As Medicare turns 60, research shows more need for enrollment help

Sixty years ago this week, President Lyndon Johnson signed Medicare into law, giving all Americans over 65 access to health coverage.

Today, nearly 69 million Americans rely on this coverage. 

Half of them get it directly from the federal government through traditional Medicare, and half from insurance companies that offer Medicare Advantage plans, also funded by the federal government.

The program now includes people with major disabilities too.

But two recent studies from a University of Michigan team suggest that many older and disabled Americans could use more help picking the best Medicare option for them.

Getting help from others or online with Medicare decisions

One of the studies shows that only about 38% of people over 65 who switch Medicare plans get any help in doing so, with much lower percentages among those who don’t have family caregivers.

In all, the study finds only about 13% of enrollees switch plans in a given year.

It also shows that only 33% of those who have Medicare use the Internet to research their options or handle other insurance matters, with much lower percentages among those who did not attend college or have lower household incomes.

The study also looked at data from 2015 to 2023 from people over age 71, and showed that the percentage getting help was never above 50% and dropped during the first years of the COVID-19 pandemic.

Use of the internet for insurance matters by Medicare enrollees over 71 rose sharply in recent years, from less than 20% to just over 30%.

Medicare decisions for people with dementia

The other recent study shows that, even though people with dementia may have very different health care needs than those without dementia, Medicare Advantage plan choice patterns are very similar for the two groups.

This suggests a lack of help in searching for the best option for someone with dementia, whether they are choosing a plan themselves or with help from a spouse, partner or adult child.

However, the study does show that people with dementia who qualify for both Medicare and Medicaid because of a low income were more likely to choose a “special needs plan” that offers more care management help.

A dizzying array of choices

The lead researcher on both studies is Lianlian Lei, Ph.D., an assistant professor in the U-M Medical School’s Department of Psychiatry.

She notes that most older adults have dozens of plans to choose from, including traditional Medicare, Medicare Advantage, and add-on plans to cover prescription drugs and other expenses.

This creates many dimensions to the decision that older adults and people with disabilities face when they first join Medicare, and then every year during Medicare Open Enrollment, which runs from mid-October to early December.

She also notes that free, unbiased help is available to help them find the plan that best fits their health needs, including state-level programs funded by federal dollars, through the State Health Insurance Assistance Program, also called SHIP. 

They can also use the Medicare system’s online Medicare Plan Compare tool to explore each option open to them. That site includes ratings of Medicare Advantage plans and Part D prescription drug plans that assign a number of stars to each plan based on quality measures and satisfaction surveys.

Meanwhile, older adults receive many promotional mailings and invitations to events from health insurance companies and insurance brokers, touting their products and services.

“If you just look at the flyer they send you, it offers little information, so if you want to know a plan’s star rating, benefits offered, or see which providers and hospitals are in its network you have to go to the internet,” she said.

“That’s what makes it so shocking that a lot of people enrolled in Medicare don’t use the internet for insurance information.”

Even if someone visits the Plan Compare site to learn about plans open to them and see their star ratings and costs, they will also need to go to the website of each Medicare Advantage plan they’re considering in order to see the current network of providers and hospitals that accept that plan, and to learn about things like the prior authorization process for some types of care.

Meanwhile, she said, “The SHIP program was designed to help people get unbiased counseling. But many people don’t know this help is available, and because it’s delivered by state agencies and relies in part on local groups and trained volunteers, there is variation in quality.”

Some people may rely on word of mouth from friends and family, but that doesn’t take into account the fact that health needs vary greatly from person to person.

If someone makes a decision based mainly on the monthly premium that they’ll pay under traditional Medicare or an MA plan, that leaves out key things like copays, deductibles and prescription drug price lists, which can greatly change the total cost of choosing that plan.

Building on previous findings, with more to do

Previous research has shown that many older adults aren’t aware of the state-level help programs and that older adults who are part of couples usually choose the same Medicare Advantage option as their spouse, even if their health needs are different.

Lei and colleagues also recently published findings about what drives people to leave a Medicare Advantage plan or return to traditional Medicare.

They show that inability to access care, and dissatisfaction with care quality, mattered much more than cost.

“Many older people probably research their health insurance less than they research buying a car, in part because it’s hard to compare different plan options, the Information is not well organized and you have to seek it from many sources,” she said.

The new papers come from Lei’s broader effort to understand Medicare-related decision-making among older adults. She and colleagues at the U-M Institute for Healthcare Policy and Innovation continue to explore different aspects of Medicare enrollment decisions. 

The data used in the studies came from two large federal surveys of older adults funded by the National Institutes of Health: the National Health and Aging Trends Study, based at Johns Hopkins University, and the Health and Retirement Study, based at U-M’s Institute for Social Research.

Additional authors: In addition to Lei, the authors of the new papers include her fellow IHPI members Donovan Maust, M.D., M.S., of the U-M Department of Psychiatry and VA Center for Clinical Management Research; Helen Levy, Ph.D., of the Institute for Social Research;  Geoffrey J. Hoffman, Ph.D. of the School of Nursing;  Hyungjin Myra Kim, Sc.D. of the U-M School of Public Health; former IHPI member Claire Ankuda, M.D., MPH, now at the Icahn School of Medicine at Mount Sinai; and U-M and VA research team members Kierstdea Petzold and Julie Strominger, M.S.

Funding/disclosures: The research was supported by the National Institute on Aging, part of the National Institutes of Health (R00AG075145, R01AG056407, P30AG066582, K76AG064427, 1R01AG074944-01).

Papers cited:

“Support and Internet Use in Navigating Medicare Plans Among Older Americans,” Journal of the American Geriatrics Society. DOI:10.1111/jgs.19516

“Older adults living with dementia enrolled in similar Medicare Advantage plans compared to those without dementia,” Alzheimer’s & Dementia: Behavior and Socioeconomics of Aging. DOI:10.1002/bsa3.70016

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