Can Washington Make Medicare and Medicaid Work Better Together?

Dan Gorenstein: America has got a $500 billion health care problem that few people have ever heard of. Nearly half of the 12 million people who are covered by both Medicare and Medicaid report they are not in good health. It’s an inefficient, ineffective system and it’s caught the attention of lawmakers like Republican Senator Bill Cassidy from Louisiana.

Sen. Cassidy: If you can come up with a set of solutions that can save the taxpayer money and make a patient’s life better, I mean, by golly you’ve found a sweet spot.

DG: Today, inside the search for that sweet spot, what that could mean for patients, and why it’s left many advocates, experts and industry insiders skeptical. From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: A bipartisan group of Senators are expected to introduce a bill today, March 14th, aiming to help people trapped in a special kind of health insurance hell — people often forced to carry two insurance cards, use two sets of benefits, decipher two sets of rules. They are known as the duals or dually eligible and despite the U.S. spending half a trillion dollars a year, we have little to show for it.

Before we dive into the details of the measure, we’re bringing in Senior Producer Leslie Walker to put the legislation into some context.

Leslie, you’ve been reporting on this for a few months now. Let’s start with who are the duals? 

Leslie Walker: Sure, so like you said at the top of the show, Dan, these are folks who are eligible for both Medicare and Medicaid. There’s about 12 million of them.

And, they’re almost all living on less than $20,000 a year, but in a lot of other ways, they’re pretty different from each other. More than a third are under 65 and have a disability. About half are people of color. A quarter speak a language other than English at home. And these folks also have a wide range of health and social needs — mental illness, chronic diseases, poverty, hunger.

DG: And you’re telling us, Leslie, that to get all of those various needs met, these folks have to navigate two exceedingly complex insurance programs. 

LW: That is correct. They generally go to Medicare for the urgent medical stuff — doctor’s visits, surgeries — and Medicaid for longer term needs, let’s help at home or a long stay in a nursing facility. And one big reason Congress is concerned is that all that care is costing nearly $40,000 per person on average.

DG: And that’s all coming out of taxpayer-funded programs.

LW: Exactly and the thing is despite spending all that money, a third of duals end up in the ER at least once a year often for avoidable reasons.

DG: And do we know, Leslie, why we’re spending so much money? Obviously these people face a bunch of serious health conditions. Is there more to it than that?

LW: The health conditions are a huge part of it for sure, Dan. But you’ve also got a maze of crazy, conflicting rules and incentives between Medicare and Medicaid, and that creates this game of hot potato.

DG: You mean each insurer’s trying to pass the patient off? 

LW: Yeah, we’ve forced these two insurance programs to cover one patient, and when you do that, you see each side trying to push costs onto the other. And that’s a recipe for a bunch of bad, wasteful care that burns money and often harms patients, like a woman that I interviewed last year.  

Saleema Render-Hornsby: I’m Saleema, I’m 33. I live in the Bronx

LW: We actually profiled Saleema Render-Hornsby on the show last September so you might remember her.

DG: I do. I remember her well.

LW: She has spina bifida — a condition that limits her use of her legs — so she needs a wheelchair to get to the store, to the doctor, to hang with friends. For years, she’d counted on this clunky chair — she called it “the Cadillac” — until one summer day she was heading to this appointment…

Render-Hornsby: The chair stopped in the middle of the road. 

LW: Saleema was completely stranded. Terrified.

Render-Hornsby: I could not move and there was nobody to help me.

LW: So she starts the process of requesting a new chair. This is early 2022. A few months later, a letter arrives from Medicare: request denied.

Render-Hornsby: I can’t understand why you would deny me my way I get around. You’re denying me my legs?

DG: But she needs the wheelchair, Leslie. 

LW: She does but under Medicare’s rules, they only cover chairs for inside the home. Medicaid covers chairs outside the home.

DG: Well then why didn’t she just go to Medicaid first?

LW: Here’s where that game of hot potato comes in, Dan.

Medicaid says they’ll only cover the chair if Saleema tries Medicare first — even though there’s like zero chance in hell Medicare’s going to cover it.

DG: Okay so this is totally maddening for the patient. 

LW: It is and that was just the beginning of this maze for Saleema. Her Medicaid plan kept jerking her around, and all this waiting it took a toll on Saleema and her family. 

Her mom forked over a thousand bucks to buy a temporary backup chair, but it didn’t fit great. The padding was flimsy. So Saleema got pressure sores, back aches, nerve pain and she ended up leaving the house less — all because she was stuck jumping through these health insurance hoops.

In all, Dan, it took 20 months — a full year and a half — for Saleema to get her new chair.

DG: Okay, so Saleema’s story is infuriating, nonsensical, certainly inefficient, but I know it’s not new, Leslie. These programs have been around for decades, but with the introduction of this bipartisan bill it now seems like some Senators have a new appetite for tackling this problem.

What’s changed?

LW: I’d say two big developments are driving it.

First, just like you, Dan, America’s aging fast. More than 80 million people are gonna be on Medicare by 2030 — a fifth will probably also be eligible for Medicaid.

DG: So in other words, this $500 billion problem is about to balloon.

LW: Big time. The second major change, Dan, is that lawmakers now actually have some data about how to tackle this problem.

Casey Schwarz with the advocacy group the Medicare Rights Center told me people had long assumed that putting a single insurance plan in charge here would be the solution, and now that’s been tried at scale.

Casey Schwarz: The past ten years has been a time of a million different projects called “duals” and a lot of different ideas. 

LW: We’ve seen this explosion of new kinds of insurance plans promising duals — at least on paper — more seamless, more coordinated care. Almost 6 million people are now covered by one of them.

Some [were] pioneered by state Medicaid agencies, spurred on by the Affordable Care Act, [and] others, known as Dual Eligible Special Needs Plans or DSNPs, are run by private insurers.

DG: Pouncing on a business opportunity here, huh?

LW: Definitely. In all, more than 20 states have gotten in on this experimentation, and every major insurer has, too — United, Humana, Aetna.

But this period of rapid growth has now reached a kind of inflection point. Many of those state-run experiments were temporary and are sunsetting in 2025. And the private market for duals — cue the food fight music. It’s become a kind of free-for-all with nearly 900 different insurance plans, aggressive marketing and questionable quality all raising alarm among watchdogs.

And all of that, Dan, leads us to one simple question.

Eric Roberts: The question is where do we go now?

LW: University of Pennsylvania economist Eric Roberts told me choosing a path forward is going to be tough. This new bipartisan bill takes its best crack at answering “what’s next,” but a lot of people are less than impressed.

Reax montage: It’s not particularly provocative or novel. // We feel like it’s got a long way to go. // There’s just nothing new there.

LW: The forecast on this legislation, Dan? Strong headwinds.

DG: Okay, we batten down the hatches and lean into those headwinds after the break.

MIDROLL

DG: Welcome back. So Leslie, before the break, you were telling us about this bipartisan bill that’s expected out   later today in the U.S. Senate. It’s been met with mixed — even some harsh reviews — from experts, industry groups and consumer advocates. Before we get into why, let’s first talk just about the bill itself. What’s the big thing it does?

LW: So it puts in place this mandate — a requirement — that all 50 states offer duals at least one super seamless insurance plan from a menu approved by federal officials.

DG: One plan, one insurance card, one place to go for all your needs and questions. That sounds like the dream if you’re a dual.

LW: It does. For some folks, this would be their first time ever getting this kind of help. And even for folks already enrolled in those private plans just for duals — the special needs plans…

DG: The D-SNPs?

LW: Yes, this bill would offer those people an option that’s like those plans on steroids with insurers doing a whole lot more work.

DG: Wow, so this bill sounds like a meaningful upgrade. 

LW: It may be, but a lot of people worry it won’t be. 

DG: Thus the harsh reviews, I guess.

LW: Exactly. Experts like Penn researcher Eric Roberts told me that figuring out how to make these two crazy complicated federal programs work like one, well oiled machine for a super diverse population is really damn hard. 

Roberts: It’s like building a high speed rail. It doesn’t happen overnight with one piece of legislation. It happens through years of practice and implementation.

LW: And this bill puts a lot of that hard work on the shoulders of states. The states that did try building these super seamless plans over the past decade really struggled. Eric told me most failed to save money or keep people out of the hospital.

DG: Now I’m seeing why the bill authors are giving states a menu of options rather than pushing one specific plan — something that could leave people like Saleema high and dry.

LW: Right, leave that menu open. Then, Dan, there’s this other mammoth problem — and the bill barely touches it.

Allison Rizer: We’re adding one more thing to an already confusing landscape of choice for dual-eligible people. 

LW: That’s Allison Rizer with the consulting group ATI Advisory. She says the insurance market for duals is a complete mess. Allison told me some people have literally 100 different plans to pick from. That includes both plans tailored just for them, but also regular Medicare plans that offer no coordination at all.

DG: And these are often very sick people, with low-incomes, many who don’t speak English trying to sort through all that. 

LW: Right, and at the same time private insurers and brokers are peppering these people with deceptive marketing. One survey of older duals found that nearly a third had seen something in a Medicare ad that they later found out wasn’t true.

DG: So does this bill do anything to help people shop for more seamless plans?

LW: Well, it proposes automatically enrolling people, but when states tried that over the last decade a lot of folks end up opting out.

DG: And just out of curiosity, why is that? 

LW: Some people were confused by how the plans work [and] worry whether their doctors would still be in network. Advocates also told me people tend to be skeptical of anything that limits their choices — even with good intentions. 

Overall, Allison Rizer’s message to Congress is: Either narrow the options for consumers and insurers here or at least make the right choice a whole lot more attractive.

Rizer: If we’re going to build an integrated program, it has to be the easy choice for dual eligible people, for health plans, for states, for providers. We cannot create a two-tier system where it continues to be easier to enroll in or offer non-integrated options.

DG: Okay, let’s take a breath. This is what you’ve told me about the bill so far. 

It requires states to offer duals at least one truly seamless plan, but doesn’t spell out which plan. Part of that is because, based on data, no one plan definitively improves care and saves money.

LW: Right. 

DG: Then you’ve got this wild west of a market, tons of confusing choices with some insurers advertising one thing but delivering something else. And the one move to clean that up is a provision that didn’t work well at the state level?

LW: That about sums it up, Dan. It’s tough sledding here. And really, Allison Rizer says, it’s up to Congress to reckon with this bill’s limitations. 

Rizer: Do you want to go big? Or do you settle for something that’s going to kick the can another 10 to 15 years down the road?

DG: And she sees the bill as written as more like a kick of the can.

LW: Yeah, if nothing changes. And that would mean some pretty sick people — and their families — will keep paying a high price. 

I talked to Hong Truong, a friend of mine last fall. Her mom is a dual and is in bad shape.

Hong Truong: In the last year, she’s been to the ER maybe about 10 times now.

LW: I know we talked at the top about Saleema and Medicare and Medicaid playing hot potato with her wheelchair, but most duals, Dan, need a lot more care than Saleema. Two-thirds have at least three chronic conditions, and half struggle with basic stuff like showering. 

So last August, here was the scene. Hong’s mom, Huu Lam, is in kidney failure. Can’t move her head; can’t eat solid food; and the family is feeling ghosted by health insurers at nearly every turn.

Truong: I don’t know. It’s a lot. A lot of emotion, frustration. And this is, like, what’s broken with health care.

LW: It started a few years back with simple stuff, like her Medicaid plan sending this terrible taxi service to pick her up for dialysis.

Truong: They never showed up on time. They wouldn’t come to the door. And then, the taxi company would also just not pick her up and say, “Oh, we only cover one ride a day.” I’m like, how could that make sense?

LW: Hong says the insurer did nothing to improve the service so she had to step in — use her own time and money to orchestrate Lyft drivers to ferry her mom around San Jose.

Then Huu’s health got worse. She needed more aides at home. 

But a state policy lets the insurer off the hook on that, and forces the dual to figure it out. So Hong and her brother ended up having to take shifts while they scrambled to find aides who could speak Chinese or Vietnamese.

Truong: I can’t interview them and I don’t know how to contact them on my own.

LW: Hong speaks neither language, so she had to rely on her relatives as recruiters. And it was the same disappearing act when Hong tried to get her mom into a nursing home. She says ultimately, the family felt abandoned by the people who were supposed to be helping. 

Truong: It’s just so frustrating when you’re just like, this all fucking sucks. Like, someone just needs to manage all of this and it’s just so frustrating.

DG: That’s a bleak picture, Leslie, of what kicking the can — maintaining the status quo — can look like for people. It’s making me think about that quote from Allison Rizer: “Do you want to go big?” What tweaks, Leslie, might it take for this bill to really help a family like Hong’s?

LW: There are a few big ones, Dan.

One: The bill would have to make it much harder for people to end up in the kind of bad uncoordinated plan that Huu Lam was enrolled in.

DG: So weed out some of the other options. Got it.

LW: Two: These new seamless plans would need serious oversight from states and the feds. Otherwise, insurers might cut corners — maybe hook a family up with a shoddy taxi service and call that “care coordination.”

And three: Congress and states need to make more high-quality services available. What good is a super seamless plan if your local nursing home has a four-year wait?

DG: Okay. So the bill is scheduled to get introduced today. Any chance we see some of those tweaks as it works its way through Congress?

LW:Hard to know, but for context: Most of my sources don’t expect the bill to pass this year and that includes Senator Cassidy himself. He told me as a doc who has treated duals and wrestled with this issue for years, he thinks this bill will help other members of Congress start to get it.

Sen. Cassidy: I’m now familiar with the issue of duals. I know what a dual is, and I know they have terrible outcomes and they cost us lots of money. Oh my gosh, we should do something about it.

LW: The Senator said he’s optimistic lawmakers can bring this over the finish line by next Congress. The one definitive thing I can say, Dan, is a lot more people in Washington now know about this $500 billion problem.

On top of this bill, Democratic Senator Bob Casey also introduced his own last week. The Biden administration is taking some baby steps to clean up that crazy market. And some states are pushing ahead on their own, including California, where Huu Lam now has a more seamless plan.

DG: And this all may lead to progress but as you’ve laid out, Leslie, it’s probably going to take a long time to make care better for people like Huu Lam and Saleema Render-Hornsby. 

LW: I think that’s right.

DG: Leslie Walker, thank you.

LW: Thanks, Dan.

DG: Senate aides tell us they expect a hearing on the issues facing dually eligible Americans later this year. No date has been set.

I’m Dan Gorenstein. This is Tradeoffs.