-income population. Most concerning, disparities in health outcomes between these two groups have not narrowed, and in some cases, are worsening."

Rishi Wadhera, investigator, Smith Center for Outcomes Research in Cardiology, BIDMC

Wadhera and colleagues also found that annual death rates for low-income older adults were generally highest in Midwestern states, such as Indiana and Ohio, and the Southeastern regions of the U.S. including Florida, Alabama, Arkansas and the Carolinas. Further research is needed to understand why high death rates persist in these regions of the US.

The findings are particularly striking given that over the last decade, a large part of U.S. policy and public health focus has been on improving the health of vulnerable and marginalized populations. Wadhera and colleagues say the study suggests that greater local and national efforts are needed to reduce health inequities.

"We know that low-income older Americans who are dually-enrolled in Medicare and Medicaid face unique challenges, such as poverty, housing instability, residence in more disadvantaged neighborhoods, and worse access to health care," said Wadhera. "Our findings suggest that in order to improve health equity for this population, public health and policy efforts are needed to directly address social determinants of health and to provide support for safety-net health care systems that tend to care for low-income patients."