Policy Paths, Research Gaps to Improve Medicare Access for Younger Beneficiaries: Emma Achola-Kothari, PhD

In the final part of her interview with The American Journal of Managed Care^®, Emma Achola-Kothari, PhD, lead investigator of "Evaluating Access to Care for Medicare Beneficiaries Younger Than 65 Years," a study published in the May 2025 issue, discusses policy implications of her findings, acknowledges key limitations, and outlines directions for future research.

Watch parts 1 and 2 to learn more about the study's context and results.

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

Transcript

How do you see your findings informing future CMS policy to improve access and reduce cost-related barriers for Medicare beneficiaries under the age of 65?

One of the ways that beneficiaries get access to supplemental coverage is through the Medigap market. This under-65 population is largely locked out of the Medigap market, so they aren't really even able to access that supplemental coverage that I was talking about earlier. I think that that's one thing that maybe we should look at, seeing how we can make it such that people under 65 can enroll in Medigap coverage.

I think that's kind of the biggest takeaway that I got from this study. I think it's also interesting that, again, looking at the growth of Medicare Advantage as a share of Medicare enrollment, how it's grown over time, that it is providing some level of financial protections, which I think is reassuring to see.

In contrast, what were some of the key limitations of your study? How might they have impacted your findings?

Some key limitations, we were using survey data, so I think that anytime you use survey data, there's some room for recall bias and people not remembering answers to the questions. We also were relying on self-reported Medicare coverage as well, so we didn't have access to enrollment files to verify, does this person actually know what they're enrolled in?

I think a lot of times, Medicare enrollment can be really confusing. Like, do I have this Medicare Advantage thing? What am I enrolled in? We are relying on what the person is telling us that they have, so I think that could be a limitation as well.

I think, as with any observational study, we're dealing with residual confounding, that these are not causal effects that we're estimating here, we're not really able to disentangle the unobservable things that could be contributing to people selecting into certain types of coverage.

That's a limitation, because we really want to create internally valid estimates that would allow us to be like, "Oh, well, being enrolled in traditional Medicare with no supplement is causing you to have these issues." We're not really able to say that, but I do think it points to some interesting things around, again, being exposed to high out-of-pocket costs and how that can make you sensitive to experiencing cost-related nonadherence and things like that.

What additional research would you like to see to build upon your findings?

With any study, we would love to be able to produce more causal research, to be able to say that this is causing, again, whether it be access issues or financial issues, I think that's one thing. It's very hard to do that work and do it well.

Going back to your previous question about limitations, something I would like to see is, again, tying these things back to outcomes. In our study, we're only able to say that people are experiencing cost-related medication nonadherence, or they're having issues finding a doctor. We're only able to measure those things.

But does reporting that mean that you're maybe experiencing more avoidable ED [emergency department] visits, that you aren't getting as much preventive care as you really should be getting? Maybe future work could tie more back to, well, what are the downstream effects of beneficiaries reporting that they're having these issues with care?