Nancy Archibald, MHA, MBA and Michelle Herman Soper, MHS

November 2, 2020

COVID-19 has exposed weaknesses in our health care system. The pandemic has had a startling impact on the 12 million individuals dually eligible for Medicare and Medicaid, many of whom have key risk factors for adverse COVID-19-related outcomes. These individuals often have significant medical, behavioral health, and long-term care needs. More than half of adults who are dually eligible:

  • Have three or more chronic conditions, such as diabetes, heart disease, and depression;
  • Require assistance with activities of daily living such as eating, bathing, or dressing; and/or
  • Have a cognitive impairment or serious mental illness, such as dementia, schizophrenia, bipolar disorder, or a developmental disability.

Furthermore, many dually eligible individuals have health-related social needs like poverty, food insecurity, housing instability, and lack of transportation.

COVID-19 has exploited the existing gaps in care, system fragmentation, and lack of coordination between Medicare and Medicaid. Across every demographic category examined in new federal data, dually eligible individuals are more likely to contract or be hospitalized for COVID-19 than Medicare-only beneficiaries. The data show that dually eligible beneficiaries are hospitalized with COVID-19-related complications at a rate more than four times higher than Medicare-only beneficiaries. These results are not surprising.

COVID-19: Exacerbating Flaws in Care for Dual Eligible Populations

In the United States, dually eligible individuals — a high-need, high-cost population — typically receive care through fragmented and uncoordinated systems. These individuals receive separate services from Medicare (e.g., hospital and post-acute care) and Medicaid (e.g., behavioral health services and long-term services and supports). Beneficiaries and their providers must navigate the maze of both Medicare and Medicaid rules, benefits, and policies. This often results in miscommunication/confusion, difficulty accessing uncoordinated services, poor quality care, and unnecessary spending.

At the same time, COVID-19 is also shining a light on how health disparities and inequities are entrenched in our health care system. Pre-pandemic, people from communities of color were two to five times more likely to be dually enrolled in Medicare and Medicaid than enrolled in Medicare alone, compared to those who are white. With COVID-19, the greatest risk factors to Medicare beneficiaries for contracting the virus and/or being hospitalized are to be dually eligible or Black, Latino or a Native American/Alaskan Native. If you control for dual eligible status, Black Medicare beneficiaries still have 1.25 times as many infections and nearly two times as many hospitalizations as those who are white.

COVID-19 has amplified all the existing risk factors facing dually eligible individuals by creating perilous conditions in nursing facilities; direct worker and informal caregiver shortages; social isolation; food insecurity; and behavioral health challenges among other serious issues. Aligning Medicare and Medicaid enrollment into one integrated program can improve beneficiary and family experience of care, better coordinate care to improve quality, and align incentives across payers and providers to support positive care outcomes and reduce costs.

Exploring the Pandemic’s Impact on Specific Medicare-Medicaid Populations

Through support from Arnold Ventures, the Center for Health Care Strategies (CHCS) is producing a blog series that explores the impact of COVID-19 on different sub-populations of dually eligible individuals. CHCS interviewed beneficiary advocates, health plans, providers, and other experts to examine how each population group is faring and ways in which Medicare-Medicaid integrated programs can offer support and mitigate the clinical and social impacts of the pandemic. The sub-population groups of focus are:

  • Users of Home- and Community-Based Services. More than one-third of individuals dually eligible for Medicare and Medicaid rely on Medicaid-funded home- and community-based services (HCBS) to live independently in their home rather than in an institutional setting. During COVID-19, many people who depend on HCBS have lost access to personal caregivers and have difficulty getting transportation to grocery stores, pharmacies, and medical appointments. For those who live alone, the need for isolation/social distancing has exacerbated feelings of loneliness and depression.
  • Individuals with Intellectual or Developmental Disabilities. Individuals with intellectual and/or developmental disabilities (I/DD) are 66 percent more likely to die from COVID-19 than those without I/DD. People with I/DD often live in congregate settings where the virus is easily transmissible. The pandemic has reduced the availability of the direct support professionals who serve this population and closed the day habilitation programs that provide other supports needed by people with I/DD.
  • Residents of Nursing Facilities. Nursing facility and assisted living facility residents experienced significantly higher rates of infection and COVID-19-related mortality than the general population, especially at the outset of the pandemic before appropriate safety protocols and personal protective equipment could be secured. About one-quarter of dually eligible individuals receive services in nursing homes or other long-term care facilities each year.
  • Individuals with Serious Mental Illness. People who are dually eligible are almost three times more likely to be diagnosed with schizophrenia, bipolar disorder, major depressive disorder, or another serious mental illness (SMI) than those who are not dually eligible. Even before COVID-19, dually eligible individuals with SMI were challenged with navigating their behavioral and physical health benefits across the Medicare and Medicaid programs. The pandemic and need for social distancing are compounding behavioral health issues and creating further care inequities.

The blog post series, which will be released biweekly through early December, reflects on the systemic inequities and fragmentation that dually eligible individuals face as they try to access the care and services they need. It also will address what role, if any, integrated financing and delivery systems can and have played in addressing this fragmentation.

The heterogeneity of this population requires specialized, targeted, and person-centered interventions to meet the diversity of their needs. Look for future blog posts in this series in the coming weeks.

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