|Title||Medicare Coverage at the End of Life: Separate and Unequal?|
|Publication Type||Journal Article|
|Year of Publication||2022|
|Journal||Journal of Pain and Symptom Management|
|Keywords||end of life, Medicare, out-of-pocket costs|
Outcomes 1. Contrast the pros and cons of different Medicare insurance types, from a patient perspective 2. Understand and describe out-of-pocket costs across Medicare Original Research Background Medicare coverage varies across beneficiaries, with some opting into Medicare Advantage (MA) versus traditional Medicare (TM); some are enrolled in supplementary insurance, and some are dually enrolled in Medicaid. It is unknown how variation affects those at the end of life and their families, Research Objectives We aim to characterize types of Medicare coverage at the end of life and assess how coverage type affects out-of-pocket spending in the last year of life. Methods We used the Health and Retirement Study, a nationally representative cohort study, to identify decedents between 1998 and 2016 with linked Medicare claims. Medicare insurance types were defined as TM alone, TM with supplementary insurance, MA, and dual eligible. We examined the sociodemographic and health characteristics of decedents across insurance groups and the reported out-of-pocket expenditures for hospitalizations in the last year of life. Results We identified 7,910 decedents, 8.5% who were enrolled in TM alone, 43.9% in TM with supplementary insurance, 27.2% in MA, and 20.5% duals. Although rates of MA grew over time, rates of TM with supplementary insurance fell. Compared to those with supplementary insurance or in MA, those in TM alone were younger, more likely to be male, in the lowest quartile of wealth, without a high school education, non-Hispanic Black, or Hispanic/Latino. Preliminary investigation of out-of-pocket costs showed that among those hospitalized in the last year of life, 31.4% of those with TM alone spent more than $2,000 out of pocket, compared to 14.9% in MA and 11.5% with supplementary insurance. Conclusion Across those enrolled in Medicare at the end of life but without Medicaid, those in TM alone are more likely to be from racial and ethnic minority groups and with lower education and wealth and yet face higher out-of-pocket spending. Implications for Research, Policy, or Practice Differences within Medicare create differential cost burdens at the end of life that may increase disparities for patients and their families.