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Table 1.  
National Poll on Healthy Aging Respondent Demographic Characteristics, US Adults Aged 50 to 64 Years, October 2018
National Poll on Healthy Aging Respondent Demographic Characteristics, US Adults Aged 50 to 64 Years, October 2018
Table 2.  
Perspectives of US Adults Aged 50 to 64 Years on Health Insurance, Health Care, and Employment
Perspectives of US Adults Aged 50 to 64 Years on Health Insurance, Health Care, and Employment
Table 3.  
Association of Low Confidence in Affording Health Insurance With Avoidance of Health Care Among US Adults Aged 50 to 64 Years
Association of Low Confidence in Affording Health Insurance With Avoidance of Health Care Among US Adults Aged 50 to 64 Years
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Nadash  P, Miller  EA, Jones  DK, Gusmano  MK, Rosenbaum  S.  A series of unfortunate events: implications of Republican efforts to repeal and replace the Affordable Care Act For older adults.  J Aging Soc Policy. 2018;30(3-4):259-281. doi:10.1080/08959420.2018.1462683PubMedGoogle ScholarCrossref
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Karaca-Mandic  P, Jena  AB, Ross  JS.  Health and health care use among individuals at risk to lose health insurance with repeal of the Affordable Care Act.  JAMA Intern Med. 2017;177(4):590-593. doi:10.1001/jamainternmed.2016.9541PubMedGoogle ScholarCrossref
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Levy  H, Buchmueller  T, Nikpay  S. Is the Affordable Care Act affecting retirement yet? https://mrdrc.isr.umich.edu/publications/papers/pdf/wp393.pdf. Published September 2018. Accessed July 8, 2019.
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Long  SK, Shartzer  A, Politi  M. Health reform monitoring survey: low levels of self-reported literacy and numeracy create barriers to obtaining and using health insurance coverage. http://apps.urban.org/features/hrms/briefs/Low-Levels-of-Self-Reported-Literacy-and-Numeracy.html. Published October 27, 2014. Accessed July 16, 2019.
16.
McWilliams  JM, Meara  E, Zaslavsky  AM, Ayanian  JZ.  Use of health services by previously uninsured Medicare beneficiaries.  N Engl J Med. 2007;357(2):143-153. doi:10.1056/NEJMsa067712PubMedGoogle ScholarCrossref
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Callegaro  M, DiSogra  C.  Computing response metrics for online panels.  Public Opin Q. 2008;72(5):1008-1032. doi:10.1093/poq/nfn065Google ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    The Importance of Considering Quality and Choice of Health Care in Addition to Cost
    Richard Fleming, PhD, MD, JD; Matthew R Fleming, BS, NRP; Tapan K Chaudhuri, MD | FHHI-OI-Camelot; Eastern Virginia Medical School
    The study by Tipirneni, et al is an interesting look at the out of pocket costs, for care reported, for individuals covered by the Affordable Care Act (ACA) Medicaid expansion program. It is not, however, a study of the quality of care provided or the choice of care provided to these individuals.

    There are several reasons why out of pocket expenses can decrease. The first would be an actual improved quality of care - with the patient’s office and hospital visits being covered in addition to the costs of testing, prescription drugs, and other related health care costs.
    That, of course, is the inference being made by this study and a Medicare-for-All approach. It is not, however what is shown here.

    There are unfortunately multiple other reasons – which are not covered in this study – which can also explain why reductions in out of pocket costs can occur. Including, inter alia:

    1. Decisions to not seek medical care because the provider the patient is required to see is different from the provider they would choose to see, if they had another insurance.

    2. Decisions by patients to not seek medical assistance due to costs and their expectations that they will not receive the same quality of care provided to people with private insurance, expectations that are at least to some extent founded by what is and isn’t covered under this government-run healthcare program.

    3. Decisions about whether the patients can afford to fill prescriptions under the ACA Medicaid expansion, given the continued run away prescription drug prices resulting from an uncontrolled BigPharma.

    4. Decisions not to undergo medical testing due to lack of coverage for such tests.

    5. Decisions to avoid hospital admission due to failure of coverage of such admissions or the requirement that they most go to a hospital different from the one they would choose to go to if they had private insurance.

    While this is by no means an all-encompassing list, it does demonstrate the tiered - caste system - level of medical care resulting from a government-run health care system.

    This paper by Tipirneni, et al, points out the limitations with the current ACA. It would be nice to think ACA provided better health care for people as a result of being part of a government-run health care program – unfortunately it does not.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Health Policy
    February 7, 2020

    Health Insurance Affordability Concerns and Health Care Avoidance Among US Adults Approaching Retirement

    Author Affiliations
    • 1Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 2Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
    • 3Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor
    • 4VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
    • 5Department of Pediatrics, University of Michigan, Ann Arbor
    • 6Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
    JAMA Netw Open. 2020;3(2):e1920647. doi:10.1001/jamanetworkopen.2019.20647
    Key Points español 中文 (chinese)

    Question  Do US adults have concerns about health insurance during retirement, and if so, are these concerns associated with avoidance of medical care?

    Findings  In this nationally representative survey study of 1028 US adults aged 50 to 64 years, 44.6% had low confidence in being able to afford health insurance during retirement, and 67.7% were concerned about potential changes to health insurance associated with changes in federal policies. Individuals with low confidence in health insurance affordability were more likely than those with higher confidence to avoid medical care and medications.

    Meaning  Policy solutions are needed to help patients better understand coverage options and navigate health care during the critical transition period before Medicare eligibility.

    Abstract

    Importance  As US adults approach Medicare eligibility at age 65 years, they face important decisions about health care and employment. Recent legislative, regulatory, and legal challenges to the Affordable Care Act may add new uncertainties to this decision-making.

    Objective  To understand adults’ perspectives on health insurance, health care, and employment near retirement.

    Design, Setting, and Participants  In October 2018, a cross-sectional online survey study of community-dwelling US adults aged 50 to 64 years was conducted with Ipsos KnowledgePanel, a nationally representative internet survey panel (completion rate, 62%). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019.

    Main Outcomes and Measures  Confidence in affording health insurance, keeping a job or delaying retirement to have employer-sponsored health insurance, concerns about potential changes to health insurance associated with changes in federal policies, and avoidance of medical care or medication because of cost.

    Results  Among 1028 respondents aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years), 51.8% (95% CI, 48.6%-55.0%) were female, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, 65.2% (95% CI, 62.1%-68.3%) were employed, and 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Approximately one-fourth of respondents (27.4%; 95% CI, 24.6%-30.4%) had little to no confidence in being able to afford health insurance over the next year, and nearly one-half (44.6%; 95% CI, 41.4%-47.8%) had little to no confidence in their ability to afford health insurance when they retire; 14.1% (95% CI, 12.0%-16.5%) reported keeping a job and 11.4% (95% CI, 9.6%-13.6%) reported delaying or considering delaying retirement to have employer-sponsored health insurance. Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential changes to their health insurance associated with changes in federal policies. In the past year, 13.2% (95% CI, 11.2%-15.5%) of respondents did not get medical care and 11.9% (95% CI, 9.9%-14.1%) avoided filling a prescription medication because of cost. After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely than those with higher confidence to avoid medical care (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) and to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001) because of cost concerns.

    Conclusions and Relevance  Many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and about potential future changes to their health insurance options associated with changes in federal policy. Policy solutions are needed to help patients better understand their coverage options and navigate health care in this critical transition period before Medicare eligibility.

    Introduction

    As US adults approach Medicare eligibility at age 65 years, they face complex decisions about health insurance and health care.1 These include considerations of current or anticipated future health conditions and related decisions about whether or when retirement should occur. Although Medicare provides nearly universal coverage for US adults aged 65 years and older, some individuals may retire earlier for health or other reasons,2 whereas others may continue working well past that age. Adults aged 50 to 64 years represent a group for whom such decisions can be complicated and consequential, because they commonly develop chronic health conditions3,4 and face increasing out-of-pocket health care costs1,5 but are not yet age-eligible for Medicare coverage. Therefore, as chronic health conditions accumulate and because a lack of health insurance has been associated with unmet health needs and poor health and financial outcomes, maintaining health insurance during this period is especially critical.6-8

    The formation of Marketplace plans and expansions of Medicaid coverage by the Affordable Care Act (ACA) have created a greater number of potential insurance options for adults aged 50 to 64 years, further complicating decisions about health insurance near and during retirement.9,10 Recent legislative, regulatory, and legal challenges to the ACA may create additional uncertainty in this decision-making process.11,12 Since January 2017, challenges at the federal level include Congress’s attempted repeal and replace of the ACA, removal of the penalty associated with the individual mandate to have health insurance, and announcements by the Department of Justice stating that the ACA preexisting condition protections would no longer be enforced.11-13

    Since implementation of the ACA and its subsequent challenges, there has been limited research comprehensively examining the perceived challenges to navigating health insurance that adults aged 50 to 64 years face as they approach retirement and how those challenges might be associated with decisions about health care and employment. Prior studies of this age group have primarily focused on tracking the uninsured rate, which has decreased from 15% in 2010 to 6% in 2015 after implementation of the ACA’s major coverage provisions,12 and likely continued to decrease in later years.14 One 2014 survey15 conducted among all nonelderly adults found limited numeracy and literacy among many adults across socioeconomic strata and found that nearly one-half of individuals with these limitations had difficulty navigating the process of selecting a health insurance plan. Before passage of the ACA, McWilliams and colleagues16 found increased health care utilization and costs after acquiring Medicare coverage at age 65 years among previously uninsured adults with a history of diabetes, hypertension, heart disease, or stroke, compared with adults with those conditions who were previously insured. However, there has been limited research examining how adults aged 50 to 64 years have navigated and used health insurance and health care since implementation of the ACA.

    In the current setting of major changes to US health insurance under the ACA and more recent federal health policy uncertainty, the objective of this study was to understand the perspectives of US adults aged 50 to 64 years with regard to health insurance affordability, health-insurance–related decision-making about employment, including retirement, and decision-making about health care. We also assessed whether potential concerns about health insurance affordability were associated with decisions to delay or avoid seeking health care.

    Methods
    Study Design

    A cross-sectional online survey study of adults aged 50 to 64 years was conducted in October 2018, as part of the University of Michigan National Poll on Healthy Aging. This study was reviewed and deemed exempt by the University of Michigan institutional review board, because it was a study of deidentified respondents. Thus, the requirement for informed consent was waived.

    Data Source

    The National Poll on Healthy Aging is a recurring, nationally representative survey of US households conducted using the Ipsos KnowledgePanel, a large, nationally representative, probability-based panel (Ipsos Public Affairs, LLC). The poll is directed by the University of Michigan Institute for Healthcare Policy and Innovation and is sponsored by AARP and Michigan Medicine, the academic medical center for the University of Michigan. National Poll on Healthy Aging surveys are conducted online 2 to 3 times each year with US adults aged 50 to 80 years. This study was conducted with a subset of adults aged 50 to 64 years as part of a multipart survey that included questions about health insurance, medication storage, memory, and pets.

    The Callegaro and DiSogra17 method for computing response metrics for online panels was used. For the overall survey fielding that included modules for adults aged 50 to 80 years, a random sample of 3202 panel members was drawn from Ipsos’s KnowledgePanel. A total of 2051 adults (excluding “break-offs,” ie, respondents who start the survey but fail to complete it) responded to the invitation and 2051 qualified for the survey, yielding a final stage completion rate of 64.1% and a qualification rate of 100%. The recruitment rate for this study, reported by Ipsos, was 13.2% and the profile rate was 63.5%, for a cumulative response rate of 5.4%.

    Measures

    Concern about health insurance affordability was assessed with the following survey items: “Please rate your confidence with the following: (1) being able to afford the cost of your health insurance and out of pocket costs over the next year; and (2) being able to afford the cost of your health insurance and out of pocket costs when you retire.” Responses options included “not at all confident,” “slightly confident,” “moderately confident,” and “very confident.” Respondents were categorized as having low confidence in health insurance affordability if they reported being not at all confident or slightly confident to either or both of these survey items.

    Avoidance of health care was determined by a no or yes response to the following items: “In the last year, have you (1) not gotten medical care because of how much it would cost you; and (2) not filled a prescription because of how much it would cost you?” Respondents were considered to have avoided health care if they reported not getting medical care and/or not filling a prescription.

    Employment decision-making was assessed by a no or yes response to the following survey items: “In the past year, have you (1) kept a job specifically to have health insurance through your employer; and (2) delayed or considered delaying retirement specifically to have health insurance through your employer?” Concern about federal policy changes to health insurance was assessed with the item, “How concerned are you about potential changes to your health insurance coverage due to changes in federal policies?” Response options included “very concerned,” “somewhat concerned,” “not very concerned,” or “not at all concerned.” Responses reporting being very or somewhat concerned were combined to indicate those concerned about federal policy changes.

    Standard demographic characteristic data on panel members were obtained from Ipsos, except for employment status, which was obtained from the National Poll on Healthy Aging survey. For 13 respondents (0.6% of the sample) who did not respond to the survey question, employment status was obtained from Ipsos data.

    Statistical Analysis

    Poststratification survey weights provided by Ipsos were applied to reflect the US population and to estimate nationally representative descriptive demographic and health statistics. Each survey item had less than 1% to 2% missing responses, and more than 97% of respondents missed 2 or fewer survey items. All respondents were included in the analysis, but percentages are reported for each survey item only among those who answered the item. Thus, missing responses are dropped from the denominator.

    For comparisons of survey responses between respondents who were working and not working, the χ2 test was used to determine statistical significance. To determine the association between health insurance affordability concerns and avoidance of health care, a multivariable logistic regression analysis was conducted, adjusting for age, gender, race/ethnicity, education, income, marital status, employment status, health status, and type of health insurance. Sensitivity analyses with alternative categorizations of variables and models with additional covariates were also conducted. Two-sided P < .05 was considered statistically significant. All analyses were conducted with Stata statistical software version 15 (StataCorp). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019.

    Results
    Survey Sample

    The study sample included 1028 community-dwelling US adults aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years) (completion rate, 62% among panel members contacted to participate). Overall, 51.8% (95% CI, 48.6%-55.0%) of the respondents were female, 68.4% (95% CI, 65.1%-71.5%) were non-Hispanic white, 11.7% (95% CI, 9.6%-14.1%) were non-Hispanic black, and 12.9% (95% CI, 10.7%-15.5%) were Hispanic (Table 1).17 Of the respondents, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, and 17.9% (95% CI 15.4%-20.8%) had an annual household income of less than $30 000. Most respondents (65.2%; 95% CI, 62.1%-68.3%) were employed, whereas 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Less than one-half (42.9%; 95% CI, 39.8%-46.1%) rated their health as excellent or very good, 40.5% (95% CI, 37.4%-43.6%) rated their health as good, and 16.7% (95% CI, 14.3%-19.3%) rated their health as fair or poor. Most respondents (66.2%; 95% CI, 63.0%-69.3%) had employer-sponsored health insurance, 8.3% (95% CI, 6.7%-10.3%) had an individual private insurance plan, 7.8% (95% CI, 6.1%-10.0%) had Medicaid, 7.8% (95% CI, 6.2%-9.8%) had Medicare, 2.9% (95% CI, 2.0%-4.3%) were dually enrolled in Medicare and Medicaid, 2.8% (95% CI, 1.9%-3.9%) had Veterans Administration or Tricare coverage, and 4.2% (95% CI, 3.0%-5.8%) were uninsured.

    Respondents were similar to nonrespondents overall, except that a greater proportion of nonrespondents were female, black, or Hispanic (eTable 1 in the Supplement). Survey estimates incorporate weights that account for these differences.

    Health Insurance Affordability Concerns

    Approximately one-fourth (27.4%; 95% CI, 24.6%-30.4%) of respondents reported low confidence in their ability to afford health insurance and out-of-pocket costs over the next year (Table 2). Nearly one-half (44.6%; 95% CI, 41.4%-47.8%) reported low confidence in their ability to afford health insurance when they retire. A total of 47.3% (95% CI, 44.1%-50.5%) of respondents had low confidence in health insurance affordability during either the next year or retirement. Respondents who were retired or not working at the time of the survey were more likely than those who were still working to report low confidence in health insurance affordability in the next year (34.2% [95% CI, 28.9%-39.8%] vs 23.8% [95% CI, 20.6%-27.4%]) but not during retirement (40.8% [95% CI, 35.3%-46.5%] vs 46.6% [95% CI, 42.8%-50.5%]) (Table 2).

    Decisions About Employment and Retirement

    With regard to employment decision-making, 14.1% (95% CI, 12.0%-16.5%) of respondents reported keeping a job in the last year specifically to maintain employer-sponsored health insurance, and 11.4% (95% CI, 9.6%-13.6%) delayed or considered delaying retirement to keep their employer-sponsored health insurance (Table 2). Overall, 18.8% (95% CI, 16.4%-21.4%) of respondents either kept a job, considered delaying retirement, or delayed retirement to maintain their employer-sponsored health insurance. Respondents who were working were more likely than those who were retired or not working to report either keeping a job (19.2% [95% CI, 16.2%-22.5%] vs 4.7% [95% CI, 2.8%-7.9%]) or considering delaying retirement (15.1% [95% CI, 12.5%-18.0%] vs 4.6% [95% CI, 2.7%-7.5%]) to maintain employer-sponsored health insurance (Table 2).

    Concerns About Changes to Federal Health Insurance Policy

    Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential future changes to their health insurance coverage associated with changes in federal policies (Table 2). Respondents who were working were almost as likely as those who were retired or not working to report these concerns (65.9% [95% CI, 62.1%-69.5%] vs 71.2% [95% CI, 65.8%-76.0%]) (Table 2).

    Avoidance of Medical Care and Association With Health Insurance Affordability Concerns

    Approximately 13.2% (95% CI, 11.2%-15.5%) of respondents said that they did not get medical care in the past year because of cost (Table 2). In addition, 11.9% (95% CI, 9.9%-14.1%) reported not filling a prescription medication because of cost concerns. Overall, 18.2% (95% CI, 15.9%-20.8%) of respondents avoided either medical care or filling a prescription because of cost concerns. Respondents who were retired or not working at the time of the survey were more likely than those who were still working to report avoiding filling a prescription (16.1% [95% CI, 12.3%-20.8%] vs 9.6% [95% CI, 7.6%-12.2%]) but not avoiding medical care (12.1% [95% CI, 8.9%-16.2%] vs 13.9% [95% CI, 11.4%-16.7%]) (Table 2).

    After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely to avoid medical care because of cost concerns (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) (Table 3). Individuals with health insurance affordability concerns were also more likely to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001). Overall, adults aged 50 to 64 years with low confidence in health insurance affordability had 3 times the odds of either avoiding medical care or avoiding filling a prescription due to cost concerns (adjusted odds ratio, 3.00; 95% CI, 2.00-4.50; P < .001).

    Sensitivity Analyses

    In sensitivity analyses, additional models were considered that classified the primary independent variable as low confidence in health insurance affordability during the next year only or during retirement only (eTable 2 and eTable 3 in the Supplement). Findings were similar to those of the primary analysis. Models that included as covariates measures of health insurance literacy (defined as confidence in understanding health insurance terms, covered services, and out-of-pocket costs) were also considered. The findings remained similar (eTable 4 in the Supplement).

    Discussion

    In this nationally representative survey of US adults aged 50 to 64 years conducted after implementation of, and subsequent legal challenges to, the ACA, nearly one-half of respondents had low confidence in their ability to afford health insurance during retirement, and most were concerned about potential future changes to their health insurance associated with changes in federal policies. Individuals reporting concerns about health insurance affordability were significantly more likely to avoid medical care, including prescription medication fills. This is troubling, given the frequent diagnosis of chronic health conditions among adults older than age 50 years,3 the high burden of poor health, with 16.7% of the respondents rating their health as fair or poor, and the overall increasing morbidity and mortality for individuals with low socioeconomic position in this age group.18,19 These findings suggest that the health insurance affordability concerns identified could translate to negative long-term health outcomes for US adults approaching Medicare age. In addition, because health insurance may be associated not only with health but also with capacity to work,20,21 such health insurance concerns may be associated with whether adults aged 50 to 64 years feel flexibility to change jobs or retire, both directly and indirectly.

    The current findings about affordability concerns among adults aged 50 to 64 years track with other recent national data about US workers’ retirement planning. In 2019, the Employee Benefit Research Institute found that 41% of workers were not confident they would have enough money to take care of their medical expenses during retirement.2 This is not surprising, because individuals aged 50 to 64 years spend 10% of their household budget on health care, and this percentage increases with age.22

    It is important to note that the timing of Medicare eligibility at age 65 years may not necessarily match the timing of retirement, because many individuals will retire before or after age 65 years. In this sample, 34.8% reported they had already retired or were not working. Adults aged 50 to 64 years who are healthy may continue to work for many years, whereas those with multimorbidity due to several chronic conditions may need to retire early for health reasons. Given the variability in the timing of retirement,23 concerns about health insurance affordability near retirement likely have less to do with concerns about Medicare and more to do with costs of current plans or transitions between plans. Increasing out-of-pocket costs in recent years1,24 may be negatively associated with people’s perceptions of their ability to afford insurance now and in the future. Likewise, adults aged 50 to 64 years may worry about transitions between employer-sponsored insurance plans, or from employer-sponsored insurance to Medicaid or Marketplace plans. In fact, prior studies of adults in their 50s and 60s have found that they are more likely to be enrolled in Marketplace plans compared with younger adults,25 and that this proportion grew between 2013 and 2015.1

    In addition to concerns about affordability of health insurance, 14.1% of adults aged 50 to 64 years reported keeping a job specifically to have employer-sponsored health insurance, a phenomenon known as “job lock,” whereas 11.4% reported delaying or considering delaying retirement to maintain employer-sponsored health insurance. The ACA’s insurance coverage expansion was intended, in part, to reduce job lock and allow individuals to change or leave their job without concerns about becoming uninsured.26 However, the current findings suggest that many older adults aged 50 to 64 years still worry about maintaining employer-sponsored insurance and keep a job for that reason, perhaps because of concerns about affordability of other health insurance options. Although other studies have found no change in labor force participation or early retirement related to ACA Marketplace or Medicaid expansion coverage,14 these findings suggest that the ACA may not have fully eliminated job lock for individuals aged 50 to 64 years who remain employed.

    Limitations

    The current study has several potential limitations. First, as with all surveys, there is the potential for recall or response bias. However, the use of a large national panel and response rate mitigate some of the concern for response bias, and survey weights were applied to account for any response differences. The selection of survey items focused on recent behavior and attitudes also help mitigate potential recall bias. Second, it is possible that respondents to an online survey may differ from the general population. However, nearly 90% of US adults aged 50 to 64 years used the internet by 2018.27 Several studies have found similar characteristics among older adult respondents to internet vs noninternet surveys, whereas other studies have found that internet samples were younger than in-person samples.28 Third, this is a cross-sectional study conducted after legal challenges to the ACA; the findings should be interpreted in the context of national policies in place at the time of the survey in October 2018. Fourth, the association identified between health insurance affordability concerns and avoidance of medical care does not signify causality. Because this is a cross-sectional study, it is not possible to determine the direction of effects—for example, whether worries about health insurance led to avoidance of medical care or vice versa. It is also possible that there are other unobserved mediators of our outcomes, although the results were adjusted for standard demographic and health characteristics.

    Implications

    Despite these limitations, the study findings have important policy implications for multiple stakeholders. For health care professionals, the results underscore the importance of discussions with patients about out-of-pocket costs to help inform decisions about timing, choice, and appropriateness of health care services.29 For employers and health insurance navigators, the findings suggest that these groups should help individuals near retirement understand coverage options and navigate health care during this critical transition period. Such education and outreach efforts are needed to help adults navigate the myriad possible health insurance transitions that can occur at age 65 years. For policy makers, it is clear that health insurance and health care remain top issues for US adults aged 50 to 64 years and that this group worries about how policy makers are addressing them.30 Policy solutions are needed to enhance the stability of health insurance affordability and availability for adults in this age group.

    Currently, several proposals are being considered by Congress to extend health insurance options to adults aged 50 to 64 years, as well as to other age groups. These proposals include a Medicare-for-all or single-payer health insurance plan that would replace the current employer-sponsored health insurance system, a renewed proposal for a public option in the ACA Marketplace, and Medicare buy-in proposals that would allow adults aged 50 to 64 years the option to buy into Medicare coverage before age 65 years.31 Future research should continue to investigate the perspectives of adults aged 50 to 64 years as changes are considered to federal health insurance policy.

    Conclusions

    In summary, this study found that many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and most worry about potential future changes to their health insurance options associated with changes in federal policy. Of concern, such worries about health insurance were associated with avoidance of medical care. Although federal legislative efforts to change the ACA and other health insurance reforms largely failed in 2018, these findings suggest that health care policy solutions are needed to help patients near Medicare age understand their coverage options and navigate health care during this critical transition period.

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    Article Information

    Accepted for Publication: December 11, 2019.

    Published: February 7, 2020. doi:10.1001/jamanetworkopen.2019.20647

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Tipirneni R et al. JAMA Network Open.

    Corresponding Author: Renuka Tipirneni, MD, MSc, Division of General Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd, Bldg 16, Room 419W, Ann Arbor, MI 48109 (rtipirne@med.umich.edu).

    Author Contributions: Dr Tipirneni and Mr Kirch had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Tipirneni, Solway, Malani, Luster, Kullgren, Kirch, Scherer.

    Drafting of the manuscript: Tipirneni, Luster.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Kirch.

    Obtained funding: Malani.

    Administrative, technical, or material support: Tipirneni, Solway, Luster, Kullgren, Singer.

    Supervision: Tipirneni, Malani, Kullgren, Scherer.

    Conflict of Interest Disclosures: Dr Kullgren reported receiving consulting fees from SeeChange Health, HealthMine, and the Kaiser Permanente Washington Health Research Institute and honoraria from the Robert Wood Johnson Foundation, AbilTo Inc, the Kansas City Area Life Sciences Institute, and the American Diabetes Association. No other disclosures were reported.

    Funding/Support: The National Poll on Healthy Aging is sponsored by AARP and Michigan Medicine. Dr Tipirneni is supported by a K08 Clinical Scientist Development Award from the National Institute on Aging (grant 1K08AG056591). Support was also provided by the Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development (HSR&D) Service. Dr Kullgren is a VA HSR&D Career Development awardee at the Ann Arbor VA.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

    Meeting Presentation: This study was presented at the Society of General Internal Medicine Annual Meeting; May 9, 2019; Washington, DC; and the AcademyHealth Annual Research Meeting; June 3, 2019; Washington, DC.

    Additional Contributions: We gratefully acknowledge the contributions of other members of the National Poll on Healthy Aging Team: Sarah J. Clark, MPH (Department of Pediatrics, University of Michigan), and Eileen Kostanecki, MA, Trish Meyer, EdM, Kara Gavin, MS, Christina Camilli-Whisenhunt, MPA, Mark Lubin, MS, and Emily Smith, MA (all from the Institute for Healthcare Policy and Innovation, University of Michigan). These individuals were not compensated beyond their usual salary.

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