Potential Inequities in Accessing Medicare Counseling

Navigating health insurance options can be difficult, and Medicare is no exception. The State Health Insurance Assistance Program (SHIP) was created under the Omnibus Budget Reconciliation Act of 1990 to help Medicare beneficiaries understand their coverage, but it’s been unclear who the program actually helps.

SHIP is a federal program that provides funding to states to counsel Medicare beneficiaries on coverage choices, eligibility, and costs. It’s overseen by the Administration for Community Living (ACL), which provides grants to states that are then often distributed to local organizations providing services through paid and volunteer counselors.

The ACL produces public reports that focus on state-level contact metrics within SHIP but do not include more granular information. To date, we haven’t known whether SHIP sites are located efficiently (i.e., in areas with high concentrations of Medicare beneficiaries) or equitably serve both low- and high-income beneficiaries. This data would help identify potential unmet needs for services, an effort that is required by the Medicare Improvements for Patients and Providers Act.

New Research

In a study published in the American Journal of Managed Care, evaluators from Boston University School of Public Health identified areas where in-person SHIP service expansion might be beneficial.

Using 27 state directories of SHIP sites (totaling over 1,500 sites) and population socioeconomic conditions, authors examined whether SHIP sites were disproportionately located in higher-income communities. SHIP sites were mapped to Zip Code Tabulation Areas (ZCTA), which allow for geographic analysis of zip codes.

To understand the characteristics of areas where SHIP counseling was more or less likely to be available, four types of geographical areas were compared:

  1. ZCTAs with SHIP services;
  2. ZCTAs without SHIP services but located in a county with SHIP services;
  3. ZCTAs located in a county without SHIP services but where an adjacent county had SHIP services; and
  4. ZCTAs located in a county without SHIP services and where no adjacent counties had SHIP services.

Linear regressions and t-tests were then used to evaluate whether SHIP counseling sites were disproportionately located in communities with higher incomes and/or fewer Medicare beneficiaries.


More than half of the ZCTAs included (63%) had a SHIP site within the ZCTA or surrounding county, a quarter (24%) only had a SHIP site in an adjacent county, and the remaining 13% did not have a SHIP within or in an adjacent county.

The authors also found that a disproportionate number of Medicare-aged eligible adults live in localities without a nearby SHIP site. Median household income and educational attainment were also lower in areas without in-person SHIP services.

Access to SHIP services may be affected by the availability of volunteer counselors, non-English services, education, and transportation options. This is especially true for beneficiaries living in low-income neighborhoods, which are more likely to be in rural areas and have more non-English speakers.

These findings only indicate associations between SHIP sites and the areas within which they’re located. The size of ZCTAs and counties also vary, so a SHIP site could be in the same county as an individual but still require a long drive to reach these services.


This study suggests that there may be inequities in where in-person SHIP services are located and potential unmet needs for service expansion. Although telephone counseling is always an option, access to in-person services is important for dually eligible individuals with complex health needs, those with hearing loss, limited English proficiency, or who need a caregiver or companion to help understand the information provided.

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