Protecting the Medically Vulnerable Amid COVID-19: Insights from the Dually Eligible Population in the United States
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Dually eligible beneficiaries are individuals enrolled in both Medicare and Medicaid. COVID-19 has exacerbated existing vulnerabilities within this population such as mental health, underscoring the importance of advancing knowledge of and supporting existing efforts to meet their needs and identifying promising practices integral to addressing current health inequities.
To emphasize the increasing impact the dually eligible beneficiary population will have on the US health care landscape, this commentary serves as a primer for readers by:
- providing an overview of the challenges and needs faced by dually eligible beneficiaries;
- discussing current pathways to address care for this population as a result of the COVID-19 pandemic; and
- identifying promising strategies to address the needs of this population during and after the COVID-19 pandemic.
Who Are Dually Eligible Beneficiaries?
The dually eligible population has grown from 8.6 million in 2006 to 12.3 million beneficiaries in 2019, with an average annual growth rate of 2.8 percent . In 2013, dually eligible beneficiaries accounted for $312.4 billion in Medicare and Medicaid combined spending . As a population with complex needs, dually eligible beneficiaries account for a significant portion of total Medicare and Medicaid spending primarily due to their heavy reliance on long-term care services and inpatient hospitalizations . This beneficiary population tends to be predominantly younger in age, female, and comprised of an ethnically and racially diverse population compared to Medicare-only beneficiaries. In 2019, 48.0 percent of dually eligible beneficiaries were from minority populations, compared with 21.6 percent of Medicare-only beneficiaries; 59.4 percent of dually eligible beneficiaries were female compared with 53.0 percent of Medicare-only beneficiaries; and 37.9 percent of dually eligible beneficiaries were younger than 65 compared with 8.1 percent of Medicare-only beneficiaries .
Dually eligible beneficiaries under age 65 qualify for Medicare based on disability status and qualify for Medicaid based on income level. As a result, these beneficiaries often need and use other supportive services, including home-based services and nursing home care. Dually eligible beneficiaries over 65 qualify for Medicare and Medicaid because of their level of income and spend down in nursing homes. Dually eligible beneficiaries use Medicare to cover primary care, many preventive services, hospital care, and prescription drugs. They use Medicaid as a secondary payer to cover services not covered by Medicare, including long-term services and supports, certain behavioral health services, and for those who qualify, Medicare premiums and cost-sharing. Some dually eligible beneficiaries are encumbered by multiple chronic conditions, long-term care needs, and cognitive disabilities including mental illnesses . Some in this population also have adverse social determinants of health from social risk factors including lack of transportation, food insecurity, and housing insecurity .
Dually Eligible Beneficiaries Face Incredible Challenges during COVID-19
The health and economic challenges experienced by dually eligible beneficiaries have persisted and escalated amidst the COVID-19 pandemic. Accumulating evidence suggests that this population bears a higher likelihood of being exposed to COVID-19 as a result of medical risk factors, racial and ethnic inequities, and adverse social determinants of health.
Medical Risk Factors
Dually eligible beneficiaries are burdened with chronic conditions  (e.g., Alzheimer’s and related dementias, asthma, chronic obstructive pulmonary disease, and diabetes), which are also key risk factors for contracting COVID-19 . Preliminary data from the Centers for Medicare & Medicaid Services (CMS) indicate dually eligible beneficiaries are almost three times as likely to get infected and be hospitalized because of COVID-19 .
Racial and Ethnic Inequities
COVID-19 has emphasized stark inequities and health disparities when addressing the needs of this population. For example, American Indian/Alaska Native, Latinx, and Black dually eligible beneficiaries are more likely to be hospitalized for COVID-19 than White dually eligible beneficiaries. In addition, American Indian/Alaska Native and Latinx dually eligible beneficiaries are more likely to be infected with SARS-CoV-2 compared with White dually eligible beneficiaries .
Adverse Social Determinants of Health
Coupled with risk factors, adverse social determinants of health have posed challenges for dually eligible beneficiaries during the pandemic. A recent study explored ways in which 14 integrated, coordinated care plans that target dually eligible beneficiaries such as Dual Eligible Special Needs Plans (D-SNPs)—which, as of June 2021, enroll 3.5 million dually eligible beneficiaries —and Medicare-Medicaid Plans (MMPs) addressed social determinants of health during the pandemic. During the early stages of the pandemic, plans reported that beneficiaries had difficulties addressing food needs and social isolation, followed by access to housing, basic home supplies and personal protective equipment . Social isolation in particular may be a potential risk among older beneficiaries living in residential facilities (e.g., nursing facilities) and community settings, for reasons including: (1) safety restrictions established in nursing facilities to combat COVID-19 have restricted visitation and social engagement to curtail viral transmission, and (2) beneficiaries who receive home- and community-based services (HCBS)—a Medicaid benefit that provides an opportunity for dually eligible beneficiaries to receive care in their home or community settings as opposed to institutional care—have limited access to care and support during the pandemic because of concerns about allowing personal care attendants into their homes. Dually eligible beneficiaries may face additional issues including limited transportation options to doctors’ appointments (which could delay their care and treatment and exacerbate potential health complications), increased food insecurity for beneficiaries who relied on receiving food from community settings, and less telehealth access, particularly for older individuals .
The glaring gap of essential services during the pandemic may increase dually eligible beneficiaries’ rates of illness, hospitalizations, and potential exposure to COVID-19. Given the complex needs of the dually eligible population, a substantial proportion of whom reside in nursing homes, and the loss of integral services from the pandemic, it is perhaps unsurprising that they are at a higher risk of being impacted by COVID-19. Fortunately, current strategies and promising practices have been used to meet the needs and challenges experienced by this population amidst the pandemic and beyond.
Current Strategies to Address Dually Eligible Beneficiary Needs Amid COVID-19
To combat the pandemic and ensure access to high-quality health care and supports for dually eligible individuals, organizations have incorporated more flexibility to address the health and social needs of beneficiaries. For example, Program of All-Inclusive Care for the Elderly (PACE) organizations provide services for over 50,000 older adults  in 31 states and primarily serve dually eligible beneficiaries who would be eligible for nursing home care (90 percent of PACE enrollees are dually eligible) among other populations nationwide. PACE organizations also provide necessary medical and social services including adult day services and other HCBS, nursing home care, meals, prescription drugs, and various counseling services and therapy, and they cover enrollees’ emergency services and hospital care. PACE organizations receive capitated payments from Medicare, which incentivize decreased inpatient hospital and skilled nursing facility costs. Evidence reveals that PACE organizations have lower hospital utilization and shorter hospital stays. In response to COVID-19, some PACE organizations were encouraged to rapidly pivot to providing increased telehealth services, delivering meal services during the day, and supporting medication adherence .
Complementing these health care delivery efforts, through their care coordinators, D-SNPs and MMPs communicated directly with their beneficiaries through outreach to address unmet health and social needs. Specifically, they addressed beneficiaries’ food insecurity challenges through expanding emergency meal programs and coordinating food delivery from local banks. These plans also delivered basic home supplies to beneficiaries, communicated with beneficiaries who were struggling with social isolation and loneliness, and connected beneficiaries with appropriate resources for their financial needs . In addition, coordinated care plans like D-SNPs and MMPs and PACE organizations include flexible benefit packages and are developing ways to vaccinate this population, including monitoring vaccination uptake, implementing reward and incentive programs to increase vaccination, and using Medicaid’s nonemergency medical transportation benefit for qualified dually eligible enrollees to access vaccines .
Facilitating communication between community resources and beneficiaries in addition to using flexibilities within D-SNPs, MMPs, and PACE organizations will support beneficiaries to gain access to necessary social services during the pandemic.
Beyond COVID-19: Improving the Health Outlook for Dually Eligible Beneficiaries
The COVID-19 pandemic has accelerated the adoption and consideration of promising practices to address the health and social needs of dually eligible beneficiaries. These practices focus on three key aspects:
- leveraging existing initiatives and data systems to improve quality of care;
- increasing emphasis on social determinants of health; and
- increasing access to health and social services through telemedicine.
Existing initiatives and federally managed data systems play a critical role in improving quality of care for beneficiaries. The Money Follows the Person (MFP) Rebalancing Demonstration Program is a Medicaid program that provides enhanced federal funding for states to transition Medicaid beneficiaries, including dually eligible beneficiaries, from institutional settings such as nursing facilities to HCBS. While some states already use MFP resources to address social needs for dually eligible beneficiaries as they transition back to the community, encouraging states to transition more dually eligible beneficiaries to community-based settings under this program could mitigate their exposure to COVID-19, especially given the adverse effects from residing in nursing facilities. In addition, dually eligible beneficiaries’ higher risk for significant mental health needs, which has increased during the pandemic, could be addressed by states continuing to implement existing models such as the Financial Alignment Initiative, which integrates primary and acute care, behavioral health, and long-term services and supports for dually eligible beneficiaries and existing state-based care-coordination health plans (e.g., Cal MediConnect) that can help to address mental health challenges for this population. A look at data systems suggests that further linkages between existing federal data surveys and data collection systems (e.g., the Centers for Disease Control and Prevention’s National Center for Health Statistics’ data collection systems) with CMS data may support future efforts to better identify dually eligible beneficiaries with unmet needs, understand their health and social needs, and ultimately improve their quality of care.
Enhanced federal Medicaid funding to states would emphasize addressing social determinants of health. For example, this funding may support coverage of additional health and social services including transportation options, protective personal equipment, meal delivery or other ways to address food insecurity, and access to vaccinations that states do not otherwise cover under state plan amendments or Section 1115 waiver demonstrations.
Additionally, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act identified a pathway of using Special Supplemental Benefits for the Chronically Ill (SSBCI) for Medicare beneficiaries, including dually eligible beneficiaries. SSCBI covers nonmedical needs that are not covered by Medicaid such as nonmedical transportation, food, and indoor air quality equipment services that Medicare Advantage plans can provide. Although few plans provided these benefits in 2020 partly due to operational challenges, an increased number of plans provided more health-related benefits. This year however, plans may consider, as evidence suggests, offering more nonmedical benefits that address social determinants of health .
Lastly, while, telemedicine has become increasingly adopted as a tool for health care service and delivery during the pandemic, dually eligible beneficiaries are less likely to have internet and smart phone access. To improve upon existing PACE organization efforts, telehealth services could address health disparities in the dually eligible beneficiary population by encouraging public-private partnerships between the federal government and the private entities who have experience working with beneficiaries residing in traditionally underserved communities. For example, private entities may consider providing services in underserved areas such as user-friendly and potentially reusable technological devices (e.g., mobile phones or tablets) that enable beneficiaries to navigate telehealth appointments and any necessary follow-ups. In addition, current COVID-19 Medicare and Medicaid telehealth flexibilities focused on telehealth reimbursement can continue to be used after the public health emergency ends. Ultimately, offering these specific supports will improve health equity and prevent potential adverse health outcomes.
The dually eligible beneficiary population is a burgeoning patient population, posing considerable economic and health impacts to the US health care system. Given the sheer heterogeneity of beneficiaries and accompanying multifactorial nature of their medical and social needs, multisectoral solutions are required to meet the needs of this population. This commentary provides promising strategies such as telehealth flexibilities, HCBS expansion for states, and SSBCI benefits to improve care for the dually eligible population. It also serves as a mechanism for stakeholders from the private, philanthropic, and civil society to collaborate and identify novel ways or build on existing initiatives to provide appropriate care and targeted supports for these beneficiaries amidst COVID-19 and beyond.
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Tweet this! #COVID19 has exacerbated existing vulnerabilities for individuals eligible for Medicare and Medicaid, or the “dually eligible”. Authors of a new #NAMPerspectives commentary identify promising strategies for meeting the needs of this population: https://doi.org/10.31478/202107c
Tweet this! “The gap of essential services during the pandemic may increase dually eligible beneficiaries’ rates of illness, hospitalizations, and exposure to #COVID19.” Authors of a #NAMPerspectives call for a multi-sectoral approach to closing this gap: https://doi.org/10.31478/202107c
Tweet this! Authors of a new #NAMPerspectives examine the unique needs and challenges faced by dually eligible beneficiaries and propose that leveraging existing initiatives and increasing access via telemedicine may help better care for this population: https://doi.org/10.31478/202107c
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