Subjective Well-Being,Depression,and Delays in Care Among Older Adults: Dual-Eligible Versus Medicare-Only Beneficiaries

Abstract

We aimed to (a) determine the role of subjective well-being and depression in care delays among Medicare beneficiaries and (b) examine whether subjective well-being and depression play a differential role among Medicare-only and dual-eligible beneficiaries. A nationally representative sample of 1,696 older adults participated in the study. Roughly, 22% of participants reported often or sometimes experiencing care delays, with more delays among dual eligibles. We found that higher levels of subjective well-being were significantly related to less frequent care delays. In contrast, higher levels of depression were significantly related to more frequent care delays. Moreover, as depression increased, the predicted probability of delays increased to a greater extent among dual eligibles than Medicare-only beneficiaries. These findings signify the importance of identifying and implementing strategies to enhance subjective well-being and reduce depression in older adults, particularly dual eligibles, to improve access to timely care.

Keywords

subjective well-being depression delays in care older adults dual eligibles

Introduction

Access to health care services plays an important role in enhancing health outcomes and reducing health disparities for older adults. In 1993, the Institute of Medicine (IOM) described access to health services as “. . . the timely use of personal health services to achieve the best possible health outcomes.” (p. 4). Access is important for the older population, which is expected to become more racially and ethnically diverse and double from 52 million in 2018 to 95 million in 2060 (Population Reference Bureau, 2019). As this population continues to grow, prompt attention to health care needs is imperative to decrease the strain of providing care for older adults who are often managing multiple comorbid conditions on the health care system (Mather et al., 2015; Population Reference Bureau, 2019). Delays in managing care, whether related to management of a chronic disease or completion of preventive activities such as screenings, can result in unmet needs and poor health outcomes leading to more serious illness, increased complications, worse prognosis, and longer hospital stays (Diamant et al., 2004).

Despite poorer health outcomes, delays in care among older adults are not uncommon. About 19% of older Americans indicate that they did not visit a provider or skipped recommended treatments or medications due to cost (Stokes, 2014), and few participate in prevention-based visits offered through Medicare (Centers for Medicare and Medicaid Services [CMS], 2016). An additional study reported that 23% of older adults did not see their provider when ill or complete health care recommendations such as getting an annual flu shot (Osborn et al., 2017). Major barriers to health care access consist of (a) financial including high costs and inadequate insurance coverage, (b) structural such as lack of access to services and transportation, (c) interpersonal including perceived provider lack of competence and the patient–provider relationship, and (d) personal such as health literacy and cultural beliefs (Fitzpatrick et al., 2004; Lee et al., 2012; Thorpe et al., 2011).

Delays in care are particularly concerning for the older adult population subgroup referred to as dual eligibles (receiving both Medicare and Medicaid) who are socioeconomically and medically disadvantaged. For this group of beneficiaries, Medicare is the initial payer for hospital and medical costs with Medicaid covering some of the remaining costs including nursing home care and home-based or community care, with coverage varying state by state (CMS, 2019a). States additionally determine criteria for eligibility, within broad national guidelines based on income limits and resource limits (money in checking and savings accounts, stocks, and bonds, etc.). States determine the type, amount, duration, and scope of services which will be offered, set the rate for payment of services, and administer the program. In 2020, a single individual, 65 years or older must have an overall income of less than $2,349 (US) monthly to be eligible for Medicaid (American Council on Aging, 2020). In 2019, the numbers of beneficiaries who were dually eligible rose to 12.2 million. While dual eligibles only account for 20% of Medicare beneficiaries, they are responsible for 34% of all Medicare spending (Medicaid and CHIP Payment and Access Commission, 2020). Relative to Medicare-only beneficiaries, dual eligibles tend to have higher rates of morbidity and mortality, hospitalizations, and emergency department visits, suggesting problems of access to and quality of care (Allen et al., 2014; CMS, 2020b). To help address possible contributing factors including fragmentation or ineffective care received by dual eligibles, CMS has initiated programs to address complex needs and align incentives, such as Modernizing Medicare Savings Programs (MSPs), Dual-Eligible Special Needs Plans (D-SNPs), and the Comprehensive Primary Care Initiative (CMS, 2019b, 2020a). These strategic initiatives mainly focus on addressing the financial, structural, and interpersonal barriers to health care faced by older adults.

As previously mentioned, personal factors also play a role in care delays; however, there is a paucity of empirical research investigating the role of personal factors in care delays in this population. One study found that lower health insurance knowledge, and particularly, lack of knowledge about preventive care coverage was significantly related to delays and avoidance of preventive care due to perceived costs (Smith et al., 2018). This may help explain why many seniors with insurance coverage still delay or avoid health care due to costs, indicating access is necessary but not sufficient. Modifiable personal factors such as well-being and depression have not yet been adequately examined relative to delays in care for older adults. Subjective well-being, advocated as a public health priority (Feller et al., 2018), has been described by Huppert as a “combination of feeling good and functioning effectively” (Huppert, 2009, p. 138). Researchers note that subjective well-being is not the same as perceived health, instead it is a construct which should be considered in its own right as an independent factor (Pressman & Cohen, 2005). Overall research concerning subjective well-being indicates that it is beneficial to good health, longevity, healthy behaviors, and better social relationships (Diener et al., 2017, 2018). Previous research has documented the impact of subjective well-being on multiple outcomes including disease progression and control, self-care activities, and functional status (Howell et al., 2007; Huppert, 2009; Ryff, 2017). Subjective well-being may serve as a positive psychological resource for older adults, enhancing their health literacy and capacity to seek timely disease management and preventive services to meet their health needs. Unlike the potential beneficial role of subjective well-being, depression is significantly associated with more perceived barriers to health care, care delays, and unmet care needs (Stein et al., 2016; Thorpe et al., 2011). In the case of dual eligibles, a vulnerable group known for high costs and complex health needs, the challenges of timely use of health services may be compounded by the low levels of subjective well-being and high levels of depression, leading to fewer psychosocial resources and decreased confidence in recognizing the need for care (Blazer, 2008).

There exists little evidence at the national level of the associations between subjective well-being, depression, and delays in care, or how the associations vary between Medicare-only and dual-eligible beneficiaries. The National Health and Aging Trends Study (NHATS), a nationally representative panel study of Medicare beneficiaries aged 65 years and older, collected rich data on subjective well-being, depression, and engagement in care during its second round of data collection in 2012. These data provide an opportunity to identify the relationship between personal factors and delays in care in older adults which persist despite having access to health insurance. The purposes of this study were to (a) determine the role of subjective well-being and depression in care delays among Medicare beneficiaries and (b) examine whether subjective well-being and depression play a differential role among Medicare-only and dual-eligible beneficiaries. Identifying personal psychological factors which reduce delays in care may support development of complementary strategies to existing CMS programs to enhance health outcomes.

Methods

Data and Sample

The NHATS is a longitudinal study that annually surveys an in-person nationally representative sample of Medicare beneficiaries ages 65 and older living in the contiguous United States. Medicare enrollment files are used as the sampling frame; participants are sampled using a stratified sample design. The NHATS collects information about demographics, physical and cognitive capacity, health conditions, living arrangements, help received with daily activities, participation in various activities, subjective well-being, and other information relevant to older adults. Surveys began in 2011 and are supported by the National Institute on Aging (NIA) under a cooperative agreement with the Johns Hopkins Bloomberg School of Public Health. Data are collected by Westat, a professional services company (Kasper & Freedman, 2020). For more detailed information on the NHATS’s sample design, please refer to the NHATS website (https://www.nhats.org/). The outcome of interest was only available in the engagement in health care section of the NHATS second round of data collection, so data for this study came from the second-round public use files of the NHATS conducted in 2012.

This study only analyzed data from community-dwelling older adults who reported delays in managing medical care (n = 2,032). Exclusion criteria included (a) having a proxy respondent (n = 154, 7.6%), (b) living in a residential care setting (n = 102, 5.0%), and (c) having missing data for some of the study variables including subjective well-being items, number of health conditions, and insurance status (n = 80, 3.9%). Hence, our final sample size totaled 1,696 older adults.

Measures

Dependent variable

Delays in care

Participants were asked, “How often do these things that you are asked to do to stay healthy or treat a health problem get delayed or not get done?” These things include managing medicines, getting tests, and lab work done, watching weight and blood pressure, or having yearly exams. The question had four response categories: never (coded as 1), rarely (coded as 2), sometimes (coded as 3), and often (coded as 4).

Independent variables

Subjective well-being

The survey includes 11 questions to measure three aspects of subjective well-being including positive and negative affect, self-realization, and self-efficacy and resilience. The subjective well-being items used in the NHATS were adapted from similar items in the Midlife in the United States (MIDUS) survey, which is a national longitudinal study of health and well-being which has been conducted since 1995/1996 (MIDUS, 2011). The MIDUS surveys are conducted by the Institute on Aging at the University of Wisconsin-Madison with funding support from the NIA. Positive and negative affect were assessed with four questions related to respondent’s frequency of feelings in the last month: cheerful, bored, full of life, and upset. Based on the frequency of the feelings, each question is assigned 1 to 5 points (1 = never, 2 = once a week or less, 3 = 2 to 4 days a week, 4 = 5 to 6 days a week, and 5 = 7 days a week). Self-realization was also assessed with four questions related to respondent’s agreement with statements about life: life has meaning and purpose, feel confident and good about self, gave up trying to improve life long ago, and likes living situation, using a three-point scale (1 = agree not at all, 2 = agree a little, and 3 = agree a lot). Self-efficacy and resilience was assessed with three questions related to respondent’s agreement with statements: other people determine activities, when I want to do something I find a way to do it, and I adjust easily to change. Each question is assigned 1 to 3 points (1 = agree not at all, 2 = agree a little, and 3 = agree a lot). After reverse coding bored, upset, the statement “gave up trying to improve life long ago,” and the statement “other people determine activities,” the sum score ranged from 11 to 41, with a higher score indicating higher levels of well-being. A study conducted in 2016, confirmed a single-factor structure for the 11 well-being items through confirmatory factor analysis (Kim et al., 2016). The Cronbach’s alpha for the subjective well-being measure was 0.77 in our study.

Depression

The NHATS survey uses the Patient Health Questionnaire-2 (PHQ-2) questions to evaluate depression. The PHQ-2 has been validated in multiple studies which indicated good criterion validity (Gilbody et al., 2007; Li et al., 2007). Depression score was a sum of the PHQ-2 questions related to respondent’s frequency of feelings in the last month: little interest/pleasure in doing things and felt down/depressed/hopeless (1 = not at all, 2 = several days, 3 = more than half of the days, and 4 = nearly every day). The sum score ranged from 2 to 8, with a higher score indicating higher levels of depression. The Cronbach’s alpha for depression was 0.56 in our study; the relatively low alpha may be due to only two items in this measure (Streiner et al., 2015).

Dual-eligible and Medicare-only

Respondents were asked whether they were also covered by Medicaid; if they additionally received Medicaid benefits they were classified as dual eligible. Those who did not report receiving Medicaid were classified as Medicare-only which includes private insurance if reported by the respondent.

Control variables

We controlled sociodemographic and health-related variables, which were potential confounders. Sociodemographic variables consisted of age (65–74, 75–84, and 85+), sex (male and female), race/ethnicity (white non-Hispanic, black non-Hispanic, and other), marital status (married/partnered and separated/divorced/widowed/never married), education level (less than high school and high school or above), and location (metropolitan and non-metropolitan). Health-related variables included number of health conditions and self-reported health. Respondents reported presence of 10 specific health conditions including heart attack or myocardial infarction, heart disease, high blood pressure, arthritis, osteoporosis, diabetes, lung disease, stroke, dementia or Alzheimer’s disease, and cancer. We counted the number of health conditions and constructed a four-category variable: (a) no conditions, (b) one condition, (c) two conditions, and (d) 3+ conditions. Respondents were also asked to self-report their current general health status using a scale ranging from 1 for excellent to 5 for poor. We constructed a three-category variable: (a) excellent/very good, (b) good, and (c) fair/poor.

Statistical Analysis

Descriptive statistics were conducted to describe the characteristics of participants. T-tests or chi-square tests were used for group comparisons between dual-eligible and Medicare-only beneficiaries. The outcome of interest was delays in care with four categories: never (coded as 1), rarely (coded as 2), sometimes (coded as 3), and often (coded as 4). We first tested the proportional odds assumption. The assumption was not violated and ordered logistic regression models were used to investigate the relationships between subjective well-being, depression, and delays in care. We further explored whether the relationships varied between dual-eligible and Medicare-only beneficiaries by including interaction between subjective well-being and dual-eligible, and interaction between depression and dual-eligible. The interaction between subjective well-being and dual-eligible was not statistically significant and we did not report its estimate.

All multivariate models were adjusted for age, sex, race/ethnicity, marital status, education level, location, number of health conditions, and self-rated health status. Guidelines from NHATS regarding survey weights were used to conduct the weighted analysis and calculation of standard error estimates to account for complex surrey design (Montaquila et al., 2014). The survey weights account for differential probabilities of selection and adjust for potential bias related to nonresponse to the survey interviews, to have a nationally representative sample of Medicare beneficiaries aged 65 and older. When the independent variables are highly correlated, multicollinearity is an issue because the regression models have difficulty separating the unique contribution of each independent variable (Pallant, 2020). In collinearity diagnostics, the variance inflation factor (VIF) values greater than 10 suggest multicollinearity (Pallant, 2020). In our study, multicollinearity was not an issue because the VIF values of all variables were less than 4 (range: 1.04–3.61). All analyses were conducted using Stata Version 16.1 (StataCorp, College Station, Texas). Statistical significance was accepted at the p < .05 (two-sided) level.

Results

Population-weighted characteristics of study participants are presented in Table 1. More than half of the older adults were aged between 65 and 74 years old, 37% aged between 75 and 84, and 11% were 85 years and older. Approximately 82% were white non-Hispanic, 8% were black non-Hispanic, and 10% were other race/ethnicity. Roughly 20% did not attain a high school education, and nearly 81% lived in metropolitan areas. Approximately 47% reported excellent or very good health status, 32% reported good health, and 20% reported fair or poor health. More than 38% had three or more health conditions. Nearly 10% were considered dual-eligible. Compared with Medicare-only beneficiaries, dual eligibles were more likely to be older, non-Hispanic black or other race/ethnicity, unmarried, less educated, and have three or more health conditions. They also reported poorer health, lower levels of subjective well-being, and higher levels of depression. Roughly, 22% of older adults reported that they often or sometimes had delays in care (Table 1). Dual eligibles more frequently reported delays in care than Medicare-only beneficiaries (29% vs. 21%).

Table 1.

Characteristics of Study Participants.

Variables	All	Medicare-only	Dual-eligible	P value
Variables	Percent or mean (sample n = 1,696) (population N = 9,779,724)	Percent or mean (sample n = 1,461) (population N = 8,814,525)	Percent or mean (sample n = 235) (population N = 965,199)	P value
Insurance status
Medicare-only	90.13%
Dual-eligible	9.87%
Age (years)
65–74	52.11%	53.37%	40.61%	.002
75–84	36.60%	35.22%	49.16%
85+	11.29%	11.41%	10.23%
Sex
Male	43.35%	43.45%	42.40%	.767
Female	56.65%	56.55%	57.60%	.767
Race/ethnicity
White, non-Hispanic	82.14%	86.02%	46.67%	<.001
Black, non-Hispanic	8.07%	6.18%	25.39%
Other	9.79%	7.80%	27.94%
Marital status
Married/partnered	58.77%	60.99%	38.41%	<.001
Unmarried	41.23%	39.01%	61.59%	<.001
Education level
<High school	19.83%	16.24%	52.63%	<.001
≥High school	80.17%	83.76%	47.37%	<.001
Location
Metropolitan	80.74%	80.78%	80.46%	.940
Non-metropolitan	19.26%	19.22%	19.54%	.940
Self-rated health
Excellent/very good	47.48%	49.75%	26.79%	<.001
Good	32.43%	33.09%	26.44%
Fair/poor	20.09%	17.16%	46.77%
Number of health conditions
0	10.62%	11.14%	5.85%	<.001
1	20.89%	21.74%	13.11%
2	30.22%	30.88%	24.17%
3+	38.27%	36.23%	56.87%
Subjective well-being score	34.95 ± 0.12	35.13 ± 0.12	33.25 ± 0.39	<.001
Depression score	2.81 ± 0.04	2.75 ± 0.04	3.31 ± 0.13	<.001
Delays in care
Never	46.48%	46.26%	48.42%	.045
Rarely	31.35%	32.32%	22.47%
Sometimes	18.21%	17.67%	23.19%
Often	3.96%	3.75%	5.93%

Note. Unmarried: separated/divorced/widowed/never married.

Bivariate analyses indicated that older adults with higher levels of subjective well-being were less likely to have delays in care (odds ratio [OR] = 0.91, p < .001; Table 2). After controlling for sociodemographic and health-related variables, we found that the significant relationship remained. That is, as the levels of subjective well-being increased, older adults reported less-frequent care delays (OR = 0.92, p < .001; Table 3). The interaction term between subjective well-being and dual-eligible status was not statistically significant, indicating that the relationship between subjective well-being and delays in care did not vary between Medicare-only and dual-eligible beneficiaries. Besides subjective well-being, we found a significant relationship between depression and care delays in models with and without control variables (OR = 1.31, p < .001, Table 2; OR = 1.13, p = .029, Table 4). Older adults with higher level of depression were more likely to have delays in care. Moreover, there was a significant interaction term between depression and dual-eligible status (OR = 1.36, p = .034; Table 3). Compared with Medicare-only beneficiaries, dual eligibles had higher levels of depression. As the levels of depression increased, the predicted probability of care delays increased to a greater extent among dual-eligibles than Medicare-only beneficiaries. Our findings also indicated that compared to those aged 65 to 74 years, older adults aged 75+ were less likely to have delays in care (75–84: OR = 0.70, p = .001; 85+: OR = .61, p = .005; Table 3). Finally, those with three or more health conditions were more likely to report delays in care (OR = 1.75, p = .010).

Table 2.

Bivariate Associations With Delays in Care (Sample n = 1,696).

Variables	OR	P value	95% CI
Variables	OR	P value	Lower	Upper
Medicaid status (ref: Medicare-only)
Dual-eligible	1.10	.601	0.76	1.60
Subjective well-being score	0.91	<.001	0.88	0.94
Depression score	1.31	<.001	1.19	1.44

Note. OR = odds ratio; CI = confidence interval; Boldface indicates statistical significance (p < .05); Ordered logistic regression model was used in the analysis and the dependent variable was delays in care.

Table 3.

Factors Influencing Delays in Care (Sample n = 1,696).

Variables	OR	P value	95% CI
Variables	OR	P value	Lower	Upper
Medicaid status (ref: Medicare-only)
Dual-eligible	0.35	.047	0.12	0.98
Subjective well-being score	0.92	<.001	0.89	0.96
Depression score	1.09	.117	0.98	1.22
Depression * dual-eligible	1.36	.034	1.02	1.82
Age groups (ref: 65–74)
75–84	0.70	.001	0.57	0.87
85+	0.61	.005	0.44	0.86
Sex (ref: male)
Female	1.05	.625	0.86	1.29
Race/ethnicity (ref: white, non-Hispanic)
Black, non-Hispanic	1.19	.357	0.82	1.73
Other	0.95	.815	0.59	1.52
Marital status (ref: unmarried)
Married/partnered	1.25	.053	1.00	1.57
Education level (ref: <high school)
≥High school	1.34	.051	1.00	1.79
Location (ref: non-metropolitan)
Metropolitan	1.15	.381	0.84	1.57
Self-rated health (ref: excellent/very good)
Good	1.09	.547	0.82	1.44
Fair/poor	1.14	.421	0.83	1.57
Number of health conditions (ref: 0)
1	1.46	.075	0.96	2.21
2	1.53	.053	0.99	2.37
3+	1.75	.010	1.15	2.66

Note. Unmarried: separated/divorced/widowed/never married; OR = odds ratio; CI = confidence interval; Boldface indicates statistical significance (p < .05); Ordered logistic regression model was used in the analysis and the dependent variable was delays in care.

Indicates the interaction between two variables.

Table 4.

Average Marginal Effect of Factors Influencing Delays in Care (Sample n = 1,696).

Variables	OR	P value	95% CI
Variables	OR	P value	Lower	Upper
Medicaid status (ref: Medicare-only)
Dual-eligible	0.83	.358	0.56	1.23
Depression score	1.13	.029	1.01	1.25

Note. Boldface indicates statistical significance (p < .05); Ordered logistic regression model was used in the analysis and the dependent variable was delays in care. The model was adjusted for age, sex, race/ethnicity, marital status, education level, location, number of health conditions, and self-rated health status. OR = odds ratio; CI = confidence interval.

Discussion

This study using a nationally representative sample of older adults aged 65+, makes several important contributions to the small body of knowledge regarding relationships between personal factors such as subjective well-being and depression and delays in care. Findings suggest that subjective well-being may play a protective role while depression may play an adverse role relative to delays in care. Moreover, compared with Medicare-only beneficiaries, dual eligibles were more likely to have delays in care, with the probability of delays dramatically increasing as depression increased. Our findings suggest that access to health insurance (Medicare and/or Medicaid) and programs such as MSPs and D-SNPs may not fully address barriers to timely use of health services by older adults. Our findings strongly support the need to identify and address low levels of subjective well-being or high levels of depression to reduce the impact of these personal barriers on delays in care, particularly among dual eligibles.

We found that the higher the subjective well-being score which includes positive affect, self-efficacy and resilience, and self-realization, the lower reported delays in care among older adults. These findings align with previous studies which suggest that subjective well-being may promote greater motivation to participate in health care activities (Blazer, 2008; Howell et al., 2007; Ostir et al., 2000), better medication adherence (Ogedegbe et al., 2012), improved physical activity (Peterson et al., 2012), and enhanced psychological health (Moskowitz et al., 2017). Recent intervention research has identified strategies which can be used to address specific aspects of well-being, which may enhance overall well-being due to the overlapping, intertwined relationship between them. Savoring, described as the “ability to attend to positive experiences” (Smith & Hanni, 2019, p. 138), enhances the ability to capitalize on positive experiences. Recent research studies have reported the effectiveness of savoring interventions including an intentional reflection on positive experiences through diaries or journaling on well-being in older adults (Killen & Macaskill, 2015; Smith et al., 2020; Smith & Hanni, 2019). Another study designed to teach older adults how to identify and savor positive experiences found that this training which supports positive well-being can be effective (Friedman et al., 2017).

Self-efficacy enhances self-esteem, optimism, and confidence among older adults, increases their ability to solve problems and brings improvements in overall well-being and quality of life (Bodenheimer et al., 2002). Resilience refers to the capacity for positive adaptation, functioning and competence in the face of stressful or adverse situations (Egeland et al., 1993). Resilience may improve older adults’ ability to adapt and handle the challenges or stress related to disease management such as undesirable symptoms, poor patient-provider relationships, or conflicting information from providers. Studies suggest that interventions bolstering resilience and self-efficacy decrease depression and enhance self-management, health-related behaviors, and well-being among community-dwelling older adults (Lorig et al., 2001; Miller et al., 2019; Quinn et al., 2016). Despite the increasing significance of promoting self-efficacy and resilience among the older population, there are few identified interventions in the current literature (MacLeod et al., 2016). Some of these interventions focus on optimism and positive emotions such as savoring (discussed above) and a few studies also highlight reminiscence and life review (Bohlmeijer et al., 2007; MacLeod et al., 2016; Robinson et al., 2019; Smith & Hanni, 2019) to promote self-efficacy and resilience among older adults. These interventions also help to enhance an older adult’s focus on meaning and purpose, thereby simultaneously supporting development of self-realization. Further emphasis is needed to improve our current service care delivery models using a more focused, holistic person-centered approach. Strategies which can improve the subjective well-being of older adults include a more direct focus on well-being by providers during wellness visits, maintaining strong social support and relationships, and remaining active in one’s community (MacLeod et al., 2016; Simpson & Kovich, 2019). Using such an approach would enhance the health seeking attitudes and behaviors among older adults while improving access to timely and appropriate care in the health care settings.

Collectively, dual eligibles had more disease conditions and more delays in care. Reduced subjective well-being for this vulnerable group may be compounded due to health inequities, systemic oppression, and implicit bias which they experience in the current system. Our findings are particularly significant for this group of beneficiaries for whom some of the structural and financial barriers to care are addressed by Medicaid coverage and enhanced services, which should support more timely access to care. Our findings that high levels of depression played a greater role among dual eligibles relative to delays in care further supports the need to ensure that depression is addressed in this subpopulation. Miller et al., (2019) assert that depression is one of the most prevalent mental health problems in older adults, nearly 10% to 15% of community-dwelling older adults aged 65 years and over experience depressive symptoms at any given time. It has also been reported that patients who are depressed are three times more likely to be nonadherent to treatment recommendations than a patient who is not depressed (DiMatteo et al., 2000). The National Quality Forum (NQF) has identified a set of specific measures that are sensitive to the unique needs of dual eligibles; detection and treatment of depression was identified as one of seven initial measures for immediate implementation (NQF, 2012). Providers have the opportunity at every interaction with older adults to assess well-being and depression; assessment must go beyond asking older adults to rate their health. If issues are identified, providers can then determine how best to provide the support needed to either enhance well-being or decrease depression, thereby potentially empowering the patient to further engage in and access care in a timely manner.

There are some limitations in this study. The data used for this study is cross-sectional in nature, thus true cause and effect between subjective well-being, depression, and delays in care cannot be ascertained. We cannot exclude the reverse association; that is, because older adults had less-frequent care delays, they reported higher levels of subjective well-being and lower levels of depression. The significant associations between subjective well-being, depression, and delays in care may be explained by omitted aspects of health or socioeconomic status. As discussed in the introduction, delays in care can be attributed to a variety of factors including financial, structural, interpersonal, and personal. While this study found lower likelihoods of delays in relation to higher levels of subjective well-being and lower levels of depression among Medicare beneficiaries, other factors not controlled in this study may have played a role in these outcomes. Longitudinal and more information from NHATS would be beneficial for further examining factors influencing care delays in detail among older adults. As well, the data collected for the NHATS survey is self-reported and therefore subject to bias. While examples of possible reasons for delays in care were listed for use during data collection, individual perceptions of what constitutes a delay may vary widely. The questions concerning subjective well-being use “last month” as the reference period, thus the response may not reflect subjective well-being as a stable construct over time.

Conclusion

In our study, nearly 90% of older adults reported having at least one health condition and more than one-third reported three or more conditions. To effectively manage multiple comorbid conditions and meet their complex health care needs, access to timely and appropriate care is very important. This study highlights the clinical and public health importance of identifying ways to enhance subjective well-being and reduce depression for older adults, especially for dual eligibles. Our findings suggest interactions with older adults need to go beyond a disease-focused medical approach and use a bio-psycho-social well-being and prevention approach (Delle Fave et al., 2018).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

This study was exempt from ethical approval as it was a secondary analysis of publicly available data.

ORCID iDs

Dongjuan Xu

Vicki L. Simpson

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