Commonwealth Fund: Medicare member experience varies by state

Access to care

In terms of healthcare access, the report revealed that different statewide infrastructure is driving disparities.

Older adults on Medicare tend to have better healthcare access than younger adults, according to the report, with less than 5% of older beneficiaries saying they don't have a usual source of care compared to 21% of younger beneficiaries saying the same. There are also statewide variations, with older adults in Wyoming, Alaska and New Mexico being more likely to lack a usual source of care.

Differences could stem from statewide infrastructure and workforce problems, the report noted.

There are also disparities in experiences with prior authorizations, a practice payers like Medicare Advantage plans use for utilization management. However, critics state that prior authorizations can delay healthcare access for patients and create bureaucratic headaches for providers.

Across the United States, 48% of Medicare Advantage plans require prior authorization for specialist visits or preventive care services. Prior authorizations were more common in Medicare Advantage plans in Washington, Virginia and the District of Columbia compared to South Dakota, North Dakota and Vermont.

Quality of care

Statewide variations persist when looking at healthcare and clinical quality, as measured by potentially preventable hospital admissions.

"Preventable hospitalizations can occur when people with chronic conditions experience acute exacerbations, often when the underlying disease is detected late or poorly managed," the report authors explained. "High rates of preventable hospitalizations often indicate opportunities for earlier disease detection and better care management, but they also can reflect local practice patterns and local health system capacity."

Across the U.S., there were 26.4 preventable hospital admissions per 1,000 Medicare beneficiaries. However, in West Virginia, that figure was 35 preventable admissions per 1,000 beneficiaries, nearly double the rate in Idaho, where there were 14 preventable admissions per 1,000 beneficiaries.

Costs and affordability

Notably, there are considerable disparities in cost and affordability, a result of variable healthcare service costs and Medicare Advantage design at the state level.

All said, 3.8% of Medicare beneficiaries over age 65 have gone without care due to cost, compared with 15.1% of younger beneficiaries. But in a state-by-state breakdown, the researchers found steep differences. In Louisiana, 6% of older Medicare members have gone without care due to costs, while in Vermont, that figure is only 1.6%.

There are also serious differences in prescription drug costs. In the U.S., the average percent of total Part D drug costs paid by beneficiaries shakes out to 7%. But in North Dakota, that figure is 12.8% and in D.C., that figure is 3%.

Population health

Population health metrics likewise vary by state.

For example, 62% of Medicare beneficiaries nationwide have three or more chronic conditions. But in a state like Alabama, that figure is 71%. In Wyoming, 45% of Medicare beneficiaries have three or more chronic conditions.

Meanwhile, life expectancy remains abysmal, especially in the states where Medicare spending is the highest.

In Mississippi and West Virginia, where Medicare spending per beneficiary ranges from $11,000 to around $13,000, life expectancy after age 65 is about 16 years. In Hawaii, where Medicare spending per beneficiary is the lowest in the nation, members can expect to live another 20 years after age 65.

"Life expectancy has many contributing factors, including public health policies and socioeconomic conditions, as well as medical care," the report authors explained.

But it's not just life expectancy and chronic disease burden that's unequally felt.

Medicare beneficiaries in certain states feel health-related social factors more acutely than those in others. Notably, 40% of beneficiaries in New Mexico said they've experienced loneliness, a social determinant of health that can affect the health of seniors. In North Carolina, that figure is 28.7%.

Why the state-by-state disparities?

According to the Commonwealth Fund, statewide differences in Medicare experiences boil down to statewide differences in healthcare policies.

"Although Medicare is a national program, health outcomes, access to needed healthcare, the affordability of care and quality of care all vary widely for the people it covers," the report authors said. "Medicare performs better in states where Medicare Advantage plans and prescription drug plans offer better coverage, making care easier to access and afford."

For example, each state has a different health infrastructure, influencing access to care and clinical quality. And being that most Medicare beneficiaries get some or all of their coverage through Medicare Advantage plans, they might see different plan benefits that influence their experiences.

Finally, there is a regionality to healthcare costs, which can influence out-of-pocket costs. Because Medicare pays a percentage of a medical bill, patients living in areas that charge more for services will see bigger out-of-pocket costs.

"For six decades, Medicare has been one of the nation's most powerful tools for advancing health and financial security," Joseph R. Betancourt, M.D., the president of the Commonwealth Fund, said in a press release.

"As a physician, I've seen firsthand how important it is for patients to focus on their health -- and healing -- instead of worrying about medical bills. This scorecard highlights both Medicare's remarkable impact and the urgent need to ensure it delivers care equally and effectively for people in every state."

Sara Heath has reported news related to patient engagement and health equity since 2015.