For fifty years, Medicare has played a critical role in promoting economic security for older women in the United States. Today, Medicare serves 24 million women ages 65 and older, representing 56 percent of older adults enrolled in the program, and provides them with financial protection at a time in their lives when they have the greatest need for medical care and often the fewest family and economic resources. The passage of Medicare in 1965 marks a key milestone in women’s economic security and a major contribution to reducing income equality in old age between men and women.
Viewing Medicare through a gender lens can help illuminate its programmatic strengths and shortfalls, which often are masked when the program is considered in aggregate. There is no doubt the program has made a critical difference in the lives of millions of women. Gaps in coverage, however, notably the lack of coverage for long-term-care services and supports (LTSS) and high out-of-pocket spending continue to place a disproportionate burden on women. These gaps still can lead to sizable and sometimes crushing financial burdens for many women and their caregivers.
The Status of Older Women Before Medicare
In the years prior to the passage of Medicare, societal norms left many women at a considerable social and economic disadvantage. For older women, these “norms” translated into higher rates of financial insecurity and fewer social supports. Although workforce participation of women had been rising since the 1940s, in 1965, only 39 percent of women were in the paid workforce (compared to 81 percent of men) (Bureau of Labor Statistics, 2014). Among women with full-time jobs, the gender wage ratio, also known as the “wage gap,” was 60 percent (Blau and Kahn, 2007). This meant that women not only were less likely to earn an income through work, but that when employed, they earned a lower wage than men. (You only have to watch an episode of Mad Men to see how this discrimination played out in the workplace.)
This meant women not only accrued fewer savings throughout their lives, but also, unless they were married, they had limited access to retiree benefits, particularly pensions. In 1966, the year that Medicare was first implemented, one-third of women ages 65 and older lived in poverty, compared to nearly a quarter of men (U.S. Census Bureau, 2014). The poverty rates of working-age adults were considerably lower at the time. Nearly fifty years later, only one in ten women ages 65 and older live in poverty. That rate is still nearly twice that of men (see Figure 1, below).
In the 1950s and 1960s, the share of working-age Americans with hospital insurance was rising, with nearly three-quarters reporting access to that financial protection. In contrast, coverage rates for older Americans were far lower, with just over half of older adults (56 percent) in 1965 reporting any kind of insurance for hospital care (Harris, 1966). The share of older women with coverage likely was even lower, given their weaker workforce attachment and higher likelihood of living alone or being widowed by the time they passed their prime working years.
There is little published information about gender-based differences in health status, use of healthcare, and the economic burden of healthcare costs for older Americans in the era predating Medicare. What we do know is that in 1960, women turning age 65 could expect on average to live nearly sixteen more years—three years longer than men—and the top five causes of death for women were heart disease, cancer, cerebrovascular disease, accidents, and influenza and pneumonia (National Center for Health Statistics, 1965). These conditions often required medical care and hospitalization, but did not result in protracted periods of disability that necessitated paid or unpaid family care.
Since it was signed into law fifty years ago, the Medicare benefit package has expanded and evolved in ways that have provided additional assistance to older women to cover healthcare. When the program was first enacted, the benefit package had a strong focus on hospital care, which was similar to most private insurance plans available at the time. Preventive care and prescription drugs were not typical insurance benefits, as they are today. Medicare did not routinely cover Pap smears until 1990 and did not cover screening mammography until 1991 (Gornick et al., 1996). Once it provided coverage for these services, it required 20 percent co-insurance, which meant that women still could have significant out-of-pocket payments for these preventive services as well as for clinical breast exams, bone density tests, and pelvic exams—sometimes resulting in barriers to care.
older Medicare beneficiaries, out-of-pocket spending escalates with age, but women ages 85 and older, in particular, have considerably higher out-of-pocket costs than older men, largely due to their poorer health status, greater social isolation, and dependence upon paid LTSS. Notably, among women ages 85 and older, spending on LTSS was 50 percent higher ($3,954) than it was for men ($2,694) (CMS, 2010). Among women ages 85 and older, 60 percent have incomes below $20,000 per year, which could make the costs associated with LTSS extremely difficult to shoulder.
Alina Salganicoff, Ph.D., is vice president and director of Women’s Health Policy at the Kaiser Family Foundation in Menlo Park, California. She can be contacted at firstname.lastname@example.org.
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