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What is Dual-Eligibility?

9 million Americans are covered by both Medicare and Medicaid and are part of a unique community of healthcare consumers known as the dual eligible. Dual-eligible beneficiaries often have complex health conditions and may be low income, meaning that their access to healthcare would be greatly limited if not for their dual-eligibility for coverage.

It has long been in the interest of federal policy makers to keep a close eye on the funding for these patients, as they are generally more “costly” than their single-covered counterparts. Not only because of their lower income status, but because their health needs and preferences are far more varied and intense than a healthier individual. Coordinating care is not only important for conservation of fiscal resources, but ensuring that the patient’s needs are met in the most comprehensive and efficient way.

The set up for dual-eligibility is not dissimilar from the standard qualification for Medicare and Medicaid: in this case, Medicare is the primary payer for dual covered individuals. As is the case with other low-income patients, Medicaid is the “safety net” for more expensive healthcare needs.

Who is Considered Dual-Eligible for Coverage? 

In 2008, the last time coverage was fully assessed, the majority of those covered by both services were beneficiaries 65 years and older (61% according to the Kaiser Family Foundation). These individuals were further broken down by “full duals”, who receive the full range of benefits from both Medicare and Medicaid, and “partial duals” who receive assistance with premiums or cost sharing only. The specifics of a patient’s enrollment, in terms of what services they can voluntarily elect, is usually mandated at the state level.

The challenge for policy makers is that even though these dual beneficiaries do not make up a very large portion of the total number of patients covered by these services, they do account for nearly a third of the spending. In 2008, national Medicaid spending for this beneficiary group totaled $129 billion, and the Medicare total slightly higher at $132 billion. The majority of this spending was for long term care services, which is in line with the overall demographic of the dually covered.

One question might be then, is this approach to coverage for this demographic sustainable? Current market research would indicate that it’s not, so what can policy makers and healthcare payers and consumers do to create a program geared specifically toward the demographic that has:

1)   the most complex healthcare needs

2)   often times, the most expensive healthcare needs

3)   and the most varied and co-occuring healthcare needs

It would behoove these groups, at the national and state level, to address the current structure and perhaps begin the process of restructuring these programs, or even creating a new program.

With Obamacare enrollment having come to an end for this year, the current focus of statistical research and tests of efficacy will no doubt be placed on Affordable Care Act outcomes. But hopefully, in the not too distant future, we will see a resurgence of interest in the dual-enrolled.