When Congress enacted Medicare and Medicaid insurance in 1965, it inadvertently created a bureaucratic challenge for Americans who straddle both programs, qualifying for Medicare because of age or disability and for Medicaid because of low income. These so-called dual-eligibles, now more than 12 million Americans, are among the poorest and sickest individuals in the USA.1 Typically, federal Medicare insurance covers acute care services, primary care, and prescription drugs, and state Medicaid insurance covers long-term services and supports, as well as Medicare premiums and cost sharing.2
Coverage by two distinct insurance programs adds to the risk that care will be fragmented and poorly coordinated. Policymakers have attempted to address this by modifying insurance benefits and payment approaches for the care of dual-eligible patients. In 2003, Congress introduced the Dual-Eligible Special Needs Plan (D-SNP) within Medicare Advantage to enhance coordination for this population.3 Since then, Congress made several additional adjustments to improve coordination and integration of services. In 2018, under the Bipartisan Budget Act, D-SNPs were permanently authorized.
A key question is whether actions by federal and state policymakers are enabling better coordination and less administrative burden for the dual-eligible population. This viewpoint article describes the structure of Medicare and Medicaid insurance and managed care plan offerings and examines their potential to integrate medical care and social services for this population.
Dual-eligible beneficiaries have a substantial mix of chronic medical and behavioral health conditions and disabilities and face significant social and financial challenges.2 They require a broad range of medical and social services. The population enrolled in both Medicare and Medicaid grew from 8.6 million in 2006 to 12.2 million in 2018.1 Approximately 39% qualified for Medicare benefits because of a disability.1 The number of beneficiaries under age of 65 grew faster than the number of those over 65. Of the dual-eligible population, 48% are from a minority race/ethnic group, 18% report poor health status, 43% do not have a high school diploma, and 55% have a least one limitation in activities of daily living.1, 2 Dual-eligible beneficiaries not only are more likely to report poorer health status but also account for disproportionately high spending for both Medicare and Medicaid programs.2