Access to Health Care

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At 69, I’m concerned about my future health and the rising cost of healthcare.

Male, age 69, in response to what worries do you have¹

Accessing quality health care services for adults age 50-plus can differ based on insurance status, costs, and other factors related to the ease and comfort with receiving care. Owing in large part to Medicare eligibility at age 65, very few older adults are without any healthcare coverage. Nevertheless, issues with accessing services continue to exist even with insurance and coverage gaps persist especially for those ages 50-64. Topics related to this include:

• Attitudes towards healthcare
• Insurance status
• Health care costs
• Satisfaction with health care/providers

Attitudes Towards Healthcare

Having adequate health insurance coverage and receiving Medicare benefits are of utmost importance to older adults.

Nine in ten adults 45 and older feel that having adequate health insurance and having Medicare benefits available to them in the future are extremely or very important.²

Adults age 50-plus are more likely to rate the U.S. healthcare system highly on quality than on accessibility.

Half (50%) of adults 50-plus say the quality of the U.S. healthcare system is either good (36%) or very good (14%). However, fewer (39%) rate the U.S. healthcare system as high in terms of accessibility.³

Concerns with health care access are more prevalent among multicultural adults 50-plus, who have greater awareness of racial/ethnic stigma, bias, or stereotyping within healthcare. For example, nearly a third or 31% of Black adults 50-plus say they perceive their race as a barrier to receiving the best health care, compared to 13% of all adults 50-plus.⁴

Adults 50 and older are increasingly likely to rate health care quality highly with increasing income (perhaps related to personal experience), however ratings of health care access do not steadily climb with income. Those having between $30k and $100k in household income tend to rate accessibility in the middling “fair” category and accessibility ratings at incomes over $100k are no better than under $30k. This could be interpreted as a broad acknowledgement of access issues.⁵

Insurance Status

While the uninsured rate of 50 to 64 year old adults is down to 8% since the implementation of the Affordable Care Act, it is significantly higher for some racial and ethnic groups.

The proportion of Hispanic as well as American Indian and Alaska Native adults ages 50–64 who are uninsured is three times greater than that of non-Hispanic White adults of the same age.⁶

Higher uninsured rates persist among Hispanic adults as they are less likely to receive coverage through their employer and are more likely to face eligibility restrictions for Medicaid/Medicare and Marketplace coverage due to documentation status as well as waiting periods for immigrants who are not citizens.^7,8 Those less familiar with the U.S. healthcare system may also face barriers including confusion about eligibility policies or difficulty navigating the enrollment process. Additionally, individuals with limited English proficiency face additional administrative barriers with enrollment and renewal. Eight in ten (79%) Heritage Leaning Primarily Spanish speakers who identify with their Hispanic heritage more closely than their American identity. Hispanic adults 50 and older indicate they would definitely use Spanish-speaking representatives if they were provided by their health insurance company, meaning that in-language support can be significantly enabling and empowering.⁹

Hispanic adults are also more likely to be covered by Medicaid than their White counterparts, and uninsured rates tend to be especially high in states that have not adopted Medicaid expansion.¹⁰

Higher uninsured rates among American Indian and Alaska Native (AIAN) adults reflect, in part, individuals who only have coverage through the Indian Health Service (IHS),¹¹ which provides health care and disease prevention services to AIAN people located mostly on or near reservations. While the IHS is the “mechanism through which the federal government fulfills its trust responsibility to provide health care to AIAN people, it is not health insurance and has been historically underfunded and unable to meet their health care needs. As such, coverage remains important for facilitating access to care” for AIAN people, according to KFF. However, “some AIAN people prefer relying on IHS for care versus enrolling in health coverage because they believe that the federal government has the responsibility to provide and fund all needed care through the IHS. Others may be unaware of the availability of other coverage options or find the enrollment process confusing or challenging.”¹²

Health Care Costs

Adults 50-plus rate the U.S. healthcare system low in terms of affordability.

Only one in six (16%) say the U.S. healthcare system is affordable.¹³ Although affordability is rated poorly across income groups, poor ratings increase with income, which could reflect broad societal concern or that affordability issues are felt across income groups. [Note: the highest income grouping is $100k-plus, so this insight applies for this income grouping, but may or may not hold after a higher income threshold.]

Health care costs are a top concern for adults ages 50-64, with concern decreasing as they become eligible for Medicare.

Almost half of adults ages 50-64 (48%) say it is difficult to afford health care costs, a stark difference from the 27% of those 65-plus who say the same.¹⁴ This compares to 54% of adults under 50. Unexpected medical bills are the top health care expense worry, more so for women. Deductibles and long-term care costs are also sources of worry.¹⁵

Around a quarter of adults ages 50-64, and one fifth of adults 65-plus do not fill prescriptions or take medications as prescribed because of cost.

Adults 50-plus are less likely to compromise their medications than adults under 50. Adults 50-plus who take four or more medications (32%) are more likely than those who take less (14%) to not take medicine as prescribed due to cost.¹⁶

Older adults have varying levels of confidence in their ability to pay for unexpected medical bills.

For example, in a study of 40–64 year-olds, four in 10 (40%) report that they are extremely or very confident they could pay an unexpected $1,000 medical bill within 30 days and another four in 10 (38%) say they are not very or not at all confident that they could. When asked at what price an individual health insurance premium would become unaffordable, one-fifth (19%) of adults ages 40–64 said at $50 a month it would become unaffordable.¹⁷

Health care costs can lead many adults ages 50-64 to skip or delay getting needed care.

In general, Medicare recipients are less likely to forego medical services. Of those ages 50-64, 43% say they or another family member living in their household put off or postponed getting health care they needed because of cost (vs. 22% of those 65-plus). Thirty-six percent of those ages 50-64 say they or another household member have not gotten a medical test or treatment that was recommended by a doctor because of cost (vs. 17% of those ages 65-plus).¹⁸

Dental care is the most skipped medical service due to cost, especially for those in their 60s.

As Medicare does not cover most dental care, this age represents an inflection point. Women are more likely to report having skipped dental and vision care than men.¹⁹ The proportion of those 65 and older who delay or forgo hearing services is two times that of those ages 50-64, reflecting the heightened need among older adults. NOTE: this survey was conducted before the historic rule enabling over-the-counter access to hearing aids (implemented October 2022).

Almost half of adults ages 50-64 (45%) have debt due to medical or dental bills.

Medicare eligible adults are less likely to live with medical debt, as only 22% of those ages 65 and older have medical debt. Black and Hispanic adults, adults with lower-income, and women are more likely to report dealing with medical debt.²⁰

Satisfaction With Health Care/Providers

Adults are highly satisfied with their primary health care provider (PHCP), including their ability to listen and communicate.

On a scale of 0 to 10, with 0 defined as extremely unsatisfied and 10 defined as extremely satisfied, nearly two-thirds (64%) of adults 50 and older rated their satisfaction with their provider as a 9 or a 10. However, adults ages 50-64 were less likely to give the highest satisfaction scores compared to adults 65 and older.²¹ Specifically, those ages 50-64 were less likely to give their PHCP high marks on listening and communication, although still about three-quarters or more gave high ratings in these areas.

Despite most older adults giving their PHCP positive ratings, stereotypes and bias in the healthcare system pose a risk to optimal care.

About 20% of people over 50 have faced discrimination in healthcare, according to U.S. National Health and Retirement data, with age being the most common reason (using a self-reported measure that asked survey respondents if they received poorer service or treatment than other people from doctors or hospitals).²² This figure may be an underestimate, as individuals may not always recognize discrimination when it happens.

Additionally, in one study of Californians, 30% of Black adults and 10% of Hispanic adults described feeling judged or treated differently by a clinician because of their race or ethnicity. Perceived discrimination in the healthcare system among Black and Hispanic adults is associated with a higher likelihood of experiencing medical mistrust.²³

When both ageism and racism intersect, they can further exacerbate care outcomes, as defined by the double jeopardy hypothesis. It states that older Black adults experience a “double disadvantage to health” due to the cumulative impact of marginalization through race and age.²⁴

Examples of how ageism and race-based discrimination can manifest in healthcare settings include:

• Ignoring or dismissing treatable concerns; e.g., falls, joint pain, hearing or vision loss.
• Missed or delayed diagnoses; e.g., dementia tends to go unnoticed among older adults, with around half of people with symptoms lacking diagnosis.
• Making assumptions about one’s abilities; e.g., a provider might assume an older patient doesn’t need to, can’t or won’t exercise.
• Talking down to patients.²⁵
• Care quality, treatment, and outcomes of disease and chronic conditions, e.g.,. cardiovascular disease.²⁶
• Less open communication of sensitive medical history and information between patients and clinicians due to medical mistrust.²⁷

Multicultural adults 50-plus want doctors that understand the implications of their race and ethnicity in their health journey. Almost nine in ten (87%) multicultural adults 50-plus indicate it is important their doctor knows the risks related to their racial/ethnic background, compared to 62% of White, non-Hispanic adults 50 and older. For Heritage Leaning Primarily Spanish speakers who identify with their Hispanic heritage more closely than their American identity. Hispanic adults 50 and older, in-language support is table stakes for culturally fluent care—97% say it is important that their doctor speaks Spanish.²⁸

Key Takeaways

• Health care accessibility remains a broadly recognized issue among adults 50-plus. Accessibility is more likely to be viewed as an issue than quality.

• Since its implementation in 2010, the Affordable Care Act has significantly reduced uninsured rates. However, due to systemic and bureaucratic barriers, coverage gaps persist, and are more likely to impact multicultural adults 50-plus. For instance, Hispanic and American Indian and Alaska Native adults 50-64 are three times more likely than non-Hispanic White adults to be uninsured.

• Medicare eligibility alleviates health care cost-related concerns for adults 65-plus, but does not eliminate the issue. Unexpected bills are the top health care cost concern, especially for those ages 50-64, with nearly half reporting medical or dental debt.

• Overall, older adults express satisfaction with their health care providers. Yet the sustained presence of age and race-based bias in the healthcare system cannot be understated. Multicultural adults 50-plus want their providers to show cultural competence and an understanding of their specific health care needs. For Heritage Leaning Primarily Spanish speakers who identify with their Hispanic heritage more closely than their American identity. Hispanic adults 50-plus, this includes language and being able to communicate with their providers in Spanish.