Correlates of Worry About Health Care Costs Among Older Adults

Abstract

Although older adults in the United States incur more health care expenses than younger adults, little research has been done on their worry about health care costs. Using data from the 2013 National Health Interview Survey (n = 7,253 for those 65+ years), we examined factors associated with older adults’ health care cost worries, defined as at least a moderate level of worry, about ability to pay for normal health care and/or for health care due to a serious illness or accident. Bivariate analyses were used to compare worriers and nonworriers. Binary logistic regression analysis was used to examine the association of income, health status, health care service use, and insurance type with worry status. Older age and having Medicaid and Veterans Affairs (VA)/military health benefits were associated with lower odds of worry, while low income, chronic pain, functional limitations, psychological distress, and emergency department visits were associated with higher odds. Practice and policy implications for the findings are discussed.

Keywords

health care costs worry low income emergency department visit Medicaid VA/military health benefits

Medicare’s near universal coverage, Medicaid supplements for low-income Medicare beneficiaries, and Medicaid coverage for both nursing home and home- and community-based long-term care services and support have provided older adults (65+ years) in the United States protection from excessive financial burden/stress from health care expenses. However, medical expenditure data for 2011 showed that among persons with medical expenses, more than 96% of older adults, compared with 89% in the 45-64 age group and 76% in the 18-44 age group, had out-of-pocket health care expenses (National Center for Health Statistics [NCHS], 2015). Of those with out-of-pocket expenses, 20% of the 65-74 age group and 19% of the 75+ age group paid between US$1,000 and US$1,999, and 14% of the 65-74 age group and 15% of the 75+ age group, compared with 12% of the 45-64 age group and 6% of the 18-44 age group, paid US$2,000 or more (NCHS, 2015).

Older adults on average have substantially lower income but more out-of-pocket health care spending than younger adults largely because they have more chronic illnesses that require ongoing health care services including hospitalization, physician visits, prescription drugs, and home health care services (Desmond, Rice, Cubanski, & Neuman, 2007; Paez, Zhao, & Hwang, 2009). A Robert Wood Johnson Foundation study based on the 2006 Medical Expenditure Panel Survey (MEPS) showed that 91% of older adults had at least one chronic illness and 73% had two chronic illnesses, and that health care spending often doubled for people with chronic illnesses and activity limitations (Anderson, 2010). The study also found that among people with chronic conditions, Medicare beneficiaries had the highest out-of-pocket expenses (US$1,343) followed by those with other government insurance (US$759), those with private insurance (US$638), those who were uninsured (US$498), and those with Medicaid (US$216). Another study based on the 2009-2011 MEPS also found that 17% of adults spent more than 10% of their income on health care, and those with more chronic illnesses had higher out-of-pocket spending (e.g., US$1,814 on average among those with diabetes mellitus, hypertension, arthritis, and heart disease, and US$1,760 among those with hypertension, arthritis, and heart disease, with no significant age-group differences; Meraya, Raval, & Sambamoorthi, 2015).

Because of their chronic illnesses, injuries caused by falls, acute cerebrovascular accidents, and infections, older adults also account for a disproportionate share of emergency department (ED) visits and return visits, an especially costly form of health care, which often result in inpatient hospital stays (Gruneir, Silver, & Rochon, 2011; Owens, Mutter, & Stocks, 2010; Pines, Mullins, Cooper, Feng, & Roth, 2013; Platts-Mills, Leacock, Cabanas, Shofer, & McLean, 2010). ED care costs for older adults have not been comprehensively studied, but a study using the 2006-2008 MEPS found that the average charge for an adult ED outpatient visit for asthma was US$1,502. These charges did not vary significantly by insurance group, but they did increase significantly with age (e.g., >US$2,000 for those 80+ years), due likely to age-associated comorbidities that complicated disease management (Wang, Srebotnjak, Brownell, & Hsia, 2014). With higher ED charges, patients are likely to be responsible for a greater portion of the charges (Wang et al., 2014).

Compared with older adults in other developed countries, who also enjoy universal health care coverage, more U.S. older adults are concerned about health care costs. For example, the 2014 Commonwealth Fund’s International Health Policy Survey found that nearly one fifth (19%) of U.S. older adults, the highest rate among all 11 countries included, reported that cost was a barrier to accessing health care, defined as not visiting a doctor, skipping a doctor recommended medical test or treatment, not filling a prescription, or skipping doses (Osborn, Moulds, Squires, Doty, & Anderson, 2014). In addition, despite having Medicare coverage, 11% of U.S. older adults reported trouble paying their medical bills, followed by Australia (7%) with lows of 1% in Norway and Sweden (Osborn et al., 2014).

With increasing longevity and rising health care costs (Cuckler et al., 2013), U.S. older adults are likely to become even more concerned about their ability to afford necessary health care. However, little population-based research has examined older adults’ worry about health care costs. Using data from a nationally representative sample of older adults, the purpose of the present study was to examine factors associated with older adults’ worry about paying for routine health care and/or a health crisis (i.e., a serious illness or accident), focusing on potential age group (65-74, 75-84, and 85+) differences.

Literature Review and Hypotheses

Extensive research has been conducted on the financial burden and stress from health care costs among individuals and families that lack health insurance, have high health insurance premiums, and/or pay high out-of-pocket health care expenses (Blumberg, Waidmann, Blavin, & Roth, 2014; Collins, Kriss, Doty, & Rustgi, 2008; Cunningham, 2009; Galbraith et al., 2011; Polsky & Grande, 2009). Studies also show that about one half of personal bankruptcies are attributable to medical spending (Himelstein, Thorne, Warren, & Woolhandler, 2009; Himmelstein, Warren, Thorne, & Woolhandler, 2005). However, only a few studies have been done on older adults’ worries about health care costs or the impact of high health care costs on their well-being.

A survey conducted by the National Council on Aging (NCOA) in 2015 found that 13% of respondents aged 60+ were not very confident and 6% were not at all confident that they would be able to afford their health care costs as they age, while 43% were very confident and 38% were somewhat confident (NCOA, 2015). However, of professionals surveyed who worked closely with older adults (e.g., Area Agencies on Aging staff, credit union managers, primary care physicians, pharmacists), only 3% were very confident that older adults would be able to afford their health care costs. Results also show that 25% and 24% of the older-adult respondents reported that medication costs and health care service costs, respectively, were a challenge, and 15% were concerned that it would be very or somewhat difficult to have enough money to last the rest of their lives, with health care costs as their top concern.

For low-income, community-residing older and/or disabled adults with multiple chronic illnesses, out-of-pocket health care costs can mount due to cost sharing (deductibles, coinsurance, and copayments) for Medicare and Medicaid-covered services; supplemental private health insurance premiums; amounts not paid for by private health insurance, such as out-of-network balance billing expenses, even if they have private health insurance; and payments for noncovered services. A qualitative study of low-income Medicare enrollees found that coverage gaps, especially the Medicare Part D (prescription drug) coverage gap (often referred to as the “donut hole”), created substantial financial stress and debt, which strongly influenced day-to-day personal, financial, and medical decision making (Grande, Barg, Johnson, & Cannuscio, 2013). Study participants reported that they had to forgo daily essentials like food and heat and delay or avoid recommended care.

Worry is a cognitive, problem-solving process about an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes and can be a constructive and adaptive coping behavior as it may involve information seeking (Borkovec, Robinson, Pruzinsky, & Depree, 1983; Dash, Meeten, & Davey, 2013; Hunt, Wisocki, & Roger, 2009). Previous research found an overall decrease in worry count, frequency, and intensity with advancing age (Babcock, MaloneBeach, Hou, & Smith, 2012; Gonçalves & Byrne, 2013; Lindesay et al., 2006). Older adults’ lower frequency and intensity of worry than younger adults may stem from their tendency to have a greater tolerance for uncertainty and to place less value on worrying (Basevitz, Pushkar, Chaikelson, Conway, & Dalton, 2008). Previous research also shows that, in general, older adults tend to favor positive over negative perspective taking and report a higher sense of control (Slagsvold & Sorensen, 2008; Sullivan, Mikels, & Carstensen, 2010).

Older adults do express worry about their family members’ and their own health, especially functional limitations, cognition, and long-term care needs (Jeon, Dunkle, & Roberts, 2006; Wisocki, 1988). A study in Israel also found that congruent with their wishes to remain independent and care for themselves, older adults’ concerns about health, especially functional health, and perceived income adequacy/inadequacy were the most important causes of their financial worries (Litwin & Meir, 2013). Previous studies have also found that although the prevalence of worries declined with age, the strength of associations between worry types and common mental disorders (e.g., depression, anxiety) either remained constant or increased in older age groups (Lindesay et al., 2006; Miloyan & Pachana, 2015).

When older adults worry about health care costs, they may not access necessary health care services, or they may forgo other essential goods and services to pay for health care, which are likely to lead to further deterioration in physical and mental health. For example, studies have found that daily financial worry had significant detrimental effects on daily pain and depressive symptoms in middle-aged and older adults with other health problems (Rios & Zautra, 2011; Shin, Sims, Bradley, Pohlig, & Harrison, 2014). Compared with older adults without economic difficulty, older adults with extended financial strain from paying for food, housing, and medical care were also found to have more negative social interactions (including inability to get needed help), which in turn exacerbated the negative effect of financial strain on their self-rated health (Krause, Newsom, & Rook, 2008).

Based on this literature review, our study hypotheses were as follows: Controlling for demographics (age, gender, race/ethnicity, marital status, level of education, employment status), worry about health care costs will be (H1) positively associated with (a) lower income, (b) poorer health and mental health status, and (c) a history of at least one ED visit and hospital stay in the past year; and (H2) negatively associated with Medicaid and Veterans Affairs (VA)/military health care coverage (as Medicaid and VA/military health care cover what Medicare does not). Based on findings of decreasing worry about finances with increasing age (Babcock et al., 2012; Gonçalves & Byrne, 2013; Lindesay et al., 2006), we also separately tested these hypotheses in younger, middle, and older age cohorts (65-74, 75-84, and 85+) to examine whether correlates of worry about health care costs differ by age cohort.

Method

Data and Sample

Data came from the 2013 U.S. National Health Interview Survey (NHIS). The annual, cross-sectional NHIS series is the principal source of information on the health of the civilian, noninstitutionalized population (NCHS, 2014). The 2013 NHIS public-use data file contains information on 41,336 households and 42,321 families, with 12,860 children and 33,557 adults interviewed as sample children and sample adults, respectively. The present study focused on the 7,253 sample adults aged 65+, after excluding 365 respondents who were proxy interviewed and an additional 114 with missing data on worry about health care costs.

Measures

Worry about health care costs was measured with two questions: How worried are you now about not being able to pay medical costs for (a) routine health care and (b) a serious illness or accident? The response categories for each question were the following: not worried at all, not too worried, moderately worried, and very worried. In this study, “worry” about health care costs is defined as being moderately worried or very worried about the costs of routine health care and/or a serious illness or accident (yes = 1, no = 0).

Income was measured as income to poverty ratio (<2, 2-3.99, 4+, and missing).

Health/mental health status included the following: (a) total number of chronic illnesses (hypertension, heart disease, stroke, diabetes, any lung problems, arthritis, and cancer ever diagnosed by a doctor or other health professional [0-7]); (b) chronic (in the past 3 months) experience of pain in neck, low back, face/jaw muscles/joints and head/migraine, and/or generalized joint pain that lasted a whole day or more (yes = 1, no = 0); (c) whether or not the respondent needed help with activities or instrumental activities of daily living (ADL/IADL; yes = 1, no = 0); (d) self-rated health (1 = poor to 5 = excellent); and (e) psychological distress measured with the six-item K6 (“feeling nervous; feeling hopeless; feeling restless or fidgety; feeling so sad or depressed that nothing could cheer you up; feeling that everything was an effort; and feeling down on yourself, no good, or worthless”; Kessler et al., 2003). Cronbach’s alpha for the K6 for the study sample was .85.

Health care service use in the past 12 months (yes = 1, no = 0 for each item): (a) Hospital ED visit and (b) overnight hospital stay.

Health insurance type (yes = 1, no = 0 for each item): Medicare, Medicaid, VA health care or military insurance (TRICARE, CHAMPVA), and private insurance.

Demographics included age, gender, race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic Asian, other, and non-Hispanic White), marital status (married/cohabiting vs. not married/cohabiting), college degree (bachelor’s or higher degree vs. no degree), and past-year employment status (worked for pay vs. did not work for pay).

Worry about living costs: The NHIS also asked about worry over not having enough money for retirement, not being able to maintain the standard of living the respondent enjoys, having enough to pay normal monthly bills, and being unable to pay rent, mortgage, or other housing costs. We examined these in connection with worry about health care costs in bivariate analyses only, given their high collinearity with worry about health care costs and with one another. (Worry about not having enough money to pay for children’s college and being unable to make the minimum payments on credit cards are not included as children’s college cost was not applicable to 90.23% of the sample and 25.48% had no credit card.)

Analysis

Analyses were conducted with Stata/MP 14’s svy function to account for NHIS’s multistage, area probability sampling design. Stata’s subpop command was used for all subsample (e.g., age 65+ only, age 65-74 only, age 75-84 only, and age 85+ only) analyses to ensure that variance estimates incorporate the full sampling design. All estimates presented are weighted except for sample sizes. Chi-square (χ²) and t tests were used to examine sample characteristics by worry status (no worry vs. worry). Hypotheses were tested using a binary logistic regression model, with worry status as the dependent variable and income, health/mental health status, health care use, and insurance types as predictors, first for all respondents and then separately for three age groups (65-74, 75-84, and 85+). Due to their small numbers, participants of “other race” were excluded from logistic regression analyses. Variance inflation factor diagnostics (Allison, 2012) found that multicollinearity was not a concern (using a cutoff of 2.50). To better interpret odds ratios (OR) from the binary logistic regression models, we followed Chen, Cohen, and Chen’s (2010) calculations: OR < 0.60 or OR = 1.68 as equivalent to a small effect size (Cohen’s d = 0.2), OR < 0.29 or OR = 3.47 as equivalent to a medium (d = 0.5) effect size, and OR < 0.15 or OR = 6.71 a large (d = 0.8) effect size.

Results

Sample Characteristics: Nonworriers Versus Worriers

Table 1 shows that 31.4% of the sample reported that they were moderately worried or very worried about their ability to pay medical costs of routine health care and/or a serious illness or accident (20.0% for routine health care costs and 28.8% for a serious illness or accident). (Further analysis showed that among those under age 65, 36.4% and 49.1% were moderately worried or very worried about their ability to pay for routine health care costs and a serious illness or accident, respectively.) Compared with nonworriers, worriers were more likely to be younger, women, not married, less educated, and racial/ethnic minorities, and to have been employed in the past year. As expected, worriers also included a significantly higher proportion of those with income <200% of the poverty line, greater numbers of chronic illnesses, lower self-rated health, higher K6 scores, and higher proportions with chronic pain, ADL/IADL limitations, and ED visits. Worriers were more likely to have Medicaid, but less likely to have VA health care/military insurance and private insurance. Moreover, 84.7% of those who worried about health care costs, as opposed to 15.0% of those who did not worry about their health care costs, were worried about their living costs.

Table 1.

Sample Sociodemographic, Health Status, and Health Care Utilization Characteristics by Worry Status (No worries/Not Too Worried vs. Moderately/Very Much Worried).

n (%)	All 7,253 (100%)	No worry 4,996 (68.63%)	Worry 2,257 (31.37%)
Age (years, M, SE)	73.67 (0.10)	74.22 (0.13)	72.47 (0.15)***
Age group (years, %)
65-74	58.88	55.80	65.60***
75-84	30.35	31.18	28.60
85+	10.77	13.02	5.87
Male (%)	44.27	46.88	38.56***
Race/ethnicity (%)
Non-Hispanic White	79.77	81.85	75.22***
Non-Hispanic Black	8.55	8.11	9.51
Hispanic	7.18	5.98	9.80
Non-Hispanic Asian	3.48	3.48	4.87
Other	0.58	0.57	0.61
Married (%)	58.31	59.26	56.23*
College degree (%)	27.76	31.08	20.48***
Past-year employment (%)	23.48	21.72	27.33***
Income to poverty line ratio (%)
<2	27.39	23.00	37.00***
2-3.99	26.38	26.58	25.95
4+	28.69	32.58	20.18
Missing	17.54	17.84	16.88
Chronic medical conditions (M, SE)	2.10 (0.02)	2.04 (0.02)	2.23 (0.04)***
Chronic pain in past 3 months (%)	60.48	57.21	67.64***
Any ADL/IADL limitation (%)	30.02	27.43	35.69***
Self-rated health (M, SE)	3.43 (0.02)	3.53 (0.02)	3.21 (0.03)***
K6/psychological distress (M, SE)	2.04 (0.06)	1.48 (0.05)	3.26 (0.13)***
ED visit in past 12 months (%)	20.46	18.29	25.20***
Hospitalization in past 12 months (%)	14.44	14.25	14.86
Health insurance coverage (%)
Medicare	81.99	82.45	80.98
Medicaid	6.45	5.61	8.29***
VA/military health care	7.56	9.12	4.13***
Private insurance	50.21	52.10	46.09***
Worry about living costs (%)	36.87	15.01	84.69***
Retirement income	29.41	10.33	71.15***
Standard of living	28.59	8.21	73.16***
Rent/mortgage payment	13.18	2.58	36.37***
Monthly bill payment	18.62	4.54	49.41***

Note. ADL/IADL = activities or instrumental activities of daily living; ED = emergency department; VA = Veterans Affairs.

p < .05. **p < .01. ***p < .001: Denote significant difference between nonworriers and worriers.

Within Age-Group Differences

Table 2 shows that the proportion of worriers declines with age (35.0%, 29.5%, and 17.1% in the 65-74, 75-84, and 85+ age groups, respectively.) Within each age group, worriers had lower income, a higher proportion with pain, lower self-rated health, and higher psychological distress. However, nonworriers and worriers did not differ in their number of chronic diseases and ED visits in the 75-84 age group, and they did not differ in ADL/IADL limitations and Medicaid coverage in the 85+ age group.

Table 2.

Within Age-Group Differences in Characteristics of Worriers and Nonworriers.

(%)	65-74 years (n = 4,144)		75-84 years (n = 2,222)		85+ years (n = 887)
(%)	No worry (65.04)	Worry (34.96)	No worry (70.51)	Worry (29.49)	No worry (82.92)	Worry (17.08)
Male (%)	49.43	41.51***	46.11	33.48***	39.53	30.18
Non-Hispanic White (%)	80.11	74.75***	83.21	75.15***	86.09	80.82*
Married (%)	67.45	62.74**	55.07	46.48**	34.16	30.91
College degree (%)	36.54	21.05***	24.03	18.32*	24.56	19.62
Past-year employment (%)	31.42	34.62	11.15	14.89	5.43	6.33
Income <2 poverty line (%)	18.36	33.17***	27.28	43.43***	32.61	48.62***
No. of chronic diseases (M, SE)	1.89 (9.03)	2.17 (0.05)***	2.23 (0.05)	2.29 (0.08)	2.28 (0.05)	2.65 (0.11)**
Chronic pain (%)	56.00	66.00***	58.24	69.42***	59.91	77.18***
Any ADL/AIDL limitation (%)	49.89	65.83***	67.75	82.17***	83.69	86.26
Self-rated health (M, SE)	3.67 (0.03)	3.25 (0.04)***	3.39 (0.03)	3.17 (0.06)***	3.30 (0.04)	2.94 (0.11)**
Psychological distress (M, SE)	1.38 (0.06)	3.29 (0.16)***	1.54 (0.09)	3.01 (0.18)***	1.80 (0.12)	4.25 (0.35)***
ED visit (%)	14.41	24.15***	21.58	24.30	27.04	41.39***
Hospitalization (%)	12.15	13.65	15.80	16.87	19.53	18.66
Health insurance (%)
Medicare	78.42	77.92	87.63	86.60	87.37	87.78
Medicaid	5.75	7.77*	5.28	9.60***	5.81	7.83
VA/military health care	8.64	4.45***	9.74	4.10**	9.70	0.71***
Private insurance	51.51	44.95**	53.11	47.72	52.22	50.85

Note. ED = emergency department; VA = Veterans Affairs; ADL/IADL = Activities of Daily Living/Instrumental Activities of Daily Living.

p < .05. **p < .01. ***p < .001: Denote significant difference between nonworriers and worriers within each age group.

Factors Associated With Worry About Health Care Costs

Table 3 shows that for the total sample, lower income or missing income (as opposed to income ≥400% of the poverty line), chronic pain, ADL/IADL limitations, higher psychological distress, and past-year ED visits were associated with higher odds of worry, while higher self-rated health and having Medicaid or VA/military insurance were associated with lower odds. Of the control variables, being Hispanic or Asian, and past-year employment were associated with higher odds of worry, while older age, male gender, and having a college degree were associated with lower odds,

Table 3.

Correlates of Worry About Health Care Costs: ORs and 95% CIs From Logistic Regression Analyses.

	All (n = 7,135) OR [95% CI]	65-74 years (n = 4,081) OR [95% CI]	75-84 years (n = 2,183) OR [95% CI]	85+ years (n = 871) OR [95% CI]
Age	0.95 [0.94, 0.96]***
Male	0.81 [0.71, 0.93]**	0.87 [0.72, 1.03]	0.72 [0.55, 0.94]*	0.69 [0.35, 1.35]
Race/ethnicity
(Non-Hispanic White)
Non-Hispanic Black	1.05 [0.85, 1.29]	0.98 [0.77, 1.23]	1.20 [0.82, 1.75]	1.52 [0.72, 3.21]
Hispanic	1.32 [1.04, 1.68]*	1.29 [0.96, 1.75]	1.28 [0.82, 1.99]	1.52 [0.55, 4.23]
Non-Hispanic Asian	1.67 [1.22, 2.28]**	1.30 [0.92, 1.84]	3.01 [1.55, 5.86]**	1.24 [0.32, 4.87]
Married	1.10 [0.95, 1.27]	1.16 [0.97, 1.38]	1.00 [0.76, 1.30]	1.16 [0.56, 1.42]
College degree	0.75 [0.63, 0.89]**	0.66 [0.53, 0.81]***	0.99 [0.69, 1.43]	1.44 [0.67, 3.09]
Past-year employment	1.65 [1.36, 1.94]***	1.70 [1.40, 2.07]***	1.89 [1.25, 2.87]***	2.58 [0.60, 10.98]
Income to poverty line ratio
<2	2.19 [1.76, 2.73]***	2.05 [1.57, 2.69]***	2.39 [1.46, 3.90]**	3.20 [1.11, 9.18]*
2-3.99	1.47 [1.21, 1.80]***	1.45 [1.15, 1.83]**	1.42 [0.90, 2.24]	2.14 [0.75, 6.10]
(4+)
Missing	1.59 [1.26, 1.99]***	1.53 [1.15, 2.03]**	1.79 [1.09, 2.93]*	1.99 [0.64, 6.12]
No. of chronic diseases	0.97 [0.92, 1.03]	0.97 [0.90, 1.05]	0.92 [0.82, 1.02]	1.09 [0.92, 1.29]
Chronic pain in past 3 months	1.18 [1.01, 1.37]*	1.09 [0.89, 1.33]	1.36 [1.02, 1.82]*	1.49 [0.83, 2.66]
Any ADL/AIDL limitation	1.40 [1.17, 1.67]**	1.32 [1.07, 1.63]**	1.75 [1.23, 2.49]**	0.74 [0.38, 1.45]
Self-rated health	0.87 [0.78, 0.91]***	0.82 [0.74, 0.91]***	0.97 [0.85, 1.11]	0.87 [0.65, 1.16]
Psychological distress symptom	1.11 [1.08, 1.13]***	1.12 [1.08, 1.15]***	1.10 [1.06, 1.14]***	1.13 [1.06, 1.23]**
ED visit	1.29 [1.08, 1.55]**	1.42 [1.10, 1.82]**	0.93 [0.65, 1.32]	1.99 [1.15, 3.46]*
Hospitalization	0.80 [0.64, 1.01]	0.77 [0.58, 1.02]	0.98 [0.65, 1.48]	0.56 [0.26, 1.61]
Medicare	1.02 [0.84, 1.23]	0.95 [0.76, 1.19]	1.16 [0.80, 1.68]	1.15 [0.40, 3.31]
Medicaid	0.66 [0.50, 0.86]*	0.57 [0.40, 0.82]**	0.88 [0.57, 1.36]	0.68 [0.29, 1.61]
VA/military health care	0.40 [0.30, 0.54]***	0.39 [0.27, 0.55]***	0.51 [0.27, 0.98]*	0.07 [0.01, 0.37]**
Private insurance	0.90 [0.76, 1.06]	0.87 [0.72, 1.06]	0.91 [0.68, 1.23]	0.98 [0.60, 1.60]
Design df	300	300	298	250
F	(22,279) 20.22	(21,280) 15.36	(21,278) 4.40	(21,230) 3.24
p	<.001	<.001	<.001	<.001

Note. OR = odds ratio; CI = confidence interval; ED = emergency department; VA = Veterans Affairs; ADL/IADL = Activities of Daily Living/Instrumental Activities of Daily Living.

p < .05. **p < .01. ***p < .001.

In age-group-specific models, consistent factors for higher odds of worry were income <200% of the poverty line (OR = 2.05, 95% CI = [1.57, 2.69], OR = 2.39, 95% CI = [1.46, 3.90], and OR = 3.20, 95% CI = [1.11, 9.18] in the 65-74, 75-84, and 85+ age groups, respectively) and higher psychological distress. The only consistent factor for lower odds was having VA health care/military insurance (OR = 0.39, 95% CI = [0.27, 0.55], OR = 0.51, 95% CI = [0.27, 0.98], and OR = 0.07, 95% CI = [0.01, 0.37] in the 65-74, 75-84, and 85+ age groups, respectively). Having any ADL/IADL limitation was significant in the 65-74 age group and the 75-84 age group, and ED visit was significant in the 65-74 age group and the 85+ age group. Medicaid coverage was significant only in the 65-74 age group (OR = 0.57, 95% CI = [0.40, 0.82]). Of control variables, past-year employment was significant in the 65-74 age group.

In terms of effect size, having income <200% of the poverty line had a small effect on increasing worry in all three age groups; having VA health care/military insurance had a small effect on decreasing worry in the 65-74 and 75-84 age groups and a large effect in the 85+ age group; Medicaid coverage had a small effect on decreasing worry in the 65-74 age group; ED visit had a small effect on increasing worry in the 85+ age group; and past-year employment had a small effect on increasing worry in the 65-74 and 75-84 age groups.

Discussion

This study examined factors associated with worry about health care costs among a nationally representative sample of older adults. A little less than one third of older adults reported that they were moderately worried or very worried about the costs of routine health care and/or a serious illness or accident; however, the proportion of worriers dropped to 17.1% in the 85+ age group, corroborating previous study findings that age and worry (regardless of its content) are inversely related.

As hypothesized, the most consistent, significant factor associated with worry about health care costs in all three age groups was income < 200% of the poverty line. As opposed to those with income ≥ 400% of the poverty line, low-income older adults were two-to-three times more likely to worry about being able to afford their health care costs. The findings indicate that these low-income older adults are concerned about the potentially devastating impact of health care expenditures on their already strained financial situations and the sacrifices that they are making or may be forced to make to meet their daily living needs.

Though the number of chronic illnesses was not significantly related to worry about health care costs, chronic pain, functional limitations, and self-rated health were significant factors, albeit to a small extent. The lack of significance for number of chronic illnesses is likely due to the fact that worry about health care costs stems from the financial burden/consequences of chronic illnesses, not chronic illnesses per se. A systematic review of socioeconomic variation in the financial consequences of ill health for older adults with chronic illnesses found that even though more affluent older adults had greater out-of-pocket expenses, they were less financially burdened by illness compared with older adults from lower socioeconomic backgrounds (Valtorta & Hanratty, 2013). Psychological distress was a consistent factor associated with higher odds of worry about health care costs. The relationship between psychological distress and worry may be reciprocal, with worrying contributing to psychological distress and vice versa. Longitudinal data are needed to more accurately examine this relationship.

An ED visit in the past year was a significant factor for worry about health care costs in the overall sample, the 65-74 age group, and especially in the 85+ age group. Since ED visits are by definition unplanned events that are likely due to an acute illness, injury, or other serious unanticipated medical condition (Gruneir et al., 2011), they can stoke fears of such medical emergencies and unexpected associated medical costs. Especially among low-income older adults with little cushion in their household budgets (Grande et al., 2013), ED visit episodes can significantly increase worry about health care cost burdens as well as living costs. Unlike ED visits, hospitalization episodes did not significantly contribute to worry. More research is needed to examine possible reasons for the lack of relationship between hospitalization and health care cost worry.

Though only 7.6% and 6.5% of the sample had VA/military insurance and Medicaid, respectively, this study’s key findings are the roles of VA/military insurance in alleviating older adults’ worry about their health care costs, regardless of their age, and of Medicaid in alleviating worry in the 65-74 age group—the largest segment of older adults. VA health care benefits cover a comprehensive array of programs including long-term care support and services (U.S. Department of Veterans Affairs, n.d.). Because veterans who are disabled 10% or more due to an injury or illness incurred in or aggravated by military service are not required to pay a copay for inpatient or outpatient medical care, many veterans who served during World War II, the Korean War, and the Vietnam War who use their VA health care benefits may not incur out-of-pocket costs.

For substantial numbers of older adults, the means-tested Medicaid program covers Medicare’s cost-sharing (deductibles, coinsurance, and copayments) requirements. Medicaid is also the principal payer for long-term services and supports, including nursing home and home- and community-based long-term care services, covering 62% of such costs (National Health Policy Forum, 2011). Many adults who enter long-term care facilities as private-pay patients convert to Medicaid once their financial resources are depleted. Medicaid’s availability is likely a relief for many low-income older adults. In sum, financial resources (i.e., income) and health insurance resources (i.e., Medicaid, VA health care/military insurance) are important factors in limiting worry about health care costs, and study hypotheses about their beneficial effects were largely supported.

A surprising finding was the higher odds of worry among those in the two younger age groups who did paid work in the preceding year, even though they had significantly higher income than their nonemployed peers. One plausible explanation is that older adults who worried about their health care costs may have worked to cover current or future anticipated health care costs. As the NHIS did not ask about current employment status, it was not clear whether those who worked in the past year were still working at the time of the survey. Those who had recently stopped working may also worry more in the absence of earned income or employer-provided health insurance benefits. The association between older adults’ employment status and their health care cost worries should be explored further.

Our study has some limitations due to data constraints. First, cross-sectional data can only be used to examine correlations. More research is needed to elucidate possible causal relationships among variables such as worry, psychological distress, and self-rated health. Second, cross-sectional data also prohibit investigation of individual-level temporal changes in worry. For example, despite the significant association between age and the odds of worry, we do not know whether individuals tend to reduce their worrying over time, or if worriers die earlier. Third, health care cost worry was assessed with two questions in the survey. Although the straightforward questions appear to be a valid measure of the degree of worry, it would have been better if both frequency and intensity of worry and its effects on health care service access and quality of life were assessed.

Despite these limitations, the findings provide the following practice and policy implications. First, for low-income older adults, Medicaid is often their only safety net; therefore, eligibility, benefits, and payments for necessary services (e.g., long-term care) for these vulnerable older adults should not be reduced. Medicaid benefits that are now optional and provided at state discretion such as eyeglasses and dental care are necessary to maintain quality of life. Rather than eliminate or reduce them as many states have done, they should be included in all Medicaid programs. Medicaid cuts, including attempts to shift costs to older adults themselves, will likely result in serious negative outcomes for low-income older adults’ health care, their quality of life, and both the informal and formal support systems that provide long-term care assistance for them (Eldercare Workforce Alliance, 2015). Restricting Medicaid spending per beneficiary or population group covered (e.g., low-income older adults with or without Medicare) does not address the underlying causes of rising health care costs (National Association of Area Agencies on Aging, 2015). Rather than spending cuts, Medicaid should be expanded to cover more low-income older adults, especially those with high health care needs, to ensure their access to health care services and help them maintain a minimum standard of living. Out-of-pocket health care spending should be limited or eliminated for low-income older adults.

Second, VA/military health care programs, which include nursing home, residential, and home- and community-based care, can be significant resources for low-income, older veterans. Though only a small proportion of older adults receive VA/military health benefits, these benefits are essential and should be expanded to reach more veterans in need.

Third, education on chronic disease self-management, injury prevention, and other preventive services are essential to reduce ED visits, especially among low-income older adults with multiple chronic illnesses. This, in turn, may reduce their worry about health care costs. The Affordable Care Act (ACA) provides a “Welcome to Medicare” preventive visit for new Medicare beneficiaries; a yearly wellness visit, free of charge, for those who have had Medicare Part B for longer than 12 months to develop or update a personalized prevention plan based on current health and risk factors; and several other preventive screenings without cost sharing (Nicholas & Hall, 2011; U.S. Department of Health Services, n.d.). The ACA has also made Medicare drug coverage more affordable with the gradual closing of the “donut hole.” Older adults need to be informed about these preventive services and measures that can reduce their out-of-pocket health care costs, improve their health, and reduce health care cost worries.

Fourth, we found no multi-item, validated measure of worry about health care costs. A comprehensive measure that would also assess frequency and intensity of worry about health care costs is needed. With rising health care costs, further research is also needed to examine the effects of older adults’ worry about health care costs on their access to health care services, physical and mental health, and overall quality of life.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Namkee G. Choi, PhD, is a professor in the School of Social Work, University of Texas at Austin.

Diana M. DiNitto, PhD, is a professor in the School of Social Work, University of Texas at Austin.

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