New Medicare-Medicaid ‘Dual Eligible’ Initiative Is Bad Policy
By Bob Blacato
Later this year, the Centers for Medicare and Medicaid Services (CMS) is scheduled to launch a pilot program in 27 states that could have far-reaching ramifications for America’s neediest citizens. It would shift much of the responsibility for caring for dual eligible seniors from Medicare to new programs, jointly administered by state Medicaid offices. As someone who has spent decades advocating on behalf of senior citizens, I have serious reservations about the far-reaching implications of this shift – specifically what it means for health care delivery writ large.
“Dual eligibles,” those citizens who qualify for both Medicare and Medicaid, comprise our poorest, sickest and most vulnerable populations. Because of this, they are significant drivers of costs in Medicare and Medicaid, often suffering from multiple chronic diseases that require considerable hospital, doctor, and prescription medication expenses. To ensure their needs are met, while pursuing efficiencies in care, it is critical that CMS proceed with extreme caution in establishing this demonstration initiative. Earlier this week, the Chairman of the Medicare Payment Advisory Commission (MedPAC) – the agency responsible for advising the U.S. Congress on issues affecting the Medicare program – cautioned a House committee about the rapid growth of the demonstration pilot. The American Medical Association, which represents more than 200,000 doctors and medical students across the country, has also weighed in with a resolution that urges CMS to delay the program for at least one year so that beneficiaries and stakeholders better understand it.
Policy analysts and consumer advocates have known for years that Medicare and Medicaid need to be better coordinated, however the current system has the virtue of assuring that people have access to what they are eligible for, and if denied access, beneficiaries or their advocates have clear pathways to authorities to appeal decisions in each program. By consolidating authority, plan administrators would have the responsibility for implementing these programs, while it is not yet clear whether the programs will have all the same protections in place which have helped make programs like Medicare Part D and the Program of All Inclusive Care for the Elderly (PACE) so successful.
Medicaid programs vary widely from state to state while, with small exceptions, Medicare does not. At the same time, both offer benefits that have to be fully coordinated to meet the needs of these very challenged individuals.
My primary reason for concern is that states are likely to offer varying levels of care from one another in the large number of plans they are submitting, and the ability of CMS and the states to effectively monitor the plans once they start enrolling beneficiaries seems uncertain. While I’m sure states have the best of intentions for participating in the demonstration, the fact is that some may simply not have the resources or the expertise to handle such an undertaking without ensuring beneficiaries won’t be adversely affected. Additionally, it’s important to keep in mind that many states are still struggling to recover from the recent economic downturn, which has resulted in budget shortfalls and fewer government-provided health care services.
Transferring primary responsibility for duals to Medicaid (and hence the states and private plans) could have a damaging effect on both the quality of and access to care, including serious inconsistencies with regard to how dual eligibles are treated, depending on how the benefits of Medicare and Medicaid are reconciled. The strongest argument for keeping duals in the Medicare system is that American taxpayers have a right to know that their Medicare program is ready to treat seniors equally, no matter where they live, and that each and every American senior citizen is guaranteed the same benefits. Shifting this responsibility to the states–some of whom may view this as an opportunity to cut provider payments in order to help their own fiscal situations, and many of whom may be ill-prepared for this responsibility–could lead to many duals receiving less than the proper care they have come to expect from Medicare, including specialty treatment and appropriate access to pharmaceutical products currently and effectively assured by Medicare Part D.
CMS would be wise to keep the Hippocratic Oath in mind, “first, do no harm,” when considering how best to proceed with a new program that has such potential to significantly alter health care delivery, for better or for worse. To do otherwise would be the same as turning a blind eye to those who need help the most. As Medicare continues to evolve, it’s critical that sound policies, not rushed pilot programs, dictate the path forward.
Mr. Bob Blacato is the executive director of National Association of Nutrition and Aging Services Programs. He served for 17 years on the House Select Committee on Aging and was executive director of the 1995 White House Conference on Aging (WHCOA) appointed by President Clinton.Tweet