High Costs, Narrow Networks Undermine Access for Younger Medicare, Dual-Eligible Beneficiaries: Emma Achola-Kothari, PhD

Emma Achola-Kotari, PhD, continues her conversation with The American Journal of Managed Care®, expanding on findings from her study, "Evaluating Access to Care for Medicare Beneficiaries Younger Than 65 Years," published in the May 2025 issue, with a focus on individuals with traditional Medicare and no supplemental coverage, as well as dual-eligible beneficiaries.

Watch part 1 to learn more about the study's background and key findings.

This transcript was lightly edited; captions were auto-generated.

Transcript

One key finding was that individuals with traditional Medicare and no supplemental coverage faced the greatest barriers. What do you think is driving that? Were you surprised by this trend?

I think the biggest thing maybe driving that is the cost-sharing structure of traditional Medicare. The traditional Medicare program, while you have your premiums that are covered if you've worked a certain number of years in the US, and you've paid taxes, the out-of-pocket costs can be a lot for beneficiaries.

For instance, looking at Part B services, or outpatient or physician services, beneficiaries have to pay 20% coinsurance for all of those services that they receive. Then, you separately have your out-of-pocket costs and premiums that are associated with any Part A services that you're using, as well as prescription drug coverage. It can be a very expensive benefit for beneficiaries.

A lot of folks, to fill in those gaps, will buy Medigap or have some sort of supplement that wraps around and takes care of those costs. Beneficiaries are exposed to that with no out-of-pocket maximums. You can imagine that if you don't have access to any wraparound care, whether that be because you're a dual-eligible beneficiary and you have Medicaid, or even if you're in Medicare Advantage and you have an out-of-pocket maximum on your plan, that that can create some financial barriers if you're being exposed to that level of cost sharing without any limits on your out-of-pocket spending throughout the year.

I think that, in terms of, was that surprising? It wasn't very surprising. I think it kind of makes sense, thinking about how expensive the benefit can be, and how maybe that's sort of pushed people into enrolling in Medicare Advantage, as well. I think, just intuitively, that made sense to see that those beneficiaries would face some level of cost-related issues.

You also found that among dual-eligible individuals, switching from traditional Medicare to Medicare Advantage was associated with increased difficulty finding a doctor. Why do you think that might be?

I think that that might relate to the networks that MA [Medicare Advantage] beneficiaries have to remain in. Similar to you and me with our HMO [health maintenance organization] or PPO [preferred provider organization] coverage from our employer, there's a network of providers that we could see, and our plan will cover that care. If we go out of that network, then we may be exposed to the entire cost of care or higher cost sharing.

You can imagine, you go from traditional Medicare that has no restrictions on who you can see, you can go to any willing provider who accepts Medicare, and you go from that to Medicare Advantage, which is more restrictive in the network of providers that it allows you to see, that we might see that there would be some increase.

Maybe your preferred doctor, your favorite doctor, doesn't contract with the Medicare Advantage plan that you are enrolled in. I think it does make sense to see that maybe going from less restrictive access to more restrictive access, because of networks, because plans may even create very narrow networks for care, we would see maybe some increase in the likelihood that you're reporting access issues.