This is an unedited transcript.
0:08
Good morning, everyone.
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Thank you for joining us for the second session in Our Future of Medicare series, Understanding the Medicare Population and Affordability for Consumer. My name is Jill O’Brien, I am the Associate Director of Policy here at the Alliance.
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For those of you who are new to us, welcome. We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
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This is the second session in a three part series about the future of Medicare.
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You can find more information about the theories and resources from each session on our website.
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Please join us again on May 20th for the third and final session in this series, which will explore the tradeoff of policy options to promote Medicare sustainability.
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Today’s briefing is brought to you and joint partnership with the Commonwealth Fund and Arnold Ventures.
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You can join today’s conversation on Twitter, using the hashtag, all help live, and join our community at home Health Policy, as well as on Facebook and LinkedIn.
1:08
Today’s panel has a Q and A section at the end of the event.
1:11
We want you all to be active participants, so, please, get your questions ready.
1:15
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1:21
You can use the speech bubble icon to submit questions you have for the panelists at any time. We will collect these and address them during the broadcast.
1:29
Throughout the webinar, you can also chat about any technical issues you may be experiencing and someone will attempt to help.
1:36
Now, to kick off today’s event, I’m going to introduce our moderator who will be guiding today’s discussion.
1:42
Doctor Brandon Wilson is the Director of the Center for Community Engagement and Health Innovation at Community Catalyst, where he leads the center in bringing the community’s experience to the forefront of health systems transformation and health reform efforts.
1:55
Prior to joining community catalysts, doctor Wilson served held several positions with the Centers for Medicare and Medicaid Services most recently as a Senior Public Health Advisor for the Office of Minority Health.
2:08
Thank you so much for joining us, doctor Wilson. Now, I’m going to turn it over to you to introduce our panelists.
2:13
Thank you, Jill. Good morning, everyone. We’re so delighted that we have so many of you.
2:19
For joining us for Part two of Alliance is the Future of Medicare series.
2:23
I’m really delighted to be moderating such a distinguished panel.
2:27
Will discuss how Medicare provides access to healthcare for older adults as well as people with disabilities or other qualifying health conditions.
2:36
While Medicare provides comprehensive health coverage, we do know that many beneficiaries still remain without access to important additional benefits.
2:45
As dental vision and hearing services, out of pocket cost sharing requirements also pose Rochelle Netroots, especially for vulnerable moment.
2:55
Those facing so much unmet health and social reach, this session will provide insight into the Medicaid, I’m sorry, the Medicare population, enrollment trends, and affordability considerations for beneficiaries in traditional Medicare, as well as Medicare Advantage.
3:11
Now, I’m going to introduce our four panelists.
3:14
Doctor Tricia Neuman is Senior Vice President of the Henry J Kaiser Family Foundation, director of the Foundation’s Program on Medicare Policy.
3:24
Doctor Neuman focuses on topics such as the health and economic security of older adults, Medicare, and out of pocket spending trends, prescription drug costs, payment, and delivery system reforms, and a policy option to scope and Medicare for the future.
3:40
Didn’t wanna hear from doctor Loren Saulsberry, who’s an Assistant Professor in the Department of Public Health Scientist at the University of Chicago, versus status policies to significantly maricopa’s birds.
3:52
Specifically, she’s interested in the experiences of Medicare beneficiaries managing chronic conditions.
3:59
Doctor Eric
4:00
Roberts is the Assistant Professor of Health Policy and Management at the University of Pittsburgh School of Public Health.
4:07
His research examines the provision and financing of health care among low-income populations, including the impacts of alternative payment models.
4:16
I’m providing serving providers serving low-income populations.
4:21
Finally, I am pleased to introduce Lindsey Copeland, cost of Medicare Rates Center’s Director of Federal Policy.
4:28
She’s responsible for developing and implementing a health equity driven advocacy agenda.
4:34
That is, informed by the organization’s experience helping people with Medicare, navigate, immersion, and systemic access, affordability, and coverage issues.
4:44
Now, I will turn it over to doctor Newman for opening remarks.
4:57
Doctor Newman, you’re muted.
5:16
And the sponsors, uh, the Arnold Arnold Ventures and the Commonwealth Fund for putting together this panel on such an important topic.
5:25
It is also wonderful to be here with such terrific panelists. I’m going to talk a bit about the population on Medicare, affordability, a challenge, and affordability challenges. So, if I could start with my first slide, please.
5:41
And the next slide, please.
5:46
As you can see here, this is the the bars represent characteristics of the Medicare population. And I think the point I want to make broadly is that many people on Medicare enjoy good health.
5:58
But a significant share have functional, cognitive, and other challenges. And while we think of the Medicare population is one that is generally aged 65 and older, here, what you can see is 14% are under age 65, and living with disabilities. They qualify for Medicare because they have become eligible for Social Security disability. This is a population that is often under the radar. And I’m bringing to your attention because a lot of the work that we have done says, this is, not only a highly vulnerable low-income population.
6:34
But one that tends to be less satisfied with Medicare, because many of their needs are not fully met by the program, like Durable Medical Equipment. And some of the mental health services that they often rely upon.
6:47
You can see that 30% almost have functional impairments, which is a proxy for lots of health issues.
6:53
24% are in fair, poor health and then I want to pause on this 21% who have a cognitive impairment and I want to pause on that because what I’m hearing more and more and perhaps Lynsey, on her panel will talk about this more is that Medicare has become more complicated.
7:10
And there are a lot of expectations for people to choose their plan, to choose their plan annually to choose among, you know, 30, 60 plantains depending on where they live.
7:21
And to make good decisions and timely decisions about enrollment and and medical choices. And, you know, the real challenge here is that so many people on Medicare do have child mental health challenges and cognitive issues. That make it especially difficult for them.
7:37
to do, is, will do what is expected to maximize their coverage, and their health care, as they grow older, and as their needs grow more significant.
7:48
Can I have the next slide?
7:51
Thank you. Here, I want to point out, and if you can start on the left side of the slide.
7:57
When you think about the Medicare population, you may see images of people who are golfing and retirement communities and totally enjoying their later years. But keep in mind that median income is less than $30,000 per person or put otherwise. Half of all people on Medicare live on $30,000 or less. And you can think about what you yourself make and think about how challenging that might be. Because expenses don’t go away for people as they grow older. They certainly have different expenses.
8:27
They may not be paying for education, but they have food rent, health, care, and other and transportation and, you know, so on and so forth.
8:37
If you look at the middle panel, that’s savings, and what you can see here is that median savings is a little bit under $74,000.
8:46
That is not enough for one year in a nursing home, in a semi private room. It’s not enough for many of the expenses that people have If they have a shock in a financial shock, that comes to them a major expense. This is what, you know, the typical person has in their bank, in their life savings.
9:05
I really want to point out here the disparity in savings between White Black and Hispanic people on Medicare, half of all white Medicare beneficiaries have meet, have savings of about 100 close to $120,000. Contrast that with Black and Hispanic beneficiaries.
9:25
Half of all people have less than 15. In the case of black beneficiaries or $10000 in the case of Hispanic beneficiaries.
9:32
So, there’s a real difference with ****, how comfortable people are in their retirement, and how able they are to pay for a major expense.
9:42
Like a cancer drug, for example, that’s not fully covered by Medicare, or some, or a long term care expense.
9:49
A similar pattern holds for home equity. You can see for yourself, Can I have the next slide, please?
9:56
So, what does Medicare cover, Part A Unfortunately, Medicare, as I said, is getting more complicated.
10:03
There’s a part A, part B, part C and part D Part A is the part that covers inpatient care generally like hospitals, skilled nursing facility and hospice care, which isn’t always inpatient or, and hospice, which isn’t always inpatient, and home health, sorry. Which is outpatient. But generally, we think of this as the inpatient part of the program because that’s where the dollars go.
10:26
Part B covers outpatient services visit, physician and other services. Part A is funded by payroll taxes.
10:34
Part B is cut as covered funded mainly by premiums in general revenues.
10:40
Part C doesn’t have separate financing. That’s what you think of as Medicare Advantage. And that’s the part of the program that involves Medicare contracting with private insurers.
10:51
To provide benefits through HMO’s and PPO’s, and then there’s Part D that covers prescription drugs that’s provided through standalone plans or Medicare Advantage plans.
11:02
Can I have the next slide, please?
11:05
Medicare provides good benefits, typical benefits of a health insurance plan, but it is, you know, it does have some gaps in coverage that lead to relatively high out of pocket costs.
11:16
Significantly, Medicare does not have an out of pocket cap on cost sharing, so unlike most insurance plans, for people who incur major expenses, there’s no absolute limit on out of pocket costs. This is something that has been an issue and concern raised by policymakers.
11:33
Over the years that has not been one that has been addressed.
11:37
Medicare doesn’t have an out of pocket kab on Part D prescription drugs.
11:42
That’s something that has been talked about a lot in the past couple of years.
11:46
And is something that was included in the balanced budget Act that is, has passed the House and is now stalled in the Senate. It is.
11:54
It raises serious concerns mostly for people who take very high cost specialty drugs.
12:00
Medicare has limited premium and cost sharing assistance for low-income beneficiaries.
12:05
Unlike the Medicaid Expansion coverage for low-income populations who are under age 65, these benefits are subject to an asset test, which restricts the number of people who can get cost sharing Wraparound cost sharing assistance.
12:19
Medicare doesn’t cover: generally doesn’t cover long term services and supports, which can be quite expensive.
12:25
Dental services are not generally covered and hearing and routine eye exam.
12:31
Exams are not covered, all of which have been subject to some policy discussion, but none of which have could have made it across the finish line.
12:41
So, as a result, and can I have the next slide, please?
12:45
Out of pocket costs are a serious concern for people on Medicare. When we look at an out of pocket spending as a share of household budgets, we see that people on Medicare pay substantially more than people who are not on Medicare as a share of their household expenses. 14% of household budgets go to health expenses, and here what you see is that the typical Medicare person pays a little bit more than $6000.
13:13
This was a couple of years ago, in out of pocket spending, both premiums and services.
13:20
No premiums are not an insignificant share of the total.
13:24
And note that obviously people who have significant needs pay substantially more.
13:29
And older people in particular are paying more, not just because this is a long term bill, they incur long term care expenses, but healthcare needs increase with age. And so not surprisingly is health care needs increase. So two out of pocket expenditures.
13:48
Can I have the next slide, please?
13:51
A rising share of people are, are enrolling in Medicare Advantage plans, and this is fundamentally changing how we think about Medicare today. I think when we all heard about The Medicare For All discussion, people were thinking of a national plan and national program. And it is a national program. But more and more, Medicare is looking like a marketplace.
14:13
And as you can see in this slide, within a couple of years, more than half of all people on Medicare will be getting their Medicare benefits through a private insurance plan, an HMO, or PPO.
14:25
And this is this is a significant change and one that I think more is more attention to understand how the program is evolving and what it means for peoples.
14:37
Now, there are many reasons why people might be attracted to a Medicare Advantage Plan.
14:42
one, and can I have the next slide slide, please, is that Medicare Advantage plans typically offer extra benefits. And extra benefits are clearly a draw, particularly to people, when they’re coming on Medicare, and they’re thinking about sure, I’d like an eye exam, or, Sure, I’d like a fitness benefit.
14:59
These are very, These are appealing, and then, these are benefits not covered by traditional Medicare.
15:05
Medicare Advantage also has the, There’s the benefit of being simple. You get one all in, one.
15:12
You get, you don’t need a supplemental plan.
15:14
Like many people in traditional Medicare Gat, and you don’t need a separate Part D plan.
15:21
They also tend to have low payments. Now, you might say this is, you know, why is this is too good to be true?
15:28
It’s not totally surprising in that the way the payment structure is set up, Medicare actually pays more for people in Medicare Advantage plans. Then it pays for traditional Medicare beneficiaries who look similar. That may be counter-intuitive because you think of Managed Care is being sort of a cheaper or less, a more efficient option than traditional Medicare.
15:50
As the payment system is currently structured, Medicare pays more for each person in a, In a Medicare Advantage Plan than it pays for similar people in traditional Medicare, according to medpac.
16:03
So there’s, there is this big shift now going on between two into Medicare Advantage.
16:09
And I, you know, I think we can talk a bit. We’ve talked about the benefits, I think there are some tradeoffs, or the beneficiary, that are less well clear.
16:18
one of which are network restrictions, which people may or may not be aware of, when they sign up, another might be prior authorization restrictions, which don’t apply to traditional Medicare.
16:29
There’s cost sharing for services that may or may not. They may not matter to people when they’re healthy.
16:35
That could be an issue for people who are sick.
16:38
Then there is also the issue for people who are transitioning back to traditional Medicare, who cannot buy a Medigap Policy. If they have a preexisting condition, because the guarantee issue protections that people know a lot about thanks to the ACA.
16:54
Do not apply to Medigap, so people with preexisting conditions in almost all states can be denied a plan. Next slide, please.
17:03
And somewhat surprisingly to us, we did a study, and we looked at people reporting, costs related problems.
17:10
And given what I just showed you about out of pocket spent, extra benefits in Medicare Advantage, we were somewhat surprised to see, if you look on this left side, that people in Medicare Advantage are a larger share of people in Medicare Advantage Report having costs related problems than people in traditional Medicare.
17:30
And that particular So that.
17:32
And that is particularly due to so many people having supplemental coverage, which helps people in traditional Medicare, not incur huge expenses.
17:44
The people who are particularly at risk are people in traditional Medicare, without supplemental coverage in there.
17:52
six million people who fall into that category, and the people who are best protected are people in traditional Medicare who have a supplement.
18:01
So, you can see in the first group, for example, the one on the left, 12% of people in traditional Medicare, with, with supplemental coverage, The yellow bar, say they have costs related problems as compared to 30% who have no supplemental coverage and 19% who are in a Medicare Advantage Plan.
18:23
The same patterns also persist for people, whether they are white, black, or Hispanic.
18:29
But I do want to point out the relatively high rate of people on Medicare, who are black, who have relatively high costs, related problems.
18:39
This is self reported compared to people who are white and the overall average.
18:45
And you can see here that when you compare traditional Medicare with Medicare Advantage, it may be somewhat surprising, but it appears that 32% of people in Medicare Advantage say they have a cost related problem compared to 24% of people in traditional Medicare overall.
19:03
So, these are trends that we are watching. And these are important because, as Medicare, spending continues to rise out of pocket costs will continue to be a serious concern.
19:14
And if I could have the last, next slide, please?
19:18
Here, what you see is this is selected out of pocket costs, a share of average social security benefits.
19:26
And what we looked at the ad is premiums and deductibles to show to sort of illustrate that as as cost sharing, Medicare spending has increased over time. So, too has out of pocket spending of premiums and deductibles, not taking into account other expenses as a share of social security spending.
19:47
And while I have your attention, I wanted to just do a shameless plug.
19:52
For a new interactive that we have put out, which is, you can see the link below, which walks through the basics of spending and financing. And the end of the effects on out of pocket spending, which you can look out when you have more time. So, I want to thank you.
20:08
My last slide just shows you more resources available to you as the Kaiser Family Foundation website. We hope they’re helpful, and I look forward to listening to our panelists.
20:20
Thank you so much, doctor Newman, That was really helpful and given us some insight into enrollment and what trends are like for the Medicare population.
20:30
Now, I would like to turn it over to doctor software who will present information on disparities.
20:42
Good morning. Many thanks to the alliance, Arnold Ventures and the Commonwealth Fund for hosting this event. I’m very pleased to be here with you today and discuss the important topic of disparities in the Medicare population, particularly in relation to beneficiaries with chronic conditions as, this is a population that I’ve focused on in evaluating policies that might significantly narrow, such health disparities. Next slide, please.
21:08
The majority of Medicare beneficiaries have two or more chronic conditions. And this is important because a great amount of the spending for these beneficiaries with multiple chronic conditions makes up some of the largest shares of national Medicare expenditures. Next slide, please.
21:27
And there are a range of chronic conditions that Medicare beneficiaries manage, but some of the top reported. Chronic conditions include hypertension and high cholesterol, which are the largest green bars here you see towards the bottom of this chart. Next slide, please.
21:45
Studies have shown for some time and continue to demonstrate that chronic disease burden is not evenly distributed across the Medicare population, and that communities of color experience higher prevalence of certain conditions, such as hypertension and diabetes.
22:00
Next slide.
22:03
In spite of having identified significant racial and ethnic disparities years ago, inequities in the US Health system persist. And within the Medicare program, some of the dominant areas of investigation to identify these Medicare disparities have included assessing differences and use, which includes types of health services that are received and costs, including those incurred by payers, insurance companies, as well as patient out of pocket expenses. And you’ll hear me underscore throughout my comments that geography has some role in the disparities observed within the Medicare population. As more and more evidence comes to light, expands our understanding in this area.
22:43
I also want to make a note that while I focus on these specific areas and domains today where there’s a predominance of research, I want to note that there are many other types of disparities in population based areas that incorporate the diversity of the Medicare population, and all of the intersectionality of those patients were greater attention is needed.
23:03
Next slide.
23:06
To disparities have been shown within the Medicare population in the use of health services, This particular chart chart plots the percent of White Medicare beneficiaries on the X axis, and the percent of black beneficiaries on the Y axis that are receiving a blood hemoglobin hemoglobin tests that’s critical to diabetes care. And, as we can see in this chart, that particular test is being received more frequently by White Medicare beneficiaries across multiple cities in the US. Note that this disparity was originally identified and data from the late 19 nineties and early two thousands. And part of the reason why I include this year’s to just show you that some of these disparities have been identified over time, but I can tell you that this particular disparity in this very important test for diabetes patients still produce persists today for Medicare beneficiaries.
24:00
Next slide, please.
24:03
In addition, disparities have been shown within the Medicare population in terms of costs for health services and another study evaluating end of life care. This time, this chart is, plotting, spending by black beneficiaries six months before death on the X axis, and the percent and the spending by white beneficiaries on the Y axis. And across US states, again, we can see that were higher spending for black beneficiaries for end of life care.
24:32
Next slide, please.
24:36
And as I mentioned, I’m an underscore geography, because as we look across the United States, my focus use, primarily domestic. That you’re gonna see for what’s termed ambulatory care. Sensitive conditions, which you can think of as many of the chronic conditions that we’ve already kind of talked about today, your diabetes care, your hypertension, care, and the resulting hospitalizations that are associated with those conditions. That these are ones that largely, you know, given the right care team, and the right host of services and supports, can be managed at home. And yet, across the United States, we see great differences in terms of the hospitalizations that reserve result from poor management of these conditions.
25:22
Next slide, please.
25:25
So, there’s been increased attention for leveraging the Medicare Program to advance health equity, and, in some ways, reduce some of these health disparities that we continue to see and monitor.
25:39
And, as a part of that, I really like this demographic by the Robert Wood Johnson Foundation, which shows that there’s a key difference. And, an important one between equality and equity As we move into an era where personalized medicine, and the idea that individual patients are met, where they are with the care that is appropriate and culturally tailored to them. That may mean that different types of services. And supports are required by different individuals. And that as that bucket of services and supports tailored appropriately, is really what we’re going forward to. give everyone the best optimal opportunity, and achieving health, which we call health equity.
26:24
Next slide, please.
26:27
And there has been some evidence that Medicare coverage can shrink some of the racial and ethnic disparity gaps that we’re seeing. So, this is a busy slide. But what I want to draw your attention to are the horizontal arrows that are pointing to the right and the filled in triangles that are in orange, versus the non filled in triangles that just have an orange outline. And just, if we look across, you know, the share of the uninsured, If we think about. those without a usual source of care, like a primary care physician, or even an inability to see a physician because of costs or the financial burden, and even health status, So, you know, or self reported health?
27:11
What you can see is those without Medicare, once they achieve eligibility status and are able to go into Medicare, see a shift from, you know, having For kind of outcomes and, And, and, and and in that area. Sorry, whichever one, it is to Having a greater kind of amount of Security in that particular outcome. What is of note, though, is whether we look to the left panel here in the white black disparity across Medicare beneficiaries, or the white Hispanic disparity to the right panel here, B Is That none of these are getting to this vertical dotted line, which would be effectively, the zero here on the bottom of the X axis, which would mean that. And that disparity no longer exists, and we’re seeing equal amounts of use in these outcomes across these different populations. So, overall, Medicare is, in some ways, it seems for evidence, being able to improve these outcomes. However, it’s not quite bringing all populations to parity.
28:17
Next slide, please.
28:20
As we investigate more and more different areas and get in more detail within the Medicare Program as to what types of populations are experiencing particular types of use or services within Medicare.
28:37
We’ve been evaluating those, particularly with chronic conditions who require some type of home health services and are finding that across different racial and ethnic populations, that there’s our reliance on unpaid and formal caregiving, as well as agency sponsored providers. So here in this graph, we’re plotting on the Y axis, the number of provider days of of received home health care use. And the Y axis, you can see different populations within Medicare. And I want to point your attention to these top gray bars here, as well as the black bars here at the bottom. Respectively, those are representing the unpaid, informal caregivers often provided by family and friends and in the black agency sponsored providers.
29:23
Next slide, please.
29:26
And we’ve seen during, particularly during the pandemic and during …, that the challenges in the disparities that are experienced by Medicare beneficiaries with chronic conditions has been placed really stark relief and become salient topic of conversation. And as you can see here, those that were hospitalized for coven Among beneficiaries that had chronic conditions, you tended to have a much higher prevalence of these conditions placing them at greater risk for hospitalization during a public health crisis.
29:58
Next slide, please.
30:01
So, taken all together, what are some of the considerations for thinking about future policy directions for the Medicare population with chronic conditions? Well, the first, and, as I think, you know, we’ve seen, is, context is important. But also the interpretation. So, I, you know, showed one chart that involved across different geographic locations where the use of a particular health service being in this important test for diabetes care had some disparities across populations. I also showed a chart that demonstrated that there were cost differences, You know, are those appropriate differences?
30:38
Maybe they represent quality of care and these types of investigations, and considering both the health topic, the service, as well as, the contexts will be really important to interpreting the quality of care, different types of Medicare beneficiaries are receiving. Second, measurement is also critically going to be important. Both the methods you buy that are employed by either health agencies, public health departments, and public health practitioners, as well as researchers, to study these important topics. And what specific metrics and outcomes are evaluated there. Again, there’s a question of whether those are always appropriate, given the situation, And as I think we’ve seen in many contexts, you know, what gets measured is often what gets improved. So the data availability for different types of care across health systems will be vitally important as well.
31:33
Geography. I’ve, you know, hopefully made a case for it, but I see more and more literature and evidence within the Medicare disparity space that comes to light. That geographies playing a key role. And that’s just not at a national level, but that’s also at State levels. Local City levels, and, you know, across rural and urban settings. So, you know, for what we have, I think it’s important to think about what the existing infrastructure might be versus what we need to build a new to really address Medicare disparities and where the leavers might be within the Medicare Program to do that. Next line.
32:15
You’re just provide some of the key resources for frameworks to think about Medicare disparities, different mapping sources, for that, and for those who are looking for some additional and further information. And my next and last slide, just has some contact information in case if you have further questions or interests. Thank you.
32:38
Sales Barry, Thank you for this information.
32:40
We all know that it’s really impossible to speak about affordability, are accessibility costs are having already without just discussing inequities and disparities.
32:52
But now we’re going to turn it over to hear from doctor Roberts.
32:58
Thank you so much, Brandon, and thanks to the alliance and to Arnold Venture’s Commonwealth Fund, and my colleagues for this really engaging presentation. May I get the next slide, please?
33:13
So today, I want to spend a couple of minutes talking about the complexity of insurance coverage for low-income Medicare beneficiaries and some opportunities for policy reform to improve how coverage works for this vulnerable population.
33:26
Next slide, please.
33:28
So, low-income Medicare beneficiaries navigate complex and fragmented sources of insurance coverage.
33:34
And this complexity arises not just within Medicare, between the choice of a Medicare Advantage plan or traditional Medicare, as Tricia mentioned, but also from the patchwork of programs that supplement Medicare and help to lower out of pocket costs for low-income individuals.
33:48
There are three major types of programs that I’ll discuss there displayed in the figure on the right that shows the income eligibility limits for the different programs.
33:56
First of these is Medicaid, which supplements Medicare for the lowest income beneficiaries who also have low assets.
34:02
Medicaid wraps around Medicare, and it covers services that Medicare does not, such as long term care. It also covers Medicare’s out of pocket costs.
34:11
Income limits for Medicaid vary by state and they range from approximately 75% to 100% of the federal poverty level.
34:18
Second are the Medicare Savings Programs, which help to pay for Medicare premiums.
34:24
And in some cases cost sharing, There are three Medicare savings programs that have different income eligibility limits, and that cover different benefits, and the uppermost eligibility limit for these programs is 135% of poverty.
34:37
Finally, there’s the Part D low-income Subsidy, which is a separate program that helps to pay for Medicare Part D premiums and cost sharing.
34:46
The uppermost eligibility limit for the Part D low-income subsidy is 150% of the federal poverty level, and that program is actually separately administered from Medicaid and Medicare Savings Programs. So you’ll see that each of these programs covers different benefits and has different income limits.
35:01
They also differ in their administration. And this leads to a fair amount of complexity for this populations coverage. Next slide, please.
35:10
So this complexity poses several challenges: It requires individuals to navigate multiple programs with different rules and benefits.
35:16
This can make it hard for individuals to enroll in programs which they’re eligible, and Tricia mentioned some of the cognitive limitations that individuals face as they age. So this complexity adds to the challenges that people face just navigating their Medicare coverage options.
35:31
In addition, eligibility rules for these programs are restrictive, and they exclude many people with low to moderate incomes from assistance.
35:38
So, as I showed on the prior slide that there, there are sharp income eligibility cutoffs for Medicaid, Medicare savings programs, and the low-income subsidy. So people who have incomes that are slightly above these thresholds qualify for much less help.
35:51
And this can lead to coverage cliffs, which increase out of pocket costs and reduce care among near poor individuals.
35:57
Just as a point of reference, about a quarter of all Medicare beneficiaries have incomes between 300% of the federal poverty level are about 13 to $26,000 per year for an individual. So there’s a large portion of the population with limited income and resources that are not poor enough to get substantial assistance, but yet may have limited ability to finance costs of care on their own, which can be quite high in the Medicare program. Next slide, please.
36:24
This patchwork also raises some other challenges the separate administration of Medicare and Medicaid for people who qualify for both programs known as dual eligibles makes it hard to sort of navigate to separate insurance products.
36:36
With rare exceptions, dual eligibles basically have to navigate to completely different insurance programs rather than one integrated product.
36:44
And alongside this challenge of navigating Medicaid, the Medicare savings programs and the low-income subsidy beneficiaries must simultaneously navigate their Medicare coverage options.
36:52
And this involves weighing complex tradeoffs between traditional Medicare and Medicare Advantage, how individuals weigh these tradeoffs, things like the breadth of provider networks, cost, sharing, and coverage of supplemental benefits may be affected by whether individuals get Medicaid or other financial assistance. Next slide, please.
37:09
So, in the balance of my time today, I’m going to talk a little bit about the financial assistance programs that are available to low-income Medicare beneficiaries. And I will discuss three inter-related areas of concern.
37:20
one is the low take up of programs among those who are eligible.
37:24
Second, or the coverage cliff’s among the near poor, so individuals who are ineligible for much of the health of these programs provide, because of the restrictive eligibility rules. And then the third is the challenge of getting Medicare and Medicaid to work well together for people who qualify for and have both programs known as the dual eligibles.
37:41
The most important takeaways from this presentation are that many individuals don’t get the additional coverage they need or for which they qualify.
37:49
So this leads to access concerns and affordability concerns among low-income beneficiaries, and for people who do get Medicare and Medicaid coverage is still poorly co-ordinated across programs.
38:00
And so I’m going to discuss some opportunities for policy reforms to enhance financial protection and improved co-ordination of care for low-income beneficiaries.
38:07
Next slide, please.
38:10
And then we can advance one more from that. So this chart shows the different programs that are serving low-income Medicare beneficiaries, and I show this chart in part two.
38:21
Reveal the complexity of the programs in terms of what is covered, how the programs are administered, and who is eligible.
38:27
So just to review quickly, Medicaid serves the lowest income beneficiaries with low assets.
38:32
It’s the most comprehensive coverage, It sort of supplements Medicare and pays for stuff that Medicare does not, like long term care. Also, dental, vision and hearing care, depending on the state.
38:41
It will pay for Medicare’s premiums and cost sharing. But eligibility is limited to individuals with very low incomes.
38:48
They have to be have incomes of less than 75 to 100% of poverty, depending on the state.
38:53
And assets of less than $2000 for an individual, or $3000 for a couple, which is very restrictive.
38:59
So individuals with modestly higher incomes can qualify for one of the Medicare savings programs. The Medicare Savings Programs are also administered by Medicaid, and so there’s sometimes referred to as limited Medicaid benefits or partial Medicaid benefits.
39:12
Now, within the Medicare Savings Programs, there is complexity.
39:16
The most generous of the Medicare Savings Programs known as the qualified Medicare Beneficiary Program is available to individuals with incomes below the federal poverty level and modest assets, But they’re slightly higher asset limits than the full Medicaid program. The qualified Medicare Beneficiary Program pays for Medicare Part A and B premiums and cost sharing.
39:34
So individuals generally have very low or no out of pocket costs if they qualify for this program.
39:40
But if your income is slightly above this 100% of the federal poverty threshold, you only qualify for more limited benefits to the Medicare Savings Programs that pay for that part D premium.
39:49
But you don’t get help with Parts A and B, cost sharing.
39:52
So there’s the substantial kind of cliff in coverage that arises right around this 100% of poverty threshold that I’ll elaborate on in a moment.
40:00
For the Part B Premium Assistance is provided through two Medicare Savings Programs, the specified low-income Medicare Beneficiary Program, and the qualifying individual programs, the uppermost income eligibility limit for those programs is 135% of the federal poverty level.
40:15
Now, you’ll notice there’s some overlap in the eligibility rules between Medicaid and the Medicare Savings Programs, And so there are a fair amount of qualified Medicare beneficiaries who can currently have full Medicaid. So this reveals not only the complexity across the programs, but interactions among them.
40:31
Separately from Medicaid in the Medicare Savings Programs, there’s the low-income subsidy, which is administered by the Social Security Administration instead of states.
40:39
This comes in two varieties, the full LIS, which is available to the lowest income individuals and a partial LIS that provides partial premium subsidies and partial cost sharing subsidies.
40:49
And that’s available up to 150% of poverty and you can have modestly higher assets to qualify for that program.
40:57
Now, everyone who qualifies for Medicaid in the Medicare savings programs qualifies for the low-income subsidy.
41:02
And as a result, people who have Medicaid or the Medicare savings programs are eligible to be automatically enrolled in the low-income subsidy. So this provides sort of it.
41:10
Use your pathway and CLAS. But the converse is not true.
41:14
There are people who qualify for the low-income subsidy, but who do not qualify for Medicaid in the Medicare savings programs, and they have to separately apply for the LIS with the Social Security Administration, adding a fair amount of just logistical complexity to the application process.
41:30
Next slide, please.
41:33
So I just want to highlight sort of this complexity through three vignettes. These are three hypothetical patients that I’ll just sort of illustrate what they qualify for based on their demographic characteristics income in the state where they live.
41:44
So, our first hypothetical patient is Garcia is age 65 and lives in Pennsylvania.
41:50
She has an income of $13,000 a year, which is 95% of the federal poverty level and low assets, about $1800.
41:57
She is eligible for Medicaid and therefore, qualifies to be automatically enrolled in the Part D low-income subsidy when she has when she receives Medicaid.
42:07
Ms. Butler has identical characteristics to Ms.
42:10
Garcia, but lives in Connecticut, a state with more restricted income eligibility limits for Medicaid. And as a result, Ms. Butler would be ineligible for Medicaid in Connecticut despite having the same income and assets as an individual in Pennsylvania.
42:23
However, she is eligible for the qualified Medicare Beneficiary Program that pays for parts A and B cost sharing and premiums, and is eligible for automatic enrollment in the OAS.
42:33
Finally, mister Smith, age 70 living in California has an income of $14,000 per year, or about 136% of poverty. And monist assets.
42:42
income is slightly above the upper most limit for the Medicare Savings Programs. And so he’s ineligible for those and for Medicaid.
42:49
However, he would qualify for the partial Part D low-income subsidy, although this would require a separate application with the Social Security Administration, because mister Smith is ineligible to be automatically enrolled in the low-income subsidy.
43:02
I also want to note one other thing about these three individuals here. All three individuals would qualify for Medicaid under the eligibility rules that apply to non elderly adults, which are just based on income.
43:12
And in Medicaid Expansion, States entitle individuals to Medicaid coverage if their income is less than or equal to 138% of poverty. So there’s this important distinction between the eligibility rules and Medicaid and Medicare savings programs for low-income Medicare beneficiaries and the Medicaid eligibility rules that apply to the non elderly and non disabled population. And this transition and rules can be quite jarring for individuals who are aging into Medicare illustrating another source of complexity.
43:42
Next slide, please.
43:44
And then one further from that.
43:47
So I want to talk about three issues in turn here. So one is low take up of assistance.
43:51
So these graphs show the take up of Medicaid and the Medicare Savings Programs on the left by income. And the graph on the right shows the analogous data for the Part D low-income subsidy.
44:01
So the X axis here, the horizontal axis is income measured relative to the federal poverty level. And the vertical axis is the percent of people who are enrolling in these programs.
44:10
Next slide, please.
44:11
Going to overlay the populations that are eligible for the programs here. So you can see who qualifies based on income for full Medicaid.
44:19
one of the Medicare savings programs are the Part D low-income subsidy.
44:23
And then the analogous eligibility income eligibility rules are superimposed on the LIS graph.
44:29
Next slide, please.
44:33
So one thing that immediately pops out from these graphs is that, take up of these programs as low.
44:38
Not only do about, not just half of Medicare beneficiaries who qualify for Medicaid or the qualified Medicare Beneficiary Program, the most generous sources of financial assistance take up those benefits.
44:49
Take up for the more limited Medicare savings programs that just pay for the Part B Premium is even lower. It’s as low as about 15 or 20%, depending on on the program that you’re focusing on qualifying individual versus specified low-income Medicare beneficiary.
45:04
We see an almost identical profile of take up of the LIS on the right-hand side.
45:10
Those are the prescription drug subsidies for low-income Medicare beneficiaries and this is not an accident.
45:15
Most people who received the LIS do so automatically when they enroll in Medicaid and the Medicare savings programs. So low take up of Medicaid and Medicare savings programs contributes to low take up of the Part D low-income subsidy. So there’s a large portion of near poor individuals who qualify for the … who are not receiving it.
45:33
Next slide, please.
45:35
So what are some of the factors that drive low take up?
45:39
Well, we know from research on the low-income subsidy that a lot of people who are eligible for these benefits, but not receiving them, are not aware of the benefits.
45:48
So this comes from a study that the estimated that one half of the individuals who qualified for the us, but who were not receiving it were aware of the benefit.
45:56
There’s also a strong income and racial gradient and awareness of the benefit where lower income individuals and racial and ethnic minorities who are eligible for the LIS but not enrolled, are less likely to be aware of this benefit.
46:09
So there’s important equity considerations in terms of who’s not accessing these benefits.
46:14
Next slide, please.
46:17
Related challenges, the complexity of the application process. You have to document your income and assets, at least annually to enroll in Medicaid and the MSPs. There are also asset tests for the and an income test for the low-income subsidy.
46:30
And this disproportionately disadvantages individuals with cognitive challenges.
46:35
So, the graph on the right shows the rates of take up of the Medicare savings programs and the part D low-income subsidy among individuals who qualify for these programs as a function of cognitive status as measured from a test of cognitive function.
46:46
And, I’m sorry, the numbers are a little small, But the take home message here is that about, that take up rate of the MSPs, and the low-income subsidy is about 12 to 13% points lower for individuals, who likely have dementia, based on their scores on a test of cognitive function. And we see similar patterns of low take up for individuals who have challenges working with numbers, numeracy challenges.
47:09
Next slide, please.
47:11
I also mentioned that there’s this kind of mechanical relationship between enrollment in the Medicare savings programs and the low-income subsidy, because individuals are automatically enrolled in the low-income subsidy if they have one of the Medicare savings programs.
47:22
The converse is not true again because not everyone who qualifies for the LIS qualifies for the Medicare Savings Programs.
47:29
And so the profile of LIS enrollment relative to income almost is almost identical to the profile of MSP enrollment by income.
47:37
Where individuals are not receiving the Medicare savings programs, they’re also less likely to receive the low-income subsidy.
47:43
And so the lack of auto enrollment for people who are not enrolled in one of the Medicare savings programs is unlikely a big, big, big determinant of the low take up of Part D subsidy.
47:53
Next slide, please.
47:56
So I’m now going to group the full Medicaid and qualified Medicare Beneficiary Program together In this graph I’ve taken by income to show the coverage clip.
48:06
So this kind of what I wanted to sort of emphasize here is that the the blue bars here show the take up of Medicaid and the qualified Medicare beneficiary Program by income.
48:16
You can see that it differs abruptly just around 100% of the federal poverty level.
48:20
This is the income threshold for the quality qualified Medicare Beneficiary Program.
48:25
So near poor individuals whose incomes are slightly above 100% of the federal poverty level, just aren’t eligible for the same levels of assistance, as, as individuals with incomes below 100% of the federal poverty level.
48:38
Despite the fact that they only have modestly higher incomes, and modestly higher assets, So this abrupt drop off in coverage, which I’ve called a coverage kliff has large impacts on out of pocket spending and use of care. Next slide, please.
48:52
So this comes, these graphs come from a paper that I wrote that looks at the effects of this coverage Clift for near poor individuals on their out of pocket costs and use of care.
49:01
The vertical bar in the middle of these graphs is the income eligibility threshold for the qualified Medicare Beneficiary Program.
49:09
And so individuals to the left of that bar are eligible for the program, and individuals to the right are ineligible for the program.
49:15
And you can see here that just exceeding this eligibility threshold is associated with over a 9% point increase in the probability of having high out of pocket spending, which we measured as more than $2000 over two years.
49:28
That’s sort of a surrogate for severe financial burden.
49:31
We see sharp reductions in outpatient utilization on the order of about 15% per person per year. Next slide, please.
49:38
Fewer prescriptions filled per person per year on the order of 11% overall, and 7% for medications that target common chronic diseases in the Medicare population like diabetes, hypertension, hyperlocal, …, and Depression.
49:51
So, individuals who are near poor don’t get financial assistance, despite the fact they don’t have substantial resources to pay for care. This leads to big drop-offs in coverage.
50:01
OK, next slide, please.
50:03
The third issue that I wanted to address briefly is the integration of Medicare and Medicaid for individuals who get both programs.
50:10
So, now, focusing on individuals who actually get Medicaid, there are concerns that the coverage through two bifurcated payers is suboptimal and that individuals will not receive co-ordinated care or appropriate care. Because they’re navigating essentially two separate insurance programs. So, this issue is of a particular concern for the nine million individuals who get full Medicaid.
50:33
These comprise about three quarters of all dual eligible beneficiaries.
50:37
The remaining three million dual eligible beneficiaries only get limited Medicaid benefits through the Medicare savings programs.
50:44
Why are we concerned about the full tools? Next slide, please.
50:47
Well, they’re the most medically complex Medicare beneficiaries And they incur very high healthcare costs.
50:53
So, about a third of full benefit tools have three or more functional limitations, which is far higher than among partial tools.
50:59
18% live in long term nursing facilities, and full tools account for 26% of Medicare spending and nearly 30% of Medicaid spending.
51:09
Yet, they’re only about 13 or 14% full duals of the Medicare population.
51:16
Next slide, please.
51:17
And for Full doors, Medicare and Medicaid are paying for distinct services. Medicare is the primary payer for inpatient and outpatient care, and for prescription drugs.
51:25
Medicaid is paying for long term services. And supports may also pay for dental, vision, hearing, and some medical transportation, which can vary by state.
51:34
And that these two sort of separate sets of services are typically not integrated or co-ordinated at any in any consistent fashion, because Medicare and Medicaid are completely separately administered.
51:46
So the question is, what might more integrated coverage look like and how does it compare to current coverage scenarios?
51:52
Next slide, please.
51:55
Most individuals who are dual eligibles look like folks in scenario A. They’re basically covered through two separate insurance programs that don’t talk to each other.
52:03
They might have fee for service Medicare. They might add Medicare Advantage. And then, there’ll be separately enrolled in either Fee for Service Medicaid, or a Medicaid Managed Care program in a state that covers long-term services and supports, in addition to providing other comprehensive medical coverage. Those are known as an LTSS programs managed long-term services and supports.
52:23
This provides very limited opportunities for integration or co-ordination across the programs, because, basically, Medicare and Medicaid are just operating in silos, and they’re not talking to each other.
52:32
Currently, about six million fold dual, so six fold tools are enrolled in these types of sort of least integrated coverage options. So, that’s two thirds of the dual population still has very low integrated coverage.
52:46
An increasingly common scenario is pictured in scenario B and that’s where the dual eligibles enrolled in a Medicare Advantage the SNP.
52:54
Russia mentioned the growth of Medicare Advantage overall and this has also occurred in dual eligible special needs plans, or D snips.
53:00
Addition of is provide some opportunities to co-ordinate coverage because they’re required to have contracts with state Medicaid programs that define plans, care, co-ordination, responsibilities.
53:09
The those contracts can also require DCPs to actually provide coverage of certain services that are covered by Medicaid. So that would entail a certain amount of financial and operational integration, but in general, the amount of care co-ordination that occurs between these snips and Medicaid is relatively low.
53:26
So there’s some sort of backend co-ordination between Medicare Advantage and the Medicaid programs, But individuals still look like they’re getting coverage through two separate insurance programs that don’t have explicit integration mechanisms.
53:39
Next slide, please.
53:41
So, the more integrated scenarios that we’re trying to move toward and that CMS has, has really sought to pursue, are these integrated models where the same insurers covering Medicare and Medicaid spending for the same patients.
53:54
The model that’s growing and where that has been made permanent through the 2018 Balanced Budget Act, is the fully integrated dual eligible sniper fighting SNP.
54:03
This is a scenario where the same plan or legal entity is responsible for substantially all Medicare and Medicaid spending for the same patients.
54:10
The plan will cover Medicare services, Medicaid services, including long term services and supports.
54:17
So, while there are separate flows of funds, from Medicaid and Medicare, to the plan, there is some integration at the plan level that, hopefully, will, you know, incentivize the plan to provide better co-ordinated care.
54:32
However, these plans are still pretty rare, and they only cover about 300,000 fold tools nationally.
54:38
The most integrated scenarios are pictured in Panel D on the right.
54:43
This is where Medicare and Medicaid make a single capitation payment to an integrated plan that then delivers all benefits to a dual eligible beneficiary.
54:51
Examples of these include Medicare, Medicaid plans that were implemented under the CMS financial alignment demonstrations.
54:57
These are going away and so this is not likely to become the dominant model going forward.
55:02
Those only covered about 400,000 full benefit duals the remaining 50,000 fold rules in these highly integrated models, or in programs of all inclusive care for the elderly. There is some interest in expanding these programs, but there are still relatively small, and they’re hard to scale up.
55:17
So next slide, please.
55:20
So the growth and integrated coverage is more likely to come from these D snips and then find SNPs that are the fully integrated plans, as well as an intermediate class SNPs, known as Heidi snips.
55:29
ID snips sits somewhere in the middle between the snips, and by the SNPs. They can cover long term care or behavioral health services, but not necessarily both.
55:38
Um, and the growth opportunities will probably increase this. More states implement managed care programs and Medicaid, but we’ll cover long-term services and supports. So that provides an opportunity to integrate Medicare and Medicaid within a managed care framework, which which is what the … model is. CMS has also continue to strengthen integration standards across all classes of SNPs, including fide SNP. So there’s a lot of appetite for expanding this model.
56:01
Next slide, please.
56:02
So what do we know about these different models? Well, in general, the SNPs that are not highly integrated do not outperform other Medicare Advantage plans in measures of access to care satisfaction with care among tools.
56:13
This is from some work that I’ve done that compares dual eligibles access to care and satisfaction with care in …
56:19
SNPs, Regular Medicare Advantage plans, and traditional Medicare … do seem to offer some advantages in terms of out of pocket cost protections and access to dental care.
56:29
But on other measures, you can ask it begin to wrap up. And then the next one I’ll just I’ll say this last slide here, so …
56:40
don’t tend to outperform we do see some benefits of fighting SNPs in terms of more integrated care, But the examples are relatively rare, and they’re from single states.
56:49
So bottom line is coverage for Medicare, Medicare beneficiaries. Low-income Medicare beneficiaries is complex and fragmented.
56:57
There are opportunities to better integrate coverage for dual eligibles who get both programs, but we need better evidence on models that can actually provide better care for both populations. And so that is an area of imminent opportunity for research and policymaking.
57:14
Thanks very much.
57:16
Thank you.
57:18
Doctor Roberts, you’re going to appreciate insightful information on one of our most vulnerable populations. You just those who are truly Medicare and Medicaid. It will now turn it over to Lindsay Copeland who will talk about enrollment.
57:43
And thank you all for that for being here, and I appreciate the opportunity to chat with you a bit today. And next slide, please.
57:58
And so, my organization, the Medicare Rights Center, is a national non-profit that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs, and public policy initiatives. We provide services and resources to three million people with Medicare, family caregivers, and professionals each year, including through our National Consumer Helpline, and, based on this experience, we know that policy changes are really needed to strengthen Medicare and advance equity. And today, I’m going to touch on a few of those opportunities, specifically, ways to simplify enrollments, to better support beneficiary, decision making, and to improve health care and prescription drug affordability.
58:38
Next slide, please.
58:41
Year after year, among the most frequent calls are our hotline, or those frommer on behalf of people who have mistakenly failed to enroll in Medicare on time, and who are facing really harmful consequences as a result.
58:52
Generally, we find these errors are rooted in the complexity of the rules concerning how, when, and whether to sign up.
58:59
While most older adults are automatically enrolled, when they first become eligible, because they’re already receiving Social Security benefits, age 65, a growing share or not. Many are working later in life deferring social security and may not even realize it impacts their Medicare coverage. Next slide.
59:19
But, unlike those who are automatically enrolled, these individuals must act must actively sign-up, while most can sign up for part A at any time without penalty. But enrolling in Part B is a much more complicated endeavor, which this slide is an attempt to show all of the complexities and considerations that go into that.
59:37
And it requires people to understand a maze of Medicare rules, and timeline, including when to sign up during Medicare, is really time limited windows, how their current insurance, if they have any, will work with Medicare, and the consequences of delaying enrollment, even by mistake.
59:54
The rules are so confusing that even HR department and an employer benefits counselors can struggle to follow that, and then fixed a really high beneficiaries who experience and mismanaged transition in faith, lifelong financial penalties, higher health care costs, and gaps in coverage.
1:00:12
Next slide, please.
1:00:15
Clear advice from the Federal Government to those approaching Medicare eligibility would help. But no such notice Somewhat surprisingly, I think to folks, is that is not required right now.
1:00:26
And that only people who already receive or have applied for Social Security before turning 65 are notified about their Medicare eligibility.
1:00:36
So, that means that those who are arguably need this information And most people who need to actively sign up are not getting it.
1:00:44
Because there’s Medicare Notification processes tied to the collection of Social Security benefits, it’s reaching a shrinking subset of beneficiaries.
1:00:52
As we saw a few slides ago, in 20 16, only 60% of Medicare eligible, 65 year olds were taking Social Security compared to 92%, two, or in 2002.
1:01:04
In part, this is due to the gradual to your increase in the Social Security at full eligibility age from 65 to 67.
1:01:11
While linking the two eligibility, the two systems made sense, when the eligibility ages were also aligned.
1:01:17
Today, it just means that people who don’t take Social Security until the age for full retirement benefit, which is currently 60, received nothing from the federal government about their initial Medicare eligibility at age 65.
1:01:30
Current law offers no remedy. There is no requirement that either SSA or CMS notify people if they’ve not yet applied for Social Security.
1:01:38
As a result, many people bear the full burden of navigating Medicare complex enrollment process alone often to disastrous effect. Next slide, please.
1:01:51
As I mentioned, we frequently hear from beneficiaries who, in this information vacuum inadvertently failed to enroll in Part B on time and are experiencing severe repercussions.
1:02:01
This includes a lifetime Part B Late Enrollment Penalty, or loopy.
1:02:05
The penalty accrues that 10% for every year the individuals should have been enrolled but wasn’t.
1:02:11
So for example, if someone mistakenly delays enrollment for seven years, they must pay 70% more every month for as long as they have Medicare amounting to a lifetime penalty.
1:02:23
An example for 2022 year would be if instead based. Part B premium. This year is $170, and 10%.
1:02:30
Their monthly premium with the penalty would be $289.17.
1:02:34
That which of the base penalty times 70%, plus the base penalty.
1:02:39
Um, currently, an estimated 776,200 beneficiaries are paying an LED. And the average amount represents a 30% increase in their monthly income.
1:02:51
This penalty is intended to encourage individuals who are newly eligible for Medicare to enroll on time, and ultimately to ensure bounds for.
1:03:00
But, because all the rules around enrollment are so complicated, and often unknown or misunderstood, many people are paying it solely due to honest error, and it could be a major and punitive burden, especially for people with limited income.
1:03:14
They may also face periods of non coverage, continuity of care disruption, and exposure to high out of pocket costs.
1:03:20
Most people who don’t enroll in Part B during their initial enrollment period, which is the seven month window around their 65th birthday, must wait until the next general enrollment period or GAP to sign up.
1:03:32
This can mean gaps in coverage as the GDP runs from January one to March 31st each year.
1:03:39
Currently, they must also wait until July first for coverage to even begin, and in the interim, facing high out of pocket costs, people may forgo care leading to worse health, and potentially higher costs down the road as well.
1:03:51
So this is an area where solutions are urgently needed. As the population ages and people stay in the workforce longer are delaying social security and as the gap between the Medicare and retirement benefit eligibility age continues to grow, more and more beneficiaries are going to face the pitfalls of the current system.
1:04:09
Next slide, please.
1:04:12
And thankfully, there are some clear and commonsense policy options. This includes the …
1:04:17
two Act, which would fill the longstanding gap and enrollment education, are acquiring the federal government to provide advance notice to people, approaching Medicare eligibility about enrollment rolls and timelines.
1:04:29
The notification will be sent to individuals aged 6365 as part of their annual Social Security statement and to people with disabilities who are in the 24 month Medicare waiting period.
1:04:39
And it would impart clearly explain the individuals’ Medicare eligibility the potential effects of delayed Part B enrollment, and information on how other types of insurance work with Medicare.
1:04:50
This would help reduce the costly enrollment errors that we see today.
1:04:53
It would also advance equity factors like language barriers, and limited Internet access likely play a role in mismanaged Medicare transition.
1:05:02
And we know that many of those who are stuck paying, the resulting financial penalties, simply can’t afford it.
1:05:07
But they also may not qualify for Medicare savings programs, which, as they’ve heard, really strict eligibility, threshold and burdensome administrative processes that limit participation.
1:05:17
And as a result for the people who are subject to these …, their financial security is often undermined month after month after month.
1:05:26
Importantly, this bill belts on the successes of the original bennies Act, passed in December 2020 and modernized transitions to Medicare in a few key ways, by eliminating the months long waits for coverage, to take effect post enrollment, and expanding CMS’s authority to grant a special enrollment periods for X Exceptional Circumstances program wide.
1:05:48
CMS published, proposed rules implementing these and other changes in late April and comments are due June 27th.
1:05:55
As expected, they seek to update those Medicare coverage effective date.
1:05:59
This includes the one and during the GDP that I just mentioned while that enrollment period run at the beginning of the year. Again, coverage currently doesn’t begin until July first.
1:06:10
And when someone enrolls in a ladder months of their initial enrollment period, again, that seven month window, and they have to wait 2 to 3 months for their coverage to become effective.
1:06:20
Finalized under the … rules beginning, January first, 2023, Medicare coverage will begin the month after enrollment for people who sign up during the last three months of their initial period, or during the GP, reducing those gaps in coverage. So people would sign up, and in their coverage will begin the very next month. instead of having to wait for so long. That doesn’t eliminate the waiting period that people still have when they need to. They missed their initial enrollment period, and have to wait until the next general enrollment period to sign up. That’s still a period of non coverage. That’s troubling, but it does reduce the weight between signing up for Medicare and coverage beginning.
1:06:58
CMS is also proposing several special enrollment periods that would allow qualifying individuals who are experiencing exceptional circumstances, like a declared disaster or emergency to enroll without having to wait for the GED and without being subject to a late enrollment penalty.
1:07:14
I won’t go through all of those, but I do really encourage everyone to take a look at the proposed rule and to weigh in as CMS notes in the press release. Accompanying the NPRM. These changes support the agency’s work to improve health equity and access to affordable coverage and care. So this is just a really great opportunity to improve the program and how beneficiaries experience it.
1:07:38
Increasing access to relief from mistaken delays in Part B enrollment would also help further the goals, as we’re revisiting efficacy, amount, and duration of the Part B Late Enrollment Penalty. And now I can go onto the next slide.
1:07:53
As Tricia mentioned, people with MA and Part D can face additional enrollment hurdles the initial and annual plan selection processes.
1:08:01
Like enrollment in first place. This can be really overwhelming and complex.
1:08:05
And one reason is the plan choice landscape.
1:08:08
This year, it’s great research from the Kaiser Family Foundation shows. the average Medicare beneficiary will choose from among 39 MA plan is the highest number in a decade and more than 50 drug plan.
1:08:20
Choosing among plans can be difficult. Even for the Savviest consumers, there’s just so much to consider.
1:08:25
Plans can vary significantly in terms of premiums, deductibles, cost sharing, and provider network benefit demands, formularies, and coverage restrictions.
1:08:34
While comparing all of these factors simultaneously as the best way to maximize values and lower costs, that’s also really time consuming and really difficult, especially for people with cognitive impairments or serious health needs.
1:08:46
Next slide.
1:08:49
And studies show that having too many plan choices can lead to poor or no enrollment decisions. And again, with thanks to the Kaiser Family Foundation, and we see that, we see that in Medicare. Far too many people are choosing not to reach you.
1:09:01
Nearly 60%, 57%, to be precise of Medicare beneficiaries don’t review or compare their coverage options annually. And tremblingly, those who have the most at stake, that just people who are older, have lower incomes, are relatively poor health, are among those who are least likely to compare their plan options.
1:09:20
This can undermine health and financial security by leading to unanticipated outcomes, like higher out of pocket costs and problems accessing preferred providers.
1:09:29
And while this widespread lack of re-evaluation could indicate that beneficiaries are generally satisfied with their current plan and so just aren’t motivated to shop around, there’s also a good amount of data showing the drivers or that beneficiary sign-up process of comparing plans. To be too challenging. They’re unaware. They need to do so, or they have limited confidence in their ability to choose a better plan.
1:09:50
And, again, here are those in fair, poor health with multiple chronic conditions are more likely to report difficulty comparing their options.
1:09:57
And this aligns with what we see in our experience, which is that many people stay in their plans year after year, even if another plan would better serve their interests.
1:10:05
And this stickiness, again, can have serious health and financial consequences, may lead to unavoidable. Avoidable costs are unrealized benefits, as people may end up paying more for plan, that don’t really work for them.
1:10:17
Others who may be initially attracted to some of those low premiums may be surprised to later find themselves without access to certain providers and exposed to high costs for other services.
1:10:28
If so much at stake, the fact that such a large share of beneficiaries aren’t comparing their coverage options warrant for tension. Next slide.
1:10:38
one way to improve the system for beneficiaries is to reduce the risk.
1:10:42
They’ll make a bad choice, means, ensuring the plans are high quality limited in number and easy to compare, for example, by standardizing plans, improving consumer tools, strengthening plan oversight, and fortifying beneficiary protections.
1:10:56
Um, next slide, please.
1:11:01
Unfortunately, like Part B enrollment challenges, those related to health care and prescription drug affordable, portability also continue to present a stained way on our national hotline.
1:11:12
Medicare provides vital health coverage. Gaps in services, and high cost sharing requirements, which you’ve covered today can put it out of reach, in particular, for enrollees color.
1:11:22
For example, study after study shows that vision, dental, and hearing care is cost prohibitive for millions, and that Black and Hispanic Medicare enrollees are among those most likely to report difficulty affording the care.
1:11:34
And while most people with Medicare can’t afford high rising prescription drug costs, as Tricia laid out, these challenges are particularly acute for enrollees color.
1:11:44
Next slide, please.
1:11:47
And, financial challenges, along with rising health care, excuse me, and prescription drug costs, antiquated Program Rules, and Burdensome Administrative requirements can make it difficult for many beneficiaries to obtain the care they need.
1:12:01
It’s really critical that policymakers, staff, and to help reduce these barriers to care.
1:12:05
This includes reducing drug prices and lowering costs for both people with Medicare and the program.
1:12:10
Some potentially effective strategies that have been under discussion include allowing Medicare to negotiate drug prices, increasing pricing transparency and accountability throughout the supply chain, and restructuring part due to better align pricing incentives and cap beneficiary costs.
1:12:26
At the same time Medicare’s low-income assistance program needs needs to be modernized to achieve administrative efficiencies and reach more people.
1:12:34
Filling gaps in coverage, slight revision and dental adhering care would also help as with shoring up Medicaid HCBS funding, and streamlining access to Medicare covered a skilled nursing facility care.
1:12:47
I know this was a lot, and I ran through some of that pretty quickly, but wanted to make sure we do have time for questions. So, thank you all for thinking about these issues with us, and I will turn it back to Brandon.
1:13:01
Thank you so much, Lindsey.
1:13:03
And I’m also going to ask all of our panelists to come back on camera.
1:13:09
I’m off mute one. Thank you all for that helpful information.
1:13:18
We’re also now going to turn our begun to begin our question and answer component of today’s webinar.
1:13:27
Please keep your responses to the minute, or less in interest of time.
1:13:32
And I’m going to first fill our first question.
1:13:38
two. first question is for doctor Newman.
1:13:46
Most Medicare Advantage programs, I’m sorry, if most Medicaid managed programs are covering more supplemental benefits.
1:13:55
At face value, it seems that it would make more sense for individuals to elect for Medicare Advantage coverage for traditional Medicare, you’ve clearly articulated the tradeoffs and risk for beneficiaries.
1:14:07
Are there any risks involved with the shift towards privatizing Medicare, even if it’s just a perception for the health care system itself?
1:14:18
Well, that’s really a great question. Let me just think about for the healthcare system itself.
1:14:25
No, I think, I think one of the issues that hasn’t gotten a lot of attention is what does this mean for healthcare providers, that we’re used to having sort of one Medicare program.
1:14:37
And now, they are increasingly having to deal with lots of different plans with different sets of rules, Which could well lead to higher administrative expenses for the provider side, because they need to figure out, United Health is a big play, or he has a big player there.
1:14:56
Lots of other smaller players at Kaiser Permanente, of course, has its own system.
1:15:02
So, I think in terms of Health System, it would be interesting, too, think about what this means for administrative complexity and cost to the provider.
1:15:12
And that’s certainly one factor and, you know, in when, you know, there’s some. There’s a lot of discussion right now about denials and prior authorizations and there was the report by the OIG that was talking about denials.
1:15:27
That also is a, is a sort of a time, responsibility for doctors who are apps or acting on behalf of their patients, who may be denied services if the denial is considered inappropriate. So, I think, well, there’s certainly benefits that we’ve talked about earlier.
1:15:46
I think there are tradeoffs in the system and miti cost to the system that haven’t gotten a lot of attention.
1:15:54
Thank you.
1:15:55
My next question is, For doctor Salzberg, You’ve made a compelling case that we have a health disparities problem.
1:16:02
And a potential solution is, The Medicare coverage can shrink some of those racial and ethnic disparities, but what are the root causes and drivers of the disparities, such as the prevalence of chronic disease amongst ethnic and racial minorities?
1:16:19
Sure. So, I think one thing to consider within this is that the problem is multi-factorial, and involves a lot of structural issues, both within the health system, but within such public programs, as the Medicare Program. I think, you know, we could, again, dice the data in different ways, whether you’re looking at it by different racial and ethnic populations, socio economic status, educational attainment, gender. And disparities have been found in all of those areas, as well as others. So, you know, this is not going to be a problem that we’re going to be able to solve with any single silo, or any single sector.
1:17:00
So, I think cross partnerships are going to be involved, but also engaging communities more. And I think there are initiatives kind of within the Medicare program to focus more on what we call the social determinants of health.
1:17:14
Which can include all of those various factors and beyond just the doctor’s office and the health care system to really start addressing where disparities are at their roots, and where different types of, as we’ve talked about today, payment mechanisms can open up the services and supports for, for those health system interventions, as well as those outside that can really start promoting health and closing some of these gaps.
1:17:43
Thank you.
1:17:45
First question is for doctor Robert.
1:17:47
It’s A quite lengthy question. So I will try to say it slowly.
1:17:53
one, we’re appreciative of your coverage to eligibles in special needs plans.
1:17:58
And I’m sure you’re aware CMS recently released the final rule on these maps.
1:18:03
one change was to the maximum out of cost calculation methodology.
1:18:07
Previously, the calculation excluded cost sharing paid by Medicaid, there’s no rule that includes all costs paid on behalf of the beneficiary, including those people.
1:18:18
The rationale was that the status quo results in increased payments, America, or Medicare cost sharing.
1:18:26
It disadvantages providers serving duly eligible individuals and a new policy.
1:18:33
Sorry.
1:18:34
Starting a new policy will actually make cost sharing more equitable for those providers.
1:18:42
In your professional opinion, um, or Backup sandwich glaringly missing is the beneficiary prospectus.
1:18:50
In your professional opinion, how that this new MOOC calculation methodologies impact beneficiaries, particularly those who are lowenthal.
1:19:02
You may be on mute, doctor Roberts.
1:19:11
I’m sorry. We’re still having trouble hearing you.
1:19:13
I guess I was muted by the organizer. Very quickly, yes, so the, the MOOC calculation now, you know, basically will count.
1:19:24
Medicaid payments of cost sharing toward the maximum out of pocket limit so that Medicare Advantage plan will start that Rules will save state, Medicaid programs, a little bit of money and will the Medicare Advantage plan will start contributing. I want to take a step back a little bit about the out of pocket cost issue. I’m a little I’m not terribly sanguine that it will change much from the beneficiaries perspective for a few reasons.
1:19:49
one is that there’s an incredible amount of confusion among providers and beneficiaries about balance filling of tools who should not receive bills for cost sharing or co-insurance for for services, but who frequently do in an inappropriate, low balance build. And we see this even in Medicare Advantage where ostensibly SNP would would know that a person is dually eligible and should not be balanced build. And yet we, we know that there’s evidence that inappropriate balanced billing in that population.
1:20:20
I think, so, I think that there’s, there’s a lot more that needs to be done on the backend, to sort of make sure that, that the, that the beneficiary really, like sees the integrated Medicaid benefit and the cost sharing protections that Medicaid delivers when they get care at the point of service. And I think that will probably require a fair amount, more of, actual integration of Medicaid coverage with the …, so that the beneficiary realize it’s sort of the full cost sharing protections that they are entitled to. one other, very quick point.
1:20:50
There is, in my research, I haven’t found that, that the variation in Medicaid coverage of Medicare cost sharing is as impactful in terms of access to care.
1:21:00
As, as other determinants, I think, even though we think of tools as being sort of fully insured at Medicaid, pays all the cost sharing, there are a lot of other demand side barriers to care difficulty, getting transportation of care, difficulty scheduling visits with providers.
1:21:13
And so, I would like to see a lot more attention on those determinants of access rather than just the sort of the out of pocket cost, cost sharing protections, although those are important. I think those are not the sole determinant of access challenges and tools.
1:21:27
Thank you. Next question is for Lindsay.
1:21:31
As you are aware, cagey emergency declarations are set to expire in mid july.
1:21:37
What major implications will this have on coverage and consumer affordability in the Medicare Program, and how can we mitigate those impacts?
1:21:46
Thank you. Yeah, slower, We’re hoping that it will be extended at least 1 or 2 more times in order to give agencies a bit more time to try and mitigate some of the potential consequences that may happen.
1:21:59
For example, when people who have been on the expanded Medicaid with more generous income, eligibility levels during the public health emergency, that will expire when the declaration does? Some of those people should have enrolled in Medicare, but maybe didn’t. And so when their Medicaid coverage terminates, that could be problematic. In a couple of ways. We think that there’s a special enrollment pip. And I’ll give me special enrollment period outlined, and if any, that for both roles that could help mitigate some of this as well. But, there are also people who may have missed their Medigap Open Enrollment period and they’re gonna need some assistance to be able to purchase those plans without any underwriting. And so, we are working on a letter to the MS outlining some of these concerns.
1:22:44
That, we’d be more than happy to share with the participants here today, OK, thank you so much.
1:22:51
So we’re on, unfortunately, close to our time for the today’s event.
1:22:57
So with this last few minutes, I’d like to turn our remaining time.
1:23:01
But we’ll work our pedals to hear any closing thoughts.
1:23:05
and we’ll start with doctor Newman, if you can give NaN of closing box?
1:23:12
I just want to thank the alliance again for drawing attention to Medicare, with more than 60 million people in our country covered by this program. It’s really important to take a good look at Medicare.
1:23:24
I think Medicare will be on the forefront of policy discussions in the coming years, mainly due to solvency challenges.
1:23:32
But I think, in large part, the debate has been focused on Medicaid and the coverage expansions that have been allowed under the Affordable Care Act.
1:23:42
I think Medicare warrants our full attention given the important role it plays or many high need low-income, and otherwise challenged individuals who need this program to have a healthy and secure retirement or for younger people as a safe and financially secure period of disability. So I want to thank you again. I think this was a great panel, and I really enjoyed listening to my fellow panelists and learned a lot.
1:24:10
Thank you. doctor Mittman. Lindsay Cope with them.
1:24:15
Sure, I would echo the thanks, and just to underscore that there are a lot of complexities that people face just trying to enroll in the program. But there are also a lot of really common sense solutions that could be adopted to help reduce some of these barriers really quickly. And without spending billions of billions of dollars. Just sending people I notice to let them know that they need to actively enrolled in Medicare would make a world of difference.
1:24:39
Thank you, doctor Salzburg.
1:24:42
I guess, similarly, echoing all the thanks to organizers, participants, moderators, and other panelists. I think I’d say that, you know, we’re in a moment right now, especially after the pandemic where there’s a lot of focus on health equity. Again, both, it’s on the policy agenda, but I think also, you know, across both research and, you know, the entire biomedical enterprise. And so, I think what I would say is most important for that is it’s been, you know, more salient on the agenda in the past and especially in terms of quality improvement. And, yet, it is one of the areas where we’ve seen less kind of lagging less growth and lagging kind of progress than some of the other quality measures and metrics that we thought about.
1:25:30
So I think as it relates to the Medicare program, especially, again, the diversity of that population and tailoring the care where they needed, and making sure that, you know, policy supports them being able to receive that care.
1:25:44
I think just keeping you, again, emphasis for data availability measurement, as well as continuing to monitor areas where we’ve seen historical disparities, and investigating new areas so that we can hopefully intervene in them. and leverage such a large program to improve care.
1:26:05
Thank you.
1:26:06
Last, doctor Robert, should have the final word, and I’ll be super quick, because I went over before. I think we pushed a lot of complexity of coverage onto the beneficiary. And so it’s incumbent on the policymaker to simplify that.
1:26:18
And we can do that in a way.
1:26:19
That also pays particular attention to the equity implications of simplification, how we integrate coverage, how we better extend financial support to individuals who need it, and make sure that they get it easily. That enrollment is not, that the challenges of enrollment are not a barrier to, getting help that is important for care.
1:26:38
Thank you so much.
1:26:40
Thank you all again for your insights for this very important topic, and unfortunately, that’s all the time that we have today.
1:26:46
Everyone who participated, please take time to complete the brief evaluation survey you will receive immediately after the broadcast ends, as well as via e-mail later today.
1:26:58
Please join the alliance again on May 22nd at 10 o’clock AM for the final briefing in the future of Medicare seventies about policy options to promote Medicare sustainability.
1:27:10
A recording of this webinar and additional materials will be available on our lives as website.
1:27:15
That concludes today’s webinar, Lindsay Tricia, Eric Laurin. Thank you for joining us today.
1:27:22
Thank you for having us.
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