Background: Most studies of heart failure (HF) in Medicare beneficiaries have excluded patients age < 65 years. We examined baseline characteristics, quality of care, and outcomes among younger and older Medicare beneficiaries hospitalized with HF in the Alabama Heart Failure Project. Methods: Of the 8049 Medicare beneficiaries discharged alive with a primary discharge diagnosis of HF in 1998-2001 from 106 Alabama hospitals, 991 (12%) were younger (age < 65 years). After excluding 171 patients discharge to hospice care, 7867 patients were considered eligible for left ventricular systolic function (LVSF) evaluation and 2211 patients with left ventricular ejection fraction < 45% and without contraindications were eligible for angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy. Results: Nearly half of the younger HF patients (45% versus 22% for ≥ 65 years; p < 0.001) were African American. LVSF was evaluated in 72%, 72%, 70% and 60% (overall p < 0.001) and discharge prescriptions of ACE inhibitors or ARBs were given to 83%, 77%, 75% and 75% of eligible patients (overall p = 0.013) among those <65, 65-74, 75-84 and ≥ 85 years respectively. During 9 years of follow-up, all-cause mortality occurred in 54%, 61%, 71% and 80% (overall p < 0.001) and hospital readmission due to worsening HF occurred in 65%, 60%, 55% and 48% (overall p < 0.001) of those <65, 65-74, 75-84 and ≥ 85 years respectively. Conclusion: Medicare beneficiaries < 65 years with HF, nearly half of whom were African American generally received better quality of care, had lower mortality, but had higher re-hospitalizations due to HF. © 2011 Elsevier Ireland Ltd.