Younger, Older Adults at Risk

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Younger, Older Adults at Risk

By Julie Ishida, The Washington Post

September 16, 2003

For many college students, finding the way around campus or planning a class schedule may be bigger priorities at the start of the school year than signing up for health insurance. But for Erin Thomas of Largo, getting coverage is a major concern. Thomas, 24, needs treatment for her Crohn's disease (chronic inflammation of the digestive tract) and no longer is covered by her parents' plans.

Others long past their twenties face insurance troubles. Patsy Jones, 51, of Roanoke, has diabetes and fibromyalgia, a painful syndrome that is difficult and expensive to treat under the best circumstances. She has never had health insurance, so she receives care at the Bradley Free Clinic in Roanoke.

Americans too old to be considered children and too young for Medicare are particularly vulnerable to gaps in the health insurance system. For young adults just starting to work and still unsettled in a career, finding stable -- and affordable -- coverage is the problem. For those between middle age and retirement, finding any coverage at a time when they are more likely to suffer from chronic illness and require complex and expensive care is the challenge.

"Younger people tend to be healthier, but they have a high rate of uninsurance," said Paul Ginsburg, president of the Center for Studying Health System Change. "For the near-elderly, the rate of uninsurance is lower, but the consequences are more severe because of the higher incidence of chronic disease and likelihood of large medical expenses."

Young adults are usually dropped from parents' coverage when they turn 19 unless they are full-time students, in which case coverage typically lasts through age 23. They can also be dropped from public insurance programs like Medicaid and the Children's Health Insurance Plan (CHIP) either when they reach 19 or when they start working and exceed the programs' income limits.

Young people are left to find insurance through the workplace, a tall order considering that most jobs available to this group are the least likely to provide health benefits.

People ages 19 to 29 accounted for nearly 30 percent of the nonelderly adult uninsured in 2001, despite comprising only 15 percent of the total U.S. population, according to an analysis of Census data by the Commonwealth Fund, a foundation that supports independent research on health and social issues.

And aside from the challenge of finding a job that offers health insurance, many young people opt not to purchase it.

"Younger people don't try as hard to be insured as older people because they don't see themselves as needing it," said Ginsburg.

Erin Thomas's access to treatment for Crohn's disease has shifted with eligibility for her parents' insurance. After the 1998 diagnosis of her illness, which made her too sick to stay in school, she dropped out midway through her sophomore year at the University of Maryland, College Park. She thereby permanently lost coverage under her father's insurance plan, which covers full-time students until age 23. Shortly thereafter, Thomas was covered under her mother's health plan. But when she changed jobs in 2002, said her mother, Pamela Thomas, her new benefit package did not cover children over age 20.

Erin Thomas did not qualify for government-sponsored Medicaid insurance, and her application for individual private coverage was denied due to her preexisting condition. By the time she learned about the Consolidated Omnibus Budget Reconciliation Act (COBRA) -- legislation that could have extended her coverage under her mother's old plan for three years -- it was too late to apply, she said.

"I was hopeful that I could get health insurance somewhere else, but after my search and being denied, I was disappointed in our health care system," Thomas said.

With no insurance, Thomas had to pay out-of-pocket for medications -- her most expensive drug cost $120 a month -- and for visits to a specialist at George Washington University Hospital and to Community Medical Care, a sliding scale clinic in the District.

This month, after managing, while ill, to earn an associate of arts degree at Prince George's Community College, Thomas returned to the College Park campus to complete her final year. She has applied for insurance through the University of Maryland, which costs about $1,100 a year -- more affordable than other policies, but a sizable sum for a college student.

When Louis Boggess of Front Royal, Va., was 16, he was dropped from Medicaid because his mother's new job paid too much for him to qualify. This change meant Boggess could not afford the $800 to $1,000 needed monthly to treat his type 1 diabetes.

Lack of regular care brought Boggess, now 19, in March to Warren Memorial Hospital in Front Royal with a blood glucose level of over 800 mg/dl, a serious medical situation requiring immediate attention. His bill, for more than $1,000, was written off by the hospital. Since May, Boggess has kept his blood glucose level under control with the help of St. Luke Community Clinic, a free clinic in Front Royal.

"Without the clinic, I wouldn't have my medications and I'd be racking up huge bills when I'd finally have to go to the hospital and probably be admitted until I got under control," Boggess said, in a statement relayed by Marge Rowe, executive director of the clinic. "Bottom line is that I could die."

But he has already developed complications of diabetes, poor sensation and wound healing in his feet, due to years of uncontrolled blood glucose, Rowe said. In July, after only two weeks as a produce stocker in a supermarket, he lost his job after missing two days of work in part due to a foot infection that has been slow to heal.

The clinic plans to work with other agencies, such as Virginia's Department of Rehabilitative Services, to help Boggess develop the skills to work in a setting more suited to his condition.

Chronically Uninsured

Older adults who have not yet reached the standard Medicare qualifying age of 65 face problems of a different sort. About 32 percent of people ages 55 to 64 have two or more chronic conditions, compared with only 3 percent of people ages 18 to 29.

People ages 50 to 64 comprised only about 14 percent of uninsured nonelderly adults in 2001. But "they are the group for which the absence of health insurance is the most threatening to their health and economic security," said Karen Davis, president of the Commonwealth Fund.

Older people who lack employer-sponsored insurance and do not receive public coverage are left with the option of purchasing individual insurance. But because of age and their greater likelihood of being sicker, they are charged higher premiums, which make insurance largely unaffordable.

And for people who retire before age 65, the insurance options are also limited because most companies do not offer health benefits to early retirees. In 2000, according to the Employee Benefit Research Institute, only 12 percent of U.S. employers offered retiree health benefits to "early" retirees under age 65.

Patsy Jones's is the all-too-familiar story of an older person who makes too much money to qualify for public health insurance but too little to pay for private insurance. She has worked part-time for Kelly Home Care Services in Roanoke as a certified nursing assistant for the last 15 years. The company has offered her insurance several times, but she has declined it because she could not afford to pay the monthly premium, $73, from her income of about $525 a month.

And so this health care worker is herself a patient of Bradley Free Clinic, where she has received care for diabetes, fibromyalgia and other medical problems. Despite her regular care through the clinic, she has accumulated about $6,600 in outstanding hospital and physician bills due to several medical procedures for which she is still contacted by collection agencies.

"I feel terrible that I can't pay, but it's not that I don't want to pay," Jones said. "I just can't."

Evelyn Zaun's working days at her cafeteria and restaurant jobs were over in February 2000 when, due to difficulty breathing, she was rushed to Warren Memorial Hospital and diagnosed with chronic obstructive pulmonary disease (COPD). Zaun, 59, lives on a monthly Social Security check of about $700, hardly enough to purchase her own insurance, which she says would cost her $583 a month.

"There would be no way I could afford it," Zaun said. "Nobody will take me."

Without coverage, Zaun, of Front Royal, receives care for her COPD and other conditions -- type 2 diabetes, high blood pressure and hypothyroidism -- at St. Luke Community Clinic. She takes 10 medications and wheels an oxygen tank wherever she goes; she pays $175 monthly for the tank, but receives most of her medications and diabetes monitoring supplies, a monthly value of about $1,700, from the free clinic.

Zaun has had to wait for two years to obtain Medicare disability coverage, which she said she will start receiving in October. But in the meantime, she has been to the emergency room three times for her COPD. While nearly all of her hospital bill, about $19,000, was written off by Warren Memorial Hospital, she has been paying about $15 a month to help pay back the assistance.

Can This Be Fixed?

Some proposals that would cover more younger and older adults are part of broader efforts to expand health insurance access to all Americans, but others are more specific to these age groups.

Raising the age cutoff for eligibility for Medicaid and CHIP from 19 would ensure more coverage of childless adults over age 18. The federal government could require health plans to cover employees' dependents until a later age than they usually do now; there is currently no federal requirement that health plans cover dependents until a certain age.

States could mandate that all colleges require their students to obtain health insurance, either through the school or through another source; some states and colleges already require that students have health insurance as a condition of enrollment.

At the other end of the age spectrum, the option to purchase Medicare before age 65 would allow more older Americans to obtain insurance, in some cases at a cheaper price than if they bought individual insurance. But subsidies would be needed to ensure access to low-income older individuals.

Expanding coverage to younger and older Americans, the two groups especially vulnerable to the lack of health insurance, is a particular concern of lawmakers, including several of the 2004 presidential candidates. Specific plans to cover more younger adults and those nearing retirement age are part of a greater effort to expand health insurance to more Americans, and combine public and private approaches in their design, said Sara Collins, senior program officer for the Commonwealth Fund.