Jeanne Madden, PhD Associate Professor Department of Pharmacy and Health Systems Sciences School of Pharmacy and Pharmaceutical Sciences Bouvé College of Health Science Northeastern University  

Medical Care Costs: Government Insurance Does Not Mean Worry Free Interview with:

Jeanne Madden, PhD Associate Professor Department of Pharmacy and Health Systems Sciences School of Pharmacy and Pharmaceutical Sciences Bouvé College of Health Science Northeastern University  

Dr. Madden

Jeanne Madden, PhD
Associate Professor
Department of Pharmacy and Health Systems Sciences
School of Pharmacy and Pharmaceutical Sciences
Bouvé College of Health Science
Northeastern University What is the background for this study?

Response: Medicare is the US public insurance program mainly serving people 65 years and older, but also some younger adults who have long-term disabling conditions. As such, on average, the Medicare population bears a heavy burden of illness and has high health care needs, compared to the general US population. The under-65 group for the most part has quite low incomes, while the older group represents a wide spectrum, from poor to well-off. Medicare beneficiaries also differ a great deal in terms of whether they have access to supplemental insurance that can help with patient cost-sharing requirements. I’m referring to Medicaid assistance, or a self-purchased Medigap plan, or retiree health benefits, etc. The cost-sharing requirements in traditional Medicare are substantial — e.g., 20% for doctor visits — and there is no annual cap on patient out-of-pocket spending. That’s in contrast to commercial insurance and Medicare Advantage managed care plans — all of those have an annual cap on patient out-of-pocket costs.

There’s a good amount of existing research on whether people in Medicare can afford their drugs, and on the affordability of medical care among younger groups such as working-aged uninsured people and those in ACA exchange plans. But there hasn’t been much research into medical care affordability among older Americans. What are the main findings?

Response: Well, we looked a two major “types” of unaffordability reported by enrollees who took part in Medicare’s big annual scientific survey. The participants were asked if they’d delayed care because of costs, and also whether they had problems paying their medical bills – including maybe they just couldn’t pay at all, had medical debts, or had been contacted by collection agencies. Roughly 11% delayed care overall, and another 11% struggled to pay the bills, and together it was 16% that did one or the other or both.

But it’s when you look closely at special vulnerable pockets within the population that you really see the troubles. Among the under-65 group, about 2 in 5 reported some type of unaffordability. We found especially high rates also among older people who have multiple chronic conditions, or who have symptoms of depression or anxiety. In addition, poverty, not surprising, was closely associated with struggling to afford care. We also noted that older people who were “near poor” reported a lot of difficulties – because not only do they have their low incomes, but they don’t qualify for financial assistance programs like Medicaid. What role does the cost of medications, especially specialty meds for psoriasis, Alzheimer’s, cancer etc play?

Response: Our study dealt with a survey section focused on medical care – this section wasn’t asking specifically about meds. There are separate questions on medication affordability, and we’ve done fairly extensive research on that in the past. Medicare’s survey recently added new questions about medical care affordability that hadn’t been asked before. Nevertheless, I imagine that high med costs often still play a role here – because that’s the thing, so many of these folks are juggling a range of expensive needs on very thin resources, and having to make decisions and trade-offs – “do I skip this prescription or that visit, or maybe I have to do both but then I can’t afford to buy food or make my rent?” This shows in the tight association between unaffordable care and symptoms of stress. Many are experiencing vulnerability along multiple, clustered dimensions What should readers take away from your report?

Response: A lot of people might assume that having this government health insurance means not having to worry about medical care costs, but that isn’t true. Medicare helps a great deal with access to care, but still not everyone gets full access to what they need. It isn’t an equitable situation on the ground. If the cost-sharing is beyond reach for someone with very modest means, they may go untreated. And for those who require treatment for multiple chronic conditions, all those individual cost-sharing amounts really add up, getting them into more trouble in terms of not being able to afford what they need.

It might help for health care providers to become aware of the extent of the problem. Either patients or providers could try to get an honest conversation going about these kinds of cost barriers, and hopefully that could lead to some strategizing around planning care that is more affordable, or maybe getting assistance for which some people maybe hadn’t realized they were already qualified. What recommendations do you have for future research as a result of this work? 

Response: It would be good to get more data and more precision around what specific types of care are hardest to afford. We have a handle on which groups of enrollees are at greatest risk, but the role of supplemental insurance, and whether people have adequate opportunity to obtain it, and whether choosing Medicare Advantage leads to better protection against exorbitant costs – that all needs a closer look. And of course, there have long been policy proposals on the table to alleviate the burden of high cost-sharing in a targeted – such as expanding Medicare’s financial assistance programs so that people in the “near-poor” bracket can also get some help, or placing a patient spending cap on traditional Medicare. If any of that happens, we’d want to look at how well it helps and especially whether it improves health outcomes for people currently at high risk of unaffordability.

No conflicts to disclose. 


Madden JM, Bayapureddy S, Briesacher BA, et al. Affordability of Medical Care Among Medicare Enrollees. JAMA Health Forum. 2021;2(12):e214104. doi:10.1001/jamahealthforum.2021.4104

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Last Updated on December 12, 2021 by Marie Benz MD FAAD