Tradeoffs recently spoke with physician and Republican U.S. senator Bill Cassidy about a new bipartisan bill he and others introduced Thursday, March 14, aimed at helping some of the country’s sickest, poorest patients.
Medicare and Medicaid combine to spend $500 billion a year on these 12 million patients, who are sometimes called “duals” or “the dually eligible.” Yet many of these people remain in poor health, in part because red tape and conflicting rules keep them from getting vital services.
When he was a working doctor, Cassidy said, he noticed that “a dually eligible patient typically has a life span 10 to 15 years shorter than that of someone who is not a dual.”
His bill, the DUALS Act of 2024, aims to fix that by giving dually eligible patients in every state the option to put a single, seamless insurance plan in charge of all of their needs, from doctor visits to long-term care. The bill’s passage and potential impact are far from certain, but Cassidy argues it’s a significant step forward.
Tradeoffs host Dan Gorenstein and senior reporter Leslie Walker talked with the senator about why he’s prioritized this little-known topic and what he hopes the bill will achieve.
This interview has been lightly edited for length and clarity.
Walker: Senator, why are you so personally invested in this issue?
Cassidy: There are a couple of reasons. When I practiced medicine, I worked in a hospital and we would commonly see patients who were duals and you can’t help but notice that a dually eligible patient typically has a life span 10 to 15 years shorter than that of someone who is not a dual.
Now, let’s take off my doctor hat and let’s put on my senator hat. There are a lot of stakeholders. It’s very difficult to get things done. But where we can all agree is that with dual eligibles, there is a lot of money spent and the outcomes are poor.
Ultimately, we’re going to have to make tough decisions that some stakeholders don’t like. But if you can come up with a set of solutions that stakeholders agree to, that can save the taxpayer money, and most importantly — as I put my doctor’s hat back on — make a patient’s life better, I mean, by golly you’ve found a sweet spot.
Walker: If this bipartisan bill passed as written, what would success look like for, let’s say, duals back in your home state of Louisiana? How would their day-to-day lives be different?
Cassidy: The problem with duals, we’ve learned, is that Medicare and Medicaid, instead of saying, “OK, I’m going to pay for this.” They say, “Wait a second, shouldn’t the other pay for it?” And there is a pushback between who’s going to pay for it. And the patient — who is often poor, who is often sick, perhaps mentally ill, elderly, perhaps less educated — is the one trying to navigate this.
So first, we can say that success would be the two programs — Medicare and Medicaid — would not be seeking to push costs upon the other, but rather be integrated. When someone who is eligible for both programs enrolls, that enrollment process would be easy and the services provided would be coordinated. Instead of being pushed like a wave of the sea, being driven and tossed by the wind, they would just — without realizing it — have a coordination of services that would be optimized for the restoration or the maintenance of their health.
Gorenstein: Senator, do you think your bill does that?
Cassidy: I am not [saying], “My gosh, this is the end of history when it comes to dual eligibles and that when we pass this bill, there’s never again a problem.” What I can say is that when we pass this bill, we begin the solution. It’s going to be easier to enroll and the services are going to be more coordinated.
Inevitably, with real-life practice, things arise. But now we have a framework by which we can solve whatever the new issue is. We’ve addressed one, and whatever the next is, we’re better prepared to address it.
Walker: One of the criticisms we’ve heard from some folks is that this bill, in a way, just adds a lane. It doesn’t pick a lane. There are still a lot of options and [insurance] plans out there, and that could dilute this bill’s impact. Why not be more directive to states and insurers here?
Cassidy: First, when we speak of “dual eligibles” there are a lot of versions of duals. A kind of “one-size-fits-all, Washington knows best” solution has never worked.
Secondly, there are big differences between states. Are you going to really have the same solution for Rhode Island and Alaska or Washington, D.C.? There are as many people living in Washington, D.C. as live in Alaska. But if you put Alaska over the lower 48, it literally stretches from Georgia to California. To put it another way, there’s that old saying: If you’ve seen one Medicaid program, you’ve seen one Medicaid program. Each state has adapted Medicaid for their unique circumstances. So I think there has to be some state flexibility.
Gorenstein: One final follow-up question here: All bills require a lot of compromise, so what’s the hardest compromise you’ve made here?
Cassidy: Our primary variable is making things better for the patient. We have found that when people understand that your primary goal is to make things better for a really vulnerable type of patient, they are willing to come on board. Yes, maybe they don’t quite like this or that, but on the whole they accept our effort.
By the way, we’ve done this before. I worked with Sen. Maggie Hassan and other senators on the No Surprises Act. We made our primary variable making sure that the patient was not in the middle of a dispute between an insurance company and a provider. Everyone could agree on that. And once we had that primary agreement — yes, it took us two years and yes, it took us lots of negotiations — that one “we are going to take the patient out of the middle” focus brought us to success.
Gorenstein: Do you expect this bill to pass this year?
Cassidy: Probably not this year. They say the first year of a Congress is for policy and the second is for politics. We are in a silly season of politics right now.
But the case here is so compelling, from whichever angle you wish to take, that I do think as we socialize this in the sense of getting everybody else comfortable with it [so they start to say,] “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,” then I am optimistic that we can get it done. We’ll do that process this Congress, and we will bring it across the finish line next Congress.