Impact of Medicare Eligibility on Informal Caregiving for Surgery and Stroke

Abstract

Research ObjectiveOver 40 million older Americans rely on informal care (unpaid assistance for personal care such and instrumental support, including toileting, bathing, and shopping). Prior work illustrates 68–230% greater spending on post‐acute care after surgery for Medicare beneficiaries compared to older commercial insurance enrollees. Such enhanced access to post‐acute care may reduce the need for family and friend caregiving support for rehabilitation following acute medical events. While use of informal care is substantial among older Americans, little is known about informal support for patients after acute medical events, and how formal post‐acute care influences its use.Study DesignWe used 1998 to 2018 Health and Retirement Study (HRS) data to assess changes in weekly hours of informal care received by individuals experiencing acute events before and after Medicare eligibility. We created two similar cohorts of individuals near the Medicare eligibility age: pre‐Medicare, or individuals ages 59–66 and not covered by Medicare; and Medicare, or individuals ages 67–74. We used a threshold of 67, rather than 65, for the Medicare cohort to account for the two‐year lookback period used in HRS survey questions. The cohorts were matched using inverse probability treatment weights. A regression discontinuity design assessed three types of caregiving – the proportion of respondents receiving care, intensity of care among care recipients, and care intensity among all respondents – before and after Medicare eligibility. We estimated generalized linear models with a log link and gamma distribution that regressed informal care on Medicare status, a centered age variable, and an interaction between Medicare status and centered age. Sensitivity analyses included stratification by surgery type and by sex.Population Studied4264 Health and Retirement Study participants near the age of Medicare eligibility in one of three self‐reported acute medical cohorts: stroke, heart surgery, or joint surgery.Principal FindingsAmong near‐retirement individuals, 2031 (47.6%) had a stroke, 1038 (24.3%) underwent heart surgery, and 1038 (28.0%) underwent joint surgery. Of the 937 (22.3%) of patients who reported receiving care from an informal caregiver, average care measured 34.0 (SD: 49.2) weekly hours. Mean (SD) weekly informal caregiving hours were 7.5 (27.0) overall, and 12.1 (34.7), 3.8 (18.5), and 2.9 (14.1) for stroke, heart surgery, and joint surgery patients, respectively. In adjusted analyses, the proportion of stroke patients receiving informal care decreased from 39.5% to 28.6% (or by 28%) and the average weekly amount of care decreased from 21.0 to 10.3 hours (or 51%) after Medicare enrollment. Non‐significant decreases were observed for the other medical cohorts. There was a non‐significant average decrease of 22.8 hours (or 40%) in the intensity of care received by men after one of three events.ConclusionsAccess to Medicare coverage was associated with a 51% reduction in informal care received by older Medicare stroke patients, potentially by increasing access to post‐acute services.Implications for Policy or PracticePost‐acute care is increasingly targeted for cost savings under Medicare policies, which may restrict access to post‐acute care and rehabilitation, impacting demand for informal care for older adults with stroke.