Understanding the Challenges Faced by Dual-Eligible Individuals in Medicare and Medicaid
KFF's research offers crucial insights into policy issues facing individuals enrolled in both Medicare and Medicaid, known as dual-eligible individuals. Approximately 12 million people fall into this category, reporting poorer health outcomes and needing more assistance with daily activities compared to those only enrolled in either program. This demographic faces unique challenges in managing healthcare through dual coverage systems.
In this arrangement, Medicare typically acts as the primary payer, covering medical and post-acute care, while Medicaid supplements this coverage by covering premiums and most cost-sharing expenses. Among these individuals, 8.6 million have "full benefits," granting them access to Medicaid services that Medicare does not cover, while the remaining 3.5 million have partial benefits focused on premium assistance.
Recent data analysis from 2022 and 2023 Medicare and Medicaid claims highlights how the prevalence of chronic conditions leads to higher expenditure per enrollee among dual-eligible individuals compared to non-dual enrollees. Even though dual-eligible individuals constitute a significant portion of Medicare and Medicaid populations, they account for a disproportionate share of spending. This elevated spending stems primarily from the higher number of chronic conditions within this group.
The concentration of dual-eligible enrollees varies by state, influenced by factors such as income distribution, age demographics, and Medicaid eligibility standards. States like New York and Connecticut, for example, have a higher share of dual-eligible beneficiaries compared to places like Utah.
Financially, dual-eligible individuals represent 15% of the traditional Medicare population, yet they account for 29% of its spending. In Medicaid, they constitute 13% of enrollment but contribute to 30% of spending. The increased Medicare per person spending is especially prevalent among full-benefit dual-eligible individuals, given their greater access to medical services and higher rates of chronic conditions.
Medicaid spending per person is significantly higher for full-benefit dual-eligible individuals compared to those with partial benefits or Medicaid-only enrollees. This discrepancy is largely due to the inclusion of long-term care and other services not covered by Medicare, alongside a higher incidence of chronic conditions in this demographic.
This analysis, supported by Arnold Ventures, utilizes comprehensive datasets to evaluate the dynamics of enrollment, spending, and chronic health conditions among dual-eligible individuals, offering policy insights without external influence on the findings. Dual-eligible individuals with chronic conditions significantly contribute to Medicare and Medicaid spending, with costs particularly high for those requiring long-term care services.