With lawmakers in Washington, D.C. and state houses getting ready to make major health policy decisions, a pair of University of Michigan studies shows how past policy decisions have affected older Americans with modest or low incomes. 

The findings could also help inform upcoming decisions about health insurance programs that are currently open to people with incomes under about $60,000 per person, and programs aimed at those living in or near poverty.

One study, just published in JAMA Health Forum, looks at people who turned 65 in the time since the Affordable Care Act’s insurance provisions took effect in 2014, compared with those who turned 65 before the ACA. 

It shows that the more recent group have lower out of pocket health costs and have had fewer hospitalizations as they aged into Medicare eligibility. 

This has implications for overall Medicare spending as they continue to age.

The study focused on people whose incomes were up to four times the poverty level, making them potentially eligible for help paying for health insurance if they needed to buy it when they were in their pre-Medicare years. 

It also looked at the subgroup who were eligible for Medicaid depending on their income and whether they lived in a state that expanded Medicaid under the ACA. 

The other study, also published in JAMA Health Forum, shows that half of people who are both old enough for Medicare and have incomes low enough to qualify for Medicaid did not know that they had to renew their Medicaid coverage every year. 

This requirement had been in place before the COVID-19 pandemic, but temporarily stopped from 2020 to 2024. 

The reinstatement of annual renewals happened through a process called unwinding. 

In all, the study finds that 12% of these dual eligible individuals lost their Medicaid coverage during the unwinding. 

Half of them said they had gotten it back, but they were the most likely to say they had gone without care they needed because of cost.

Extending ACA

Federal and state lawmakers have decisions to make in coming months about whether to extend ACA insurance premium subsidies and tax credits that are set to expire after this year, whether to change Medicaid eligibility and benefits at the state level, and how to structure Medicaid funding at the federal level.

“We hope evidence in these studies informs upcoming decisions related to funding, requirements, eligibility or cost supports for Medicaid, ACA, and related insurance programs,” said Renuka Tipirneni, M.D., M.S., the lead author of both studies and an associate professor of internal medicine at the U-M Medical School. 

“It will also be important to continue to study the health, health care use and health costs of those who have yet to age into Medicare since the ACA went into effect.” 

Tipirneni is a general internal medicine physician at Michigan Medicine, and a member of the U-M Institute for Healthcare Policy and Innovation.

More about the first study

For the study of people who aged into Medicare before and after the ACA’s insurance cost supports and Medicaid expansions took effect in 2014, Tipirneni and her colleagues used data from the Health and Retirement Study. 

Based at the U-M Institute for Social Research and funded by the National Institutes of Health, the HRS is a longitudinal study of people age 51 and over. 

The researchers focused on 2,782 people with incomes up to 400% of poverty, who aged into Medicare between 2010 and 2012 or between 2016 and 2018. 

For those with incomes up to 138% of poverty, they also examined whether they lived in a state that had expanded Medicaid before 2016. Nearly 1,000 of the total sample had Medicare records available to be studied.

Those who entered Medicare after the ACA took effect had lower out of pocket health costs by an average of $417 per year, compared with the pre-ACA group, and had fewer hospitalizations each year. 

There were no differences between the groups in their total Medicare costs, their health status or their use of outpatient or emergency care. 

SEE ALSO: Medicaid ‘cliff’ adds to racial and ethnic disparities for low-income older adults

As for Medicaid eligible individuals, the percentage who reported that they had limits on their ability to carry out basic self care tasks went down more in states that had expanded Medicaid. 

But other measures did not differ based on Medicaid expansion status. 

The decline in out of pocket health costs was smaller for those living in expansion states than in non-expansion states. 

Tipirneni notes that this may be because those who had Medicaid before they aged into Medicare would have had little or no cost sharing on Medicaid but might not have enrolled in Medicaid after aging into Medicare, or might not have enrolled in one of the Medicare Savings Programs for lower income adults. 

Tipirneni notes that Congressional action on renewing ACA insurance subsidies and tax credits, or letting them expire, will especially impact people in their final pre-Medicare years. 

Under the ACA insurers can charge them higher premiums than younger people. 

“The study findings underscore the importance of ACA subsidies to keeping insurance affordable not only for eligible adults ages 19 to 64, but also to potentially keep people healthier so that once they turn 65 they will be less likely to be hospitalized or pay a large amount out of pocket,” said Tipirneni. 

“We hope that our findings will help Congress understand the impact that even a few years of exposure to ACA insurance requirements and programs have had on older adults.” 

More on the second study

For the study of dual eligible individuals, Tipirneni and her colleagues carried out a survey through a polling organization. 

They questioned 843 people age 65 and older who had had both Medicare and Medicaid coverage in the past year, and incomes less than the federal poverty level, which is about $15,000 for an individual. 

These older adults were interviewed in early 2024, as Medicaid unwinding was in full swing but not yet concluded in all states. 

Annual renewals of Medicaid coverage require individuals to demonstrate by their renewal date that their income is still below eligible levels, or they will lose their insurance coverage.

In all, 16% said they had heard a lot about the return of annual Medicaid renewal requirements, and 35% had heard a little. 

But 49% of the group had heard nothing at all. 

The researchers also asked about how those who had heard of the unwinding had gotten their information.

SEE ALSO: ACA Helped Make Health Insurance Access More Equal, But Racial and Ethnic Gaps Remain

Not all of the respondents may have hit their renewal date by the time they were surveyed, but the researchers found that 45% had completed a renewal in the last year, 37% had not completed a renewal, and nearly 18% did not know that renewal was required. 

In all, 88% had been on Medicaid continuously over the six months before the survey, 6% lost Medicaid coverage but got it back, and 6% lost Medicaid and did not get it back.

Of those who lost Medicaid and got it back, 31% said they had gone without care because of cost. 

By comparison, 18% of those who said they had lost Medicaid and not gotten it back indicated they went without care because of cost, as did 6% of those who had maintained their Medicaid enrollment. 

Cost related barriers were more common for dental and home care services, which Medicaid typically covers.

“While the rate of Medicaid coverage loss was relatively low among dual eligible individuals at the time of the study, we found evidence of more barriers to health care for those who lost Medicaid. Since older adults and people with disabilities have greater health care needs, barriers to care from loss of coverage could lead to worsening health outcomes,” said Tipirneni. 

Eric T. Roberts, Ph.D., senior author of the second study and an associate professor at the University of Pennsylvania, added, “Ongoing assistance from state Medicaid agencies, health plans, and community organizations is needed to help dual eligible adults maintain Medicaid coverage or connect them with financial assistance programs like Medicare Savings Programs or the Part D Low-Income Subsidy.”

Additional authors: In addition to Tipirneni, the research teams included other faculty and staff affiliated with IHPI. Roberts is the senior of the dual eligible paper. 

Funding: The studies were funded by grants  from the National Institute on Aging of the National Institutes of Health (K08AG056591 and R01AG076437).

Disclosures: John Z. Ayanian, M.D., M.P.P., the director of IHPI, is senior author of the Medicare age-in study and at the time was editor of JAMA Health Forum but recused himself from the review process.

Papers cited: 

"Health Care Utilization and Costs for Older Adults Aging Into Medicare After the Affordable Care Act," JAMA Health Forum. DOI: 10.1001/jamahealthforum.2024.5025

"Medicaid Unwinding Experiences in Dual-Eligible Older Adults," JAMA Health Forum. DOI: 10.1001/jamahealthforum.2024.4692