Guest Commentary: Promoting Healthy Aging for Dual Eligibles

Laura Kimberly, MSW, MBE
Director of Special Projects
Jefferson School of Population Health

As we enter the final days of 2010, it seems like an opportune moment to look ahead at milestones we anticipate in 2011, and we have a major demographic milestone coming down the pike – the first wave of baby boomers in the United States will turn 65 in 2011. This means that, in 2011, the first baby boomers will become eligible for Medicare. Today, the number of adults age 65 and older accounts for about 13 percent of the population in the United States. With the influx of the boomer generation, this proportion is expected to increase to nearly 20 percent by 2030. Given the current structure for financing health and long-term care services for older adults, the anticipated growth in the aging population will have serious budgetary implications for our government-sponsored Medicare and Medicaid programs, which are already contending with significant fiscal pressure.

Older adults with multiple chronic conditions present a particular challenge. While they make up only 20 percent of Medicare beneficiaries, they account for about 80 percent of Medicare expenditures. Medicare, financed and administered by the federal government, covers acute care and other health care services, while Medicaid picks up the long-term care (LTC) tab, and older adults must pay privately for LTC if they do not meet the means-tested criteria for Medicaid. Nearly 70 percent of adults over age 65 will need LTC services at some point, and currently Medicaid pays for 40 percent of all LTC spending ($177.6 billion).

Within the Medicare population, nine million older adults are enrolled in both Medicare and Medicaid (and known as “dual eligibles”), representing 21 percent of all Medicare beneficiaries. Half of dual eligibles are in fair or poor health, which is more than twice the rate of other Medicare beneficiaries, and they suffer from a great number of multiple complex, chronic conditions. One of the greatest challenges in maintaining the health of this population is the lack of coordination between Medicare and Medicaid. Due to the absence of incentives for Medicare and Medicaid to work together, health and long-term care services for dual eligible adults, many of whom have multiple complex chronic conditions, are fragmented and poorly organized at best.

Models such as the Program of All-Inclusive Care for the Elderly (PACE) and demonstration programs including the Medicare Advantage Special Needs Plans have sought to address this issue by streamlining the organization, financing and delivery of services for community dwelling dual eligibles (i.e. the PACE program provides and manages medical, social and rehabilitative services by combining Medicare and Medicaid funding streams). However, more data is needed to spell out the impact of these models on quality, cost and effective service delivery, and it is not clear that these small-scale models provide sufficient incentive for Medicare and Medicaid to work together on a broader scale.

When asked, the vast majority of older adults indicate that they would prefer to stay in their own homes and communities for as long as possible. So how do we enable older adults to remain healthy and active, living in the setting of their choosing? By increasing the focus on health and wellness, including preventive care, and by better coordinating care upstream, we can help reduce downstream adverse outcomes such as ED visits, hospitalizations, and, ultimately, nursing home stays. This calls for a more integrated, rational approach to the financing and delivery of health and long term care services for older adults.

More research is needed to generate policy recommendations that address the lack of coordination between Medicare and Medicaid and propose effective solutions. At JSPH, we have recently convened the Healthy Aging Research Team (HART), a research interest group for faculty and staff eager to explore and address the challenges and opportunities associated with our aging population in the context of population health. To learn more about our group, please click here.