Who Are the Uninsured Elderly in the United States?

Identifying groups at-risk to extreme heat: Intersections of age, race/ethnicity, and socioeconomic status

Anthropogenic climate change has resulted in a significant rise in extreme heat events, exerting considerable but unequal impacts on morbidity and mortality. Numerous studies have identified inequities in heat exposure across different groups, but social identities have often been viewed in isolation from each other. Children (5 and under) and older adults (65 and older) also face elevated risks of heat-related health impacts. We employ an intersectional cross-classificatory approach to analyze the distribution of heat exposure between sociodemographic categories split into age groups in the contiguous US. We utilize high-resolution daily air temperature data to establish three census tract-level heat metrics (i.e., average summer temperature, heat waves, and heat island days). We pair those metrics with American Community Survey estimates on racial/ethnic, socioeconomic, and disability status by age to calculate population weighted mean exposures and absolute disparity metrics. Our findings indicate few substantive differences between age groups overall, but more substantial differences between sociodemographic categories within age groups, with children and older adults from socially marginalized backgrounds facing greater exposure than adults from similar backgrounds. When looking at sociodemographic differences by age, people of color of any age and older adults without health insurance emerge as the most exposed groups. This study identifies groups who are most exposed to extreme heat. Policy and program interventions aimed at reducing the impacts of heat should take these disparities in exposure into account to achieve health equity objectives.

Medicare Enrollment Rates Across Six Asian Subgroups in the USA

OBJECTIVES

Although Medicare is a vital source of health insurance coverage for older Americans, little is known about Medicare enrollment among older Asians. This study aimed to examine heterogeneity in Medicare enrollment across the six largest subgroups of Asian Americans (Chinese, Japanese, Filipino, Indian, Korean, and Vietnamese), in relation to their citizenship status and labor force participation.

METHODS

Data from the American Community Survey Public Use Microdata Sample (2014-2018) were analyzed for older foreign-born Asians aged 65 or older (N = 83,378). A two-level multilevel logistic regression model (states > individuals) was used to model the probabilities of Medicare enrollment, accounting for state-level residential clustering by Asian subgroup and, thus, for nonindependence among respondents from the same state.

RESULTS

The results indicated a substantial amount of heterogeneity in Medicare enrollment across the six Asian subgroups. Although the overall Medicare enrollment rate was low (90.2%), the rates varied from 85.5% among Indians to 93.8% among Koreans and Japanese. Naturalized citizens and those not in the labor force were associated with greater probabilities of Medicare enrollment. However, the relative differences in the Medicare enrollment rates across the six Asian subgroups were different by individuals' naturalization status and labor force participation (i.e., significant three-way interactions).

DISCUSSION

These results highlight that aggregated data cannot accurately represent Medicare and health insurance status of older Asians with different sub-ethnic backgrounds. Intragroup and intergroup differences in Medicare enrollment among foreign-born older Asians should be considered for targeted policy approaches for this group of older adults.

Influenza vaccination rates and location for receiving the influenza vaccination among older adult Medicare beneficiaries

OBJECTIVES

The objectives of this study were to (1) assess the trends in older adult influenza vaccination rates and (2) locations at which U.S. older adults received influenza vaccinations for the 2008-2009 to 2017-2018 influenza seasons, and (3) compare the estimates of influenza vaccination rates and locations with the estimates from other sources reported previously.

METHODS

Data from the 2009 to 2017 Medicare Current Beneficiary Survey (MCBS) were used in this analysis. The weighted sample included an average of approximately 37 million community-dwelling older Medicare beneficiaries who completed questionnaires per year. The estimates for older adult influenza vaccination rates and the locations that they used to receive the influenza vaccination were weighted and reported for the 2008-2009 to 2017-2018 influenza seasons.

RESULTS

The self-reported older adult influenza vaccination rates between 2008-09 and 2017-2018 ranged from 69.6% (24.6 million) to 75.0% (31.3 million). Across the study period, the percentage of older adults receiving the influenza vaccination at a physician office and clinic declined by 10.4%. The decline was more than offset by an increase in older adult influenza vaccination receipt at a community pharmacy, which substantially increased from 16.6% (4.1 million) in 2008-2009 to 34.8% (10.9 million) in 2014-2015. When compared with the estimates from other sources, the absolute value of the MCBS estimates corresponds with National Health Interview Survey estimates. The older adult influenza vaccination rate increased slightly between the 2008-2009 and 2017-2018 influenza seasons but is still below the 90% benchmark.

CONCLUSION

Community pharmacies-increasingly important access points for the influenza vaccination for older adults-likely contributed to the growth in the rate of older adults vaccinated with influenza vaccines.

Changes in Health Insurance Coverage Over Time by Immigration Status Among US Older Adults, 1992-2016

IMPORTANCE

Disparities in health insurance coverage by immigration status are well documented; however, there are few data comparing long-term changes in insurance coverage between immigrant and nonimmigrant adults as they age into older adulthood.

OBJECTIVE

To compare longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the nationally representative Health and Retirement Study. Data were collected biennially from 1992 to 2016. The population included community-dwelling US adults born between 1931 and 1941 and aged 51 to 61 years at baseline. Statistical analysis was performed from February 3, 2017, to January 10, 2020.

EXPOSURES

Participants were categorized as nonimmigrants (born in the US), early immigrants (immigrated to the US before the age of 18 years), and recent immigrants (immigrated to the US from the age of 18 years onward).

MAIN OUTCOMES AND MEASURES

Self-reported data on public, employer, long-term care, and other private insurance were used to define any insurance coverage. Longitudinal changes in insurance coverage were examined over time by immigration status using generalized estimating equations accounting for inverse probability of attrition weights. The association between immigration status and continuous insurance coverage was also evaluated.

RESULTS

A total of 9691 participants were included (mean [SD] age, 56.0 [3.2] years; 5111 [52.6%] female). Nonimmigrants composed 90% (n = 8649) of the cohort; early immigrants, 2% (n = 201); and recent immigrants, 8% (n = 841). Insurance coverage increased from 68%, 83%, and 86% of recent immigrant, early immigrant, and nonimmigrant older adults, respectively, in 1992 to 97%, 100%, and 99% in 2016. After accounting for selective attrition, recent immigrants were 15% less likely than nonimmigrants to have any insurance at baseline (risk ratio, 0.85; 95% CI, 0.82-0.88), driven by lower rates of private insurance. However, disparities in insurance decreased incrementally over time and were eliminated, such that insurance coverage rates were similar between groups as participants attained Medicare age eligibility. Furthermore, recent immigrants were less likely than nonimmigrants to be continuously insured (risk ratio, 0.89; 95% CI, 0.85-0.94).

CONCLUSIONS AND RELEVANCE

Among community-dwelling adults who were not age eligible for Medicare, recent immigrants had lower rates of health insurance, but this disparity was eliminated over the 24-year follow-up period because of uptake of public insurance among all participants. Future studies should evaluate policies and health care reforms aimed at reducing disparities among vulnerable populations such as recent immigrants who are not age eligible for Medicare.

The Epidemiology of Social Isolation: National Health and Aging Trends Study

OBJECTIVES

Social isolation among older adults is an important but under-recognized risk for poor health outcomes. Methods are needed to identify subgroups of older adults at risk for social isolation.

METHODS

We constructed a typology of social isolation using data from the National Health and Aging Trends Study (NHATS) and estimated the prevalence and correlates of social isolation among community-dwelling older adults. The typology was formed from four domains: living arrangement, core discussion network size, religious attendance, and social participation.

RESULTS

In 2011, 24% of self-responding, community-dwelling older adults (65+ years), approximately 7.7 million people, were characterized as socially isolated, including 1.3 million (4%) who were characterized as severely socially isolated. Multinomial multivariable logistic regression indicated that being unmarried, male, having low education, and low income were all independently associated with social isolation. Black and Hispanic older adults had lower odds of social isolation compared with white older adults, after adjusting for covariates.

DISCUSSION

Social isolation is an important and potentially modifiable risk that affects a significant proportion of the older adult population.

Evidence of Pent-Up Demand for Total Hip and Total Knee Arthroplasty at Age 65

BACKGROUND

Despite efforts to curtail the economic burden of total joint arthroplasty (TJA), utilization of these successful procedures continues to increase. Previous studies have provided evidence for pent-up demand (delaying necessary medical care until financially feasible) in health care as insurance status changes. We sought to determine whether evidence exists for pent-up demand in the TJA population when patients become eligible for Medicare enrollment.

METHODS

The 2014 Nationwide Readmission Database was used to determine the incidence of TJA. The observed increase in incidence from age 64 to 65 was compared to the expected increase. Pent-up demand was calculated by subtracting the expected from the observed difference in frequency of TJA, and excess cost was determined by multiplying this value by the median cost of a primary TJA. The Medicare Expenditure Panel Survey Household Component was used to compare out-of-pocket (OOP) costs, access to care, and insurance coverage among patients aged 60-64 (group 1) and 66-70 (group 2).

RESULTS

The expected and observed increases in TJA procedures from age 64 to 65 were 595 and 5211, respectively, resulting in pent-up demand of 4616 joint arthroplasties (1273 THA and 3343 TKA), and an excess cost of $55 million (range, $33 million-$70 million). Mean total OOP expenses for patients in group 1 were significantly greater ($1578.39) than patients in group 2 ($1143.63, P < .001). Despite spending more money OOP, the proportion of patients who were unable to obtain necessary medical care was significantly higher in group 1 than group 2 (4.9% vs 2.4%, P < .0001). This discrepancy was most prominent among patients with public insurance (10.6% vs 2.5%, P < .0001).

CONCLUSION

The findings of this study suggest that patients with hip and knee osteoarthritis likely delay elective TJA until they are eligible for Medicare enrollment, resulting in significant additional financial burden to the public health system. As the population ages, it will become increasingly important for stakeholders and policy-makers to be aware of this pent-up demand for TJA procedures.

LEVEL OF EVIDENCE

Therapeutic level IV.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE

This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out-of-pocket costs under proposed therapy caps.

METHOD

This retrospective, population-based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out-of-pocket costs.

RESULTS

Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12-14 visits.

DISCUSSIO

. Wide variation exists in potential patient out-of-pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.

Aging without Medicare? Evidence from New York City

Medicare and Social Security often are assumed to provide universal coverage for the population age 65 and older. Evidence from New York City raises doubts. Data from the Statewide Planning and Research Cooperative System, the Centers for Medicare and Medicaid Services, the Social Security Administration, and the U.S. Bureau of the Census provide evidence that 16% to 20% of New York City residents age 65 and older lack such coverage. Noncoverage is not unique to this city, but it may be particularly common there. Noncoverage is pronounced in, but not limited to, certain immigrant groups. Because the population share covered by Medicare increases with age and most hospitalizations not covered by Medicare are paid by Medicaid, Medicaid gradually may be replacing Medicare as the payer for hospitalizations for a substantial share of the 65+ population in New York City.

Gynecologic cancer outcomes in the elderly poor: A population-based study

BACKGROUND

Adults aged ≥65 years who are dually enrolled in Medicare and Medicaid are an at-risk group in health care. However, to the best of the authors' knowledge, the outcomes of women with gynecologic cancers in this population are unknown.

METHODS

The current study was a population-based cohort study of North Carolina state cancer registry cases of uterine, ovarian, cervical, and vulvar/vaginal cancers (2003-2009), with linked enrollment in Medicare and state Medicaid. Outcomes of all-cause mortality and stage of disease at the time of diagnosis were analyzed as a function of enrollment status using multivariate analysis and survival curves.

RESULTS

Of 4522 women aged ≥65 years (3702 of whom were enrolled in Medicare [82%] and 820 of whom were dually enrolled [18%]), there were 2286 cases of uterine (51%), 1587 cases of ovarian (35%), 302 cases of cervical (7%), and 347 cases of vulvar/vaginal (8%) cancers. Dual enrollees had increased all-cause mortality overall (adjusted hazard ratio [aHR], 1.34; 95% confidence interval [95% CI], 1.19-1.49), and within each cancer site (uterine: aHR, 1.22 [95% CI, 1.02-1.47]; ovarian: aHR, 1.25 [95% CI, 1.05-1.49]; cervical: aHR, 1.34 [95% CI, 0.96-1.87]; and vulvar/vaginal: aHR, 1.93 [95% CI, 1.36-2.72]). Increased odds of advanced-stage disease at the time of diagnosis among dual enrollees was only present in patients with uterine cancer (adjusted odds ratio, 1.38; 95% CI, 1.06-1.79). Stratified survival curves demonstrated the strongest disparities among women with early-stage uterine and early-stage vulvar/vaginal cancers.

CONCLUSIONS

Women aged ≥65 years who were dually enrolled in Medicare and Medicaid were found to have an overall 34% increase in all-cause mortality after diagnosis with a gynecologic cancer compared with the non-dually enrolled Medicare population. Women with early-stage uterine and vulvar/vaginal cancers appeared to have the most disparate outcomes. Because these malignancies are generally curable, they have the most potential for benefit from targeted interventions.

A Comparison of Young, Middle-Aged, and Older Uninsured Individuals in the United States: Health Beliefs and Satisfaction With Providers

This study compared three age groups of uninsured adults, young (26-44), middle-aged (45-64), and older (65≥), to examine heterogeneity of the uninsured. The pooled 2000-2007 Medical Expenditure Panel Survey was analyzed (N = 22,246). The findings demonstrated that the three groups were very different regarding their individual characteristics, health service utilization, and health beliefs. Compared with uninsured young adults, uninsured middle-aged individuals reported worse health statuses, paid higher out-of-pocket medical expenditures, and had more positive attitudes toward insurance and health care. Considering the policy goals of the Affordable Care Act, understanding the uninsured by age will facilitate targeted interventions to decrease the number of uninsured.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

OBJECTIVES

To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.

DESIGN

Cross-sectional analysis.

SETTING

Safety-net hospital in San Francisco, California.

PARTICIPANTS

English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).

MEASUREMENTS

At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.

RESULTS

Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.

CONCLUSION

Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Welfare reform and older immigrant adults' Medicaid and health insurance coverage: changes caused by chilling effects of welfare reform, protective citizenship, or distinct effects of labor market condition by citizenship?

OBJECTIVES

To examine how federal noncitizen Medicaid eligibility restriction and generous state policy affect Medicaid and health insurance coverage among older adults with different citizenship status.

METHOD

This study uses an older adult sample (65 years or older) from the Current Population Survey (CPS) and state data and employed a triple difference-in-differences approach to incorporate variations in citizenship status, time, and state eligibility.

RESULTS

Findings show that Medicaid coverage significantly declined among older noncitizens but increased among older naturalized citizens after Welfare Reform. Findings also show that the differences in older noncitizens' health insurance coverage changes were significant between generous and nongenerous states.

DISCUSSION

Medicaid eligibility affects older immigrant adults' Medicaid and health insurance coverage. Findings support the "protective citizenship" hypothesis but not the "chilling effect" and "labor market condition" hypotheses. Opposite patterns of change in Medicaid coverage between naturalized citizens and noncitizens raise doubt about the effectiveness of eligibility restrictions in reducing government spending.

Welfare reform and elderly immigrants' health insurance coverage: the roles of federal and state medicaid eligibility rules

Immigrants' access to federally-funded Medicaid became limited after welfare reform imposed restrictive noncitizen eligibility rules. This study used a representative sample from the Current Population Survey (N = 105,873) and state-level data to examine the effects of these policy changes on elderly immigrants. Triple difference-in-differences analyses show that federal restriction of eligibility had a significantly negative association with elderly immigrants' Medicaid coverage, and generous state eligibility had significantly positive relationships with Medicaid and any health insurance coverage. Findings indicate the important role of eligibility on elderly immigrants' health insurance coverage. Results call for social workers' actions to expand elderly immigrants' Medicaid eligibility.

The vulnerability of middle-aged and older adults in a multiethnic, low-income area: contributions of age, ethnicity, and health insurance

This community-partnered study was developed and fielded in partnership with key community stakeholders and describes age- and race-related variation in delays in care and preventive service utilization between middle-aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self-identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14-23) and problems obtaining needed medical care (APP=15%, 95% CI=12-20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33-56) and problems obtaining needed medical (APP=33%, 95% CI=22-45) and specialty care (APP=26%, 95% CI=16-39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

Admissions for CABG procedure in the elderly: was there a change in access to teaching hospitals after 1997?

The purpose of the study is to identify patient attributes associated with teaching hospital admissions in the elderly for coronary artery bypass graft (CABG), and to determine whether admission patterns in teaching hospitals by vulnerable subgroups of the elderly changed during 1997 to 2001, a period with significant changes in CABG admission patterns and financial situation faced by teaching hospitals. The study sample comprises elderly residents in two states, New York and Pennsylvania, and uses Healthcare Cost and Utilization Project State Inpatient data of the Agency for Health Care Research and Quality. Patient characteristics in major teaching hospitals are compared with those in rest of hospitals in a logistic regression framework using a pre-/postdesign, and controlling for county characteristics and resources, distance to hospitals, and hospital size and volume of procedures. Significant patient characteristics associated with a higher likelihood of admission to teaching hospitals included racial/ethnic minority status, transfer cases, Medicaid and private health maintenance organization insurance. A lower volume of CABG cases and an increased propensity to admit more complex cases characterized the admission patterns in teaching hospitals during 1997 to 2001. Although higher use of teaching hospitals by racial/ethnic minorities persisted, access for Medicaid patients disproportionately declined.

Longitudinal changes in access to health care by immigrant status among older adults: the importance of health insurance as a mediator

PURPOSE

This longitudinal study examined the role of health insurance in access to health care among older immigrants.

DESIGN AND METHODS

Using data from the Second Longitudinal Study of Aging, the longitudinal trajectories of having a usual source of care were compared between 3 groups (all 70+ years): (a) late-life immigrants with less than 15 years of residence in the United States ("recent immigrants"; n = 133), (b) "earlier immigrants" (15 years or longer in the United States, n = 672), and (c) U.S. born (n = 8,642). A series of hierarchical generalized linear models were run to test the mediating relationship of health insurance between immigrant status and having a usual source of care.

RESULTS

Although the probabilities of having a usual source of care increased over time across all three groups, recent immigrants were less likely to have Medicare and private insurance over time; this in turn was related to lower probabilities of having a usual source of care (indirect relationship). There was no direct relationship between immigrant status and having a usual source of care.

IMPLICATIONS

To prevent the use of more expensive forms of care in the long run, policy efforts should expand late-life immigrants' health insurance coverage by increasing affordable health insurance options.

Disaster-related injuries in the period of recovery: the effect of prolonged displacement on risk of injury in older adults

BACKGROUND

Hurricane Katrina, which struck the Gulf Coast of the United States in August 2005, initially displaced over a million people from their primary place of residence. Displaced older adults subsequently faced challenges, such as new or inferior living conditions, which could increase vulnerability to serious or life-threatening injuries such as hip fracture. The aim of this study was to determine whether Katrina victims who were displaced for a prolonged period of time were more likely to experience injuries than nondisplaced victims.

METHODS

We tracked injury outcomes including fractures, sprains or strains, and lacerations in a cohort of 25,019 older adults (age >or= 65 years) enrolled in a Medicare-Advantage Plan, for 1 year after Katrina. We used medical claims to obtain injury outcomes and analyzed propensity-score adjusted predictors of injury, including displacement status at 12 months.

RESULTS

In our sample, 7,030 (28%) older adults were displaced at 12-month post-Katrina. Displaced victims had 1.53 (95% CI: 1.10-2.13) greater odds of sustaining a hip fracture in the year after the storm and 1.24 (95% CI: 1.07-1.44) greater odds of sustaining other fractures after adjusting for other risk factors. There was no significant association between displacement status at 12 months and sprains or strains or lacerations.

CONCLUSIONS

Prolonged displacement is associated with increased risk of fracture in older adults. Emergency planners should screen temporary housing for injury hazards, and clinicians should regard displaced older adults as a vulnerable population in need of interventions such as risk communication messaging.

Delisting publicly funded community-based physical therapy services in Ontario, Canada: a 12-month follow-up study of the perceptions of clients and providers

Publicly funded community-based physical therapy (PT) services in Canada's most populous province of Ontario were partially delisted, or deinsured, in April 2005. Two previous studies examined the short-term effects from the client and provider perspectives; and in this study, we follow up with participants from these preceding studies to assess long-term consequences of this policy. Sixteen of 18 providers (89%) and 64 of 98 clients (65%) agreed to participate in a follow-up telephone interview. Our results indicate that 12 months following delisting, and despite government assurances that access would be preserved, clients rendered ineligible for publicly funded services report ongoing access barriers across Ontario. Clients in this study also express concern about their overall health and report an increased use of other insured health professionals (e.g., physicians) and services (e.g., hospitals). On the other hand, providers within the network of publicly funded clinics report an important decrease in demand for PT services, whereas those from other settings report little change. We conclude that delisting policies may have long-term consequences on uninsured or underinsured clients and that evidence-based policy planning is warranted to ensure that the goals of reform are aligned with the desired outcomes at the client, provider, and system levels.

Trends in racial disparities among the elderly for selected procedures

The authors examine trends over 1997-2001 in racial or ethnic disparities in the utilization of three costly, referral-sensitive procedures among the elderly-coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), and hip/joint replacement. Using a multivariate framework, they undertake a simultaneous examination of the relationships between patient, local area context, and health systems on these admission types after comparing them to a control group. This period spans the implementation of the Balanced Budget Act and a major Department of Health and Human Services initiative to reduce disparities in cardiovascular and other diseases. Findings suggest increasing disparities for African Americans relative to Whites in their lower utilization of CABG and PTCA over time, and increasing disparities in the utilization of hip/joint replacement among other races' relative to Whites. The authors find that racial or ethnic disparities in use of referral-sensitive procedures did not narrow over 1997-2001.

Parkinson's disease and functional decline in older Mexican Americans

The purpose of this study was to establish prevalence and five-year incidence, and explore functional decline among older Mexican Americans with Parkinson's disease (PD). Using data from the Hispanic EPESE, baseline characteristics were compared across PD response profiles. Weighted generalized estimating equations (GEE) modeled the association between PD and outcomes. Prevalence was 1.30%; incidence at wave 4 was 1.18%. Those with prevalent PD had worse function than those without PD at each wave. Progressive functional decline across time was observed among those with PD. Older Mexican Americans with PD often live in the community, and those who provide care for them may be overburdened.

Reliability and validity of the Older Americans Resources and Services (OARS) social resources scale in six European countries

OBJECTIVES

The purpose of this article is to examine data quality, reliability, and construct validity of the Older Americans Resources and Services social resources scale in six European countries (The Netherlands, Luxembourg, Italy, Austria, the United Kingdom, and Sweden).

METHODS

A questionnaire was administered through face-to-face interviews in five countries, and postal interview in the sixth, to representative populations of adults aged 50 to 90 living independently (N = 12,478). This article examines missing values and distribution of items in the social resources scale, and consistency of skew and kurtosis across countries. We performed item-total correlations and ran confirmatory factor analyses to test a three-factor model obtained in previous U.S. and Spanish analyses. Cronbach's alpha determined the reliability of the factors.

RESULTS

We observed a relatively large proportion of missing data for one item (have someone who would help you). All items correlated with a score equal to or greater than 0.20. Although the confirmatory factor analyses generally supported the acceptability of the three-factor structure in the European data, the reliability of two dimensions (dependability and affective) was unacceptably low.

DISCUSSION

Differences across countries make it unlikely that researchers can develop a single social resources scale that would have item equivalence in multiple countries.

The ESRD uninsured matter

Health-care insurance is the key to health-care access, yet the number of uninsured in the United States grows by a million persons per year and consists, in large part, of those who are financially unable to obtain medical coverage. Their unpaid medical bills add significantly to the cost of health insurance for those who do pay. Those without insurance receive care on a sporadic basis, and the risk of poor health-care outcomes is well established. The end-stage renal disease (ESRD) uninsured face unique problems related to chronicity of care and the system of chronic dialysis-care delivery. This article addresses the growing challenge of the ESRD uninsured in the United States and describes how the current system copes with the ESRD uninsured. More broadly, it discusses who the uninsured are (including undocumented immigrants), the health-care consequences of being without coverage, and how their care is currently financed. It also presents a health-care reform measure in Massachusetts designed to provide affordable insurance to those without coverage.

Caring for the New Uninsured: Hospital Charity Care for Older People without Coverage

Despite near-universal coverage through Medicare, a number of elderly residents in the United States do not have health insurance coverage. To the author's knowledge, this study is the first to document trends in the use of hospital charity care by uninsured older people. Data from the New Jersey Charity Care Program, which subsidizes hospitals for services provided to low-income uninsured people, were used to analyze trends in charity care utilization by older people from 1999 to 2004. Charity care charges are standardized to uniform Medicaid reimbursement rates and inflation adjusted using the Medical Care Consumer Price Index. From 1999 to 2004, use of charity care by older people grew much faster than it did for younger patients. As a result, older people now account for a greater share of hospital charity care in New Jersey than children. Elderly users of charity care generated higher costs per patient than their younger counterparts. Cost differences were especially salient at the upper end of the distribution, where high-cost elderly patients used significantly more resources than high-cost patients in other age groups. These results highlight an emerging source of strain on the healthcare safety net and point to a growing population of uninsured residents who have costly and complex medical needs. Similar experiences are likely to be found in other states, especially those that have growing populations of elderly immigrants who are likely to lack health insurance.

Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly?

Racial and ethnic disparities in colorectal cancer screening have been documented extensively in the literature. In July 2001 Medicare began covering colonoscopy for average-risk beneficiaries. We examined the effect of Medicare reimbursement on the rate and disparity of colorectal cancer screening among the elderly in the United States. This policy alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy.

Disparities in Disability Life Expectancy in US Birth Cohorts: The Influence of Sex and Race

Racial and sex disparities in chronic diseases and mortality are sources of health inequality and have been observed from infancy to adulthood. Disparities in health and mortality contribute to corresponding disparities in healthy life. I address two previously unanswered questions in the aging literature. First, does the racial and sex gap in healthy life narrow, persist, or expand over age and time, particularly considering severity of ill health, among the oldest old? Second, do some race-sex groups of birth cohorts live not just longer lives, but longer healthier lives, while others spend additional years in illness? To estimate the quantities, I employ a refined definition of physical disability and apply a new extension of Sullivan's method to true birth cohorts. The results suggest among the oldest old, few racial or sex disparities exist over age and time in mild disability. Yet, racial and sex disparities persist over age and time in severe disability.

Underserved elderly issues in the United States: burdens of oral and medical health care

The elderly represent approximately 12.4% of the general population (2000 Census), yet their health care expenditure and consumption represent 14% of the total (2003). Although 10% of the elderly had no medical insurance in 2000, 78% had no dental insurance. Elderly Americans' burden of medical care overuse is worsened by their out-of-pocket expenses for oral health, because this is usually not a covered benefit. In underserved communities, the management of the oral health and dental care needs of older Americans approaches negligence.