Dual Eligibles – What Does The Future of Healthcare Reform Hold?

There’s a lot you can say about the healthcare reform and its future, and unfortunately, opinion is divided. Probably one good thing you can say is that it seeks to eliminate waste and bring about transparency and accountability in the way healthcare services are provided to the citizens of the USA. Right now, even though an enormous amount of money is being spent, those who deserve the most care are not really getting what they need. And what’s more, there is no accountability for this waste.

If you consider the dual eligibles – the approximately 9 million seniors and adults with disabilities who qualify for both Medicaid and Medicare, they currently account for $250 billion every year, a sum that is almost half of the total Medicaid expenditure and one fourth of total Medicare costs. Even with all this money being earmarked for them, most of them are still in fee-for-service care.

More than half of the dual eligibles are above the age of 65, and of those who are younger, half are disabled or affected by chronic illness that requires them to seek continuous and constant care. Around 25 percent of dual eligibles are in very poor health and need skilled nursing care around the clock. Also, those who belong to lower income groups suffer from more health conditions like diabetes, stroke and Alzheimer’s disease. It’s only natural that this group, because of its specialized needs, costs more to serve. In general, the cost of care provided to dual eligibles is twice as much as that given to other Medicare beneficiaries. And with younger members of this group living longer than their older counterparts, you can see why the cost of providing care for them is very high.

The problem with the current system is that when it comes to dual eligibles, there is cost shifting from Medicaid to Medicare and vice versa because both want to optimize their revenues. Also, healthcare providers do not have any incentives to be cost-efficient and effective in the care they provide. They are usually looking out for their financial viability first. This gives rise to waste (unnecessary admissions and readmissions in hospitals and other acts that waste healthcare resources), and the shifting of responsibility and accountability from Medicare to Medicaid and in the reverse direction. There is confusion regarding coverage and payment, especially when it comes to benefits that overlap.

The healthcare reform seeks to identify how states can improve the efficacy of the care provided to dual eligibles. In general, the reforms hope to focus the system of care on the beneficiary and remove ambiguity by merging the services so that administrative hassles over different ID cards, services, providers and administrative providers become a thing of the past. If the healthcare reform is able to achieve coordination between Medicare and Medicaid with respect to the care accorded to dual eligibles and remove the fragmentation that currently exists in the system, the future of dual eligibles seems bright – finally, they will receive the quality care they deserve.