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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join host Jeff Byers, editors from Health Affairs Publishing, and guests as they discuss health policy’s most pressing news and trends.
Hello and welcome to Health Affairs This Week. I'm your host, Jeff Byers. We are recording on 09/17/2026, and we're back. We're back from a quick break, and we are talking Medicare, Medicaid integration. And to do that, we have Allison Rizer, chief growth and innovation officer from ATI Advisory on the pod to do just that.
Jeff Byers:Allison, welcome to the program.
Allison Rizer:Thank you for having me, Jeff.
Jeff Byers:So we are approaching new federal requirements for dual eligible special needs plans in 2027. So, again, this might be someone's first introduction to the topic. What are these? When do they begin?
Allison Rizer:Yeah, sure. So dual eligible special needs plans. I'm going to affectionately use the term D SNPs. So we've got two major federal D SNP programmatic changes being implemented in 2027. And the first is what I think of as really the single PDP requirement.
Allison Rizer:So in certain markets where the same organization operates both a Medicaid managed care plan and a D SNP, that organization generally will no longer be able to offer multiple D SNP plan benefit packages or PBPs to full dual eligibles in that same service area. Plans typically offer different PVPs based on market demand for different types of coverage. But CMS hasn't really placed limits on this in recent years. And so a consequence is that we have some markets with dozens, literally over 100 health plan choices available to Medicare and dual eligible people. And this can be really confusing, right?
Allison Rizer:This can cause choice overload. So in response, the intent with this particular 2027 DSNP policy is really to simplify what has become an incredibly complicated choice environment. And then the second federal DSNP policy change for 2027 is what I think of as front door aligned enrollment. So beginning in January, or really technically with open enrollment coming up here in October, DSNPs with an affiliated Medicaid health plan in the same market will only be allowed to newly enroll those full benefit dual eligibles who are also enrolled in or in the process of enrolling in the DSNPS affiliated Medicaid health plan. So the intent with this policy really is to promote alignment writ large, the same organization carrying both the Medicare and Medicaid risk for a dual eligible person.
Allison Rizer:And these sound like fairly technical insurance rules. They are fairly technical. But they're going to have, I would say, pretty consequential impacts on people in The States implementing them.
Jeff Byers:Yeah. So with that first one, it's kinda like going from the Cheesecake Factory menu to, you know, something more curated.
Allison Rizer:That that is a really good analogy.
Jeff Byers:Yes. Thank you. Thank you. Thank you. So for context, how large is the duals population compared to Medicare, Medicaid, and employer based coverage?
Jeff Byers:So how does this compare with health spending too?
Allison Rizer:Yeah. So dual eligibles actually comprise a relatively small portion of our population. There are about thirteen million twelve, thirteen million dual eligible people today compared to about 70,000,000 people in Medicare overall and about 74,000,000 people in Medicaid and CHIP. But dual eligibles account for a disproportionately large share of spending across both of these programs. So they represent like one in five Medicare beneficiaries, but roughly one in three Medicare dollars.
Allison Rizer:And in Medicaid, they represent an even smaller share of enrollment, but roughly a quarter of spending. And there's a reason for that, right? To qualify for both programs, we're generally talking about people who have low incomes, they're older adults, people with disabilities. So really as a population, they have higher rates of chronic conditions and functional and cognitive impairment, behavioral health needs, long term services and supports needs. It's a population with significant health care needs.
Allison Rizer:Before we even get to the question of how is their coverage organized. And then we take those needs, and we divide responsibility for them across two enormous programs, Medicare and Medicaid, that were never really designed to work together. So Medicare is generally responsible for medical care. Medicaid might be paying for long term services and supports or transportation or certain non medical supports. And these silos can really create very real inefficiencies and gaps for people trying to navigate them.
Allison Rizer:So a good example is someone leaving the hospital. They might need post acute care. Medicare might pay for that post acute care. But then the person's ability to transition out of post acute care may depend heavily on what Medicaid supports they have in the home. And if these supports aren't coordinated across the programs at the right time, that person may find themselves in a much more intensive setting for a longer period of time than is needed.
Allison Rizer:Or they may eventually find themselves in a long term stay or permanent placement with really significant costs and the inability to transition home. And I would say that's really one of the fundamental challenges that integration is trying to solve. It's not simply that this is a high cost population. It's that dual eligible people have needs that inherently cross the boundaries between Medicare and Medicaid. But our financing and delivery systems still largely operate on either side of that boundary.
Jeff Byers:Thanks for that. That was a great scene setting. And my next question, when we think about this population, we have these two different, you know, needs, the Medicare and the Medicaid needs, and we're trying to provide care for these individuals. Is there ever, like a way where like, maybe someone will churn out of Medicaid, but still need Medicare? Is there any churn in these of like, would they become like a one?
Allison Rizer:There is. You know, it's an interesting question. It adds more complexity, you see a lot of different scenarios. You see a lot of scenarios. So we've actually spoken with individuals who are technically eligible for both Medicare and Medicaid, but they choose to forgo the Medicare coverage, because it's more seamless and easy to access the things they need by only Medicaid coverage.
Allison Rizer:That's a huge deal. They're choosing to forgo a very large set of benefits and insurance coverage for the simplicity and ease of getting access to wheelchairs, in particular DMEs where we see this happen. But in terms of turning in and out, absolutely in the Medicaid space, it's based on a person's income and assets. And that can kind of go up, it can kind of go down depending on what's happening in that person's life. And so a person can and will churn in and out of Medicaid eligibility.
Allison Rizer:Very rare for a person to churn out of Medicare eligibility. Typically, once you're eligible, you're always eligible. But the other space this isn't exactly what you asked, but the other space where we see churn is we've got typically what we refer to as partial benefit dual eligibles and full benefit dual eligibles. You'll see churn between those categories. The partial benefit dual eligible is generally only getting support for cost shares or premiums or what have you.
Allison Rizer:They don't get access to the full suite of Medicaid benefits. The full benefit gets all that cost share and premium support. They also get access to full Medicaid benefits. And we do see churn between those two eligibility categories.
Jeff Byers:Okay, thanks. So you wrote a piece in Health Affairs Forefront in July. The piece is titled, We've Spent Decades Testing Medicare, Medicaid Integration. Why Don't We Know If It Works? And in this article, you bring up this idea that the dual population isn't a single monolith.
Jeff Byers:I think you've really just set that, you know, with my question, you you brought that to light even more. So, like, when you look to improve outcomes for this population, can you briefly outline your argument on why we haven't aligned on goals of value of integration?
Allison Rizer:Yeah, different stakeholders in healthcare generally think about value differently. So to some, that might mean lower cost. To others, value might mean increased access or better health outcomes or a better patient or provider experience or maybe reduced administrative burden. And that same tension exists when we talk about value specifically in the context of Medicare, Medicaid integration. And part of the challenge is that we haven't really aligned on what are we asking integration to accomplish.
Allison Rizer:Integration itself is not the outcome. It's the mechanism. So what is the goal? Is it to reduce total health care spending across both programs, or to improve health outcomes, or to make the system easier to navigate? Ideally, we want progress across all of those dimensions.
Allison Rizer:But we also have to acknowledge that they may or may not move in the same direction, particularly in the short term. And I think cost is a really great example here, because spending is relatively easy to measure. It's a tangible number. So it's a measure that people often think of when they think of value. But imagine for a moment someone who has had difficulty accessing care because they have been navigating these two incredibly complicated programs.
Allison Rizer:And if integration works and suddenly that person can access primary care or behavioral health care or medications or other services more consistently, their utilization and spending may increase. Is that a failure of integration? I don't think we can answer that question without really knowing what we're trying to accomplish in the first place. And what happens to that person's health? What happens to their quality of life?
Allison Rizer:Integration can create value without creating savings. And conversely, savings can occur without creating integration. And as we just kind of touched on, there's this enormous diversity within the dual eligible population. We're talking about people with very different health care and functional needs. And the value of integration for someone who is relatively healthy but might be low income may be very different from the value for someone with significant behavioral health needs or someone trying to remain in their home rather than enter a nursing facility.
Allison Rizer:And that's why we need to get a lot more explicit about what we mean by value. Value for whom, measured by what, over what period of time. And if we don't answer those questions first, we can look at the exact same integration model and come to very different conclusions about whether it was successful.
Jeff Byers:Yeah, I guess like a natural follow-up question I might have is like, in your best case world scenario, what is the value of integration to you?
Allison Rizer:I truly, I think it goes across all of those elements where wouldn't it be nice if we could cut costs from the system? But more importantly, to me, it's a single experience for a person, a single experience for the providers serving them, not having the headache of navigating eight ID cards or eight different coverage policies. To me, it's aligned incentives. At the end of the day, like if we can align the dollar, everything else would fall into place. So to me, it's like aligning the incentives in the system so that we're treating the whole person.
Allison Rizer:We're not just treating the parts of them that maybe need Medicare and the parts of them that maybe need Medicaid. Medicaid.
Jeff Byers:So you bring up the new federal requirements to start your argument. So I'm curious, in your opinion, these new federal requirements, are they a step in the right direction or not? Why?
Allison Rizer:Yeah, I think the spirit of these requirements makes a lot of sense. Again, CMS is trying to simplify choice in a very overly complex choice environment and trying to create greater alignment between Medicare and Medicaid. And for people eligible for both programs, there's this pretty intuitive argument that having the same organization accountable for both sides creates more opportunity to coordinate care and benefits and incentives. But I actually worry a little bit in the context of our broader health care system. We could experience some unintended consequences with these new requirements.
Allison Rizer:For example, they don't apply to all DSNPs, and they certainly don't apply to the much larger universe of standard Medicare Advantage plans. And I'm not suggesting they should apply across the board, but this creates an interesting tension where in an effort to simplify choice and promote integration, we may ultimately reduce the number of D SNP choices available to some dual eligible people, while leaving them with a very large number of Medicare Advantage choices that may offer little or no integration with Medicaid. In effect, we may be simplifying one dimension of choice while introducing complexity somewhere else. And this matters a lot because people don't necessarily choose coverage based on whether we as health care professionals consider it integrated. I've said this so many times, integration isn't sexy.
Allison Rizer:People choose a health plan because their doctor participates with that health plan or because a particular drug is covered or because the supplemental benefits meet their immediate needs or they recognize the name of the health plan and they trust that name. And under these new rules, someone may identify a D SNP that looks like the best Medicare option for them. But they might be unable to enroll because their Medicaid coverage is with a different organization. And that might be the appropriate trade off if alignment ultimately produces a meaningfully better experience. But we can't assume that alignment on an insurance card automatically translates into integration from the person's perspective or into that meaningfully better experience.
Allison Rizer:I think part of the real test here is, does this make health care easier to navigate? Are the benefits more coordinated? Is there less fragmentation? Are providers dealing with a more coherent system? Are we improving outcomes?
Allison Rizer:It really gets back to how are we defining value. So I see these requirements as directionally consistent with where integration policy has been heading. But I think the transition is going to teach us a lot. We need to pay close attention not only to whether more dual eligible people are becoming aligned with the same carriers, but also really what is happening to choice, what's happening to the continuity of their relationships with their providers, what does their enrollment experience look like? And and are they able to understand why certain options may or may not be available to them?
Jeff Byers:So again, the forefront article is titled, we've spent decades testing Medicare, Medicaid integration, why don't we know if it works? In it, you bring up that the history of such integration is, in fact, a history of increasingly sophisticated policy experiments. You know, many policymakers and researchers continue to pursue integration as a policy goal despite, you know, mixed evidence. You know, for example, value based care. You know, really like to talk about it.
Jeff Byers:People, you know, in their marketing and messaging. Is it actually having positive results? You know, evidence is mixed. So what say you tube Medicare Medicaid?
Allison Rizer:Yeah, this is such a good question. There is a lot of mixed evidence. And our health care system is a patchwork of solutions. Some incremental solutions, some substantial solutions, but at the end of the day, it is a patchwork. Medicare, Medicaid integration is an attempt to connect two very different programs with different financing structures and benefits and rules and delivery systems on top of everything else that is already happening in healthcare.
Allison Rizer:And that makes integration incredibly difficult to evaluate because there's not one intervention called integration. It looks different across states and programs and health plans and even for the subpopulations that we're talking about. And while we're trying to measure its impact, the world around it keeps changing. Medicare Advantage policy is changing. Medicaid policy is changing.
Allison Rizer:Provider markets, workforce capacity, technology, AI. The needs of the population itself are changing. Health care is always changing, and I would argue it's changing faster right now than it ever has. So I think we have to be careful about looking at mixed findings and jumping to the conclusion that an idea either works or doesn't work. I think the better question, and I talk about this a little bit in the blog is what are we learning from the variation?
Allison Rizer:What did we change? How well was it implemented? What are we trying to accomplish? And importantly, for whom? And what else is happening that could have influenced the outcome?
Allison Rizer:So it doesn't mean we lower the bar for evidence, or we keep pursuing an idea indefinitely because we like the theory behind it. We should absolutely be willing to stop doing things where evidence consistently shows it's ineffective. But mixed evidence is different. Mixed evidence should make us curious. Why did something work in one state, or for one population, or under one set of circumstances, but not another?
Allison Rizer:Is the idea flawed? Or is there something about the design of implementation that needs to change? So I don't think the goal should always be to get that binary verdict. Does it work? Does it not work?
Allison Rizer:It should be a health care system capable of learning and adapting as the environment and people's needs change.
Jeff Byers:Well, Rizer, thanks again for joining us today on Health Affairs This Week. That's it for Timewise for us. If you, the listener, enjoyed this episode, please send it to a friend and we will see you next week. Thanks all.