The analysis sought to describe the relationship between health insurance coverage and the quality of care that men and women experience. The most significant, consistent findings were related to access to care. For the most part, women were significantly more likely than men to report delays in care. Differences were exhibited among midlife adults who reported having diabetes or cardiovascular conditions. While gender disparities did not attain statistical significance among Medicare-insured older adults with diabetes, a few significant disparities persisted among older adults with cardiovascular conditions. Findings are consistent with prior research showing that women in midlife have more problems in accessing care, compared to men in the same period of life (Rustgi et al 2009). Attainment of Medicare-eligibility among older adults appears to reduce, but not eliminate, gender disparities in delays in care.
Analysis also demonstrated significant differences in access to care based on insurance coverage. Among midlife adults, uninsured individuals were more likely to report delays in care than other health insurance status groups. There were also some significant differences in access to care between those with private insurance vs. public insurance. However, among older adults, there were no significant differences in delays in care based on type of insurance, and the rates of reported delays were much lower than those reported by midlife adults. These patterns suggest the importance of Medicare in providing access to care for older adults, and speak to the larger issue of significant delays in care for midlife adults in the absence of health coverage provided by Medicare or other publicly supported health insurance programs. Prior research differs on whether obtaining Medicare coverage is associated with general improvement in health status, but indicates that the impact of health insurance may be more profound for persons with cardiovascular conditions or diabetes (McWilliams et al 2007a, 2007b; Polsky et al 2009).
Guidelines for cardiovascular conditions and diabetes recommend ongoing monitoring services and treatment (American Heart Association 2008; National Institute of Diabetes and Digestive and Kidney Diseases 2009). Delays in receipt of medical services and prescription drugs could lead to suboptimal quality and outcomes. Differences in access to care based on type of insurance coverage are well documented. Compared to men, women have lower incomes to meet rising health care costs, have higher rates of chronic conditions, use more health care services and rely more on public programs and insurance obtained through their spouses (Glied et al., 2008; Patchias and Waxman, 2007; Rustgi et al., 2009). It is unclear whether differences in self-reports about delays in care reflect women's greater propensity to self-identify the need for care, or greater difficulty in obtaining needed care. A recent study indicated that a spouse's transition to Medicare contributed to women's inability to gain access to care, despite having consistent insurance coverage (Schumacher et al 2009). Findings from this study suggest that more research is needed to understand better how women's unique health care needs and insurance coverage experiences affect
For the remaining quality of care indicators, there were few statistically significant gender or insurance group differences in effectiveness of care or patient-centeredness of care, and differences did not consistently favor women or men, or any insurance group.
There are several limitations to this analysis. First is the reliance on self-reported disease status to identify older adults with diabetes and cardiovascular conditions. There is the possibility of misclassification, as some individuals who self-identify as having these conditions may not actually have them. In particular, those with diabetes may not meet the clinical definition of the disease. However, there is evidence that older adults can reliably report their chronic conditions, and positive predictive value of such reports is high (Miller et al 2008; Silliman and Lash 1999).
Second, while analysis explicitly adjusts for several key individual factors—including patient self-rated health status, race/ethnicity, education and income—it does not adjust for other factors that may influence quality of care, such as patient values and care preferences, presence of comorbid conditions and geographic region. Third, even after combining three years of MEPS data, sample size limitations prevented the exploration of how disparities affect particular subgroups of men and women (e.g., Black men and women, or men and women with less education). Fourth, because of the confounding of age and Medicare coverage, we cannot rule out the possibility of the role of age in the results. Despite these limitations, analysis provides nationally representative data on gender-based and health insurance-based disparities among older adults with diabetes and