Subscribe
Share
Share
Embed
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. The Medicare population is incredibly diverse, including, of course people aged 65 and older, as well as younger individuals with disabilities. It spans all races, ethnicities, and geographic areas from residents of big cities to those in rural towns. It also reaches people at all income levels, the wealthy, the poor, and everyone in between.
Rob Lott:And so for a subset of the Medicare population, those with low incomes and limited savings, the premiums and cost sharing can impose a significant burden. And it's with that burden in mind that Congress created four Medicare savings programs specifically designed to help low income beneficiaries afford the out of pocket costs associated with securing coverage and receiving care through Medicare. But what do we actually know about the people who take advantage of the Medicare Savings Program? And what can we learn from how that population may have changed over the years? That's the subject of today's Health Policy.
Rob Lott:I'm here with Jay Wyatt Coma, a PhD candidate in the Health Policy Program at Harvard University. Together with co authors, he has a paper in the July issue of Health Affairs titled, Qualified Medicare Enrollment Trends and Characteristics of Low Income Beneficiaries. I can't wait to hear more about their findings and to learn more about its lessons for policymakers going forward. Wyatt Coma, welcome to the PODCY.
J. Wyatt Koma:Thank you so much for having me.
Rob Lott:All right, well, let's just jump right in, with some background. When was the Medicare Savings Program created and why was it necessary in the first place? I described a little bit of the sort of the context of low income beneficiaries. Is that a adequate description of the program and what else was going on there?
J. Wyatt Koma:Yeah, it's a great question. Congress created four Medicare Savings Program between 1988 and 1997 to help low income Medicare beneficiaries pay for their Medicare Parts A and B premiums and cost sharing. I think first it's helpful to make sure that we have the kind of a background on Medicare Parts A and B. So Medicare Part B is a voluntary benefit that covers people's doctor's visits and other outpatient care. And beneficiaries who receive their coverage through traditional Medicare are expected to pay a premium for their Part B coverage.
J. Wyatt Koma:Whereas for Medicare Part A, it's generally coverage for care received in hospitals and it's usually premium free for most Medicare beneficiaries after they work long enough. And really, you brought this up, but the cost sharing in Medicare can be substantial including deductibles and coinsurance in parts A and B. And it's important to note that there is no max on how much people with Medicare can spend out of pocket in traditional Medicare. Really given the sizable cost sharing, that's why the Medicare Savings Programs were introduced. And they're administered by state Medicaid programs.
J. Wyatt Koma:And their goal is really to help beneficiaries pay these premiums and cost sharing. And since these programs are administered by states, there is some variation in the eligibility criteria. Although all of the Medicare Savings Programs do have to adhere to the federal minimum standards. And so for 2025, the asset limit for a year to qualify for the Medicare Savings Program, which includes people's savings and investments like stocks and bonds was around $9,500 for an individual and around $14,000 for a couple.
Rob Lott:Got it, okay. And so I think you said the first program was created in 1989. And so it's been around, let's see, doing some quick math here, thirty five, thirty six years. What do we know about how well the program is working? How well does it achieve its goals and in what ways maybe does it fall short?
J. Wyatt Koma:Yeah, I mean, so it's important to note that about 10,000,000 low income people with Medicare were enrolled in one of the Medicare Savings Program eligibility groups in 2021. And we know that these low income people who qualify for Medicare Savings Programs are more often eligible for Medicare because of the disability rather than age. They're also more likely to be from racially or ethnically minoritized communities and they also tend to have worse health outcomes than their higher income counterparts. And we also know that beneficiaries who are dually eligible for Medicare and Medicaid, including those in Medicare Savings Programs, are also automatically enrolled in the Medicare Part D Low Income Subsidy Program. And so Medicare Part D covers prescription drugs and the Low Income Subsidy Program helps beneficiaries afford their Medicare Part D premiums and the cost sharing for those drugs.
J. Wyatt Koma:So really the combination of the Medicare Savings Program and LIS benefits can really be critically important for reducing cost related barriers to both medical care and prescription drugs for these high need populations. That said, evidence suggests that this assistance, particularly the QMB program or the qualified Medicare beneficiary program does improve access to care and it does reduce financial burdens. And we know that about 80% of the Medicare Savings Program enrollees are enrolled in the Quimby Group and about the remaining 20 other percent of low income beneficiaries in Medicare Savings Program are enrolled in a different eligibility group that really only covers premiums for parts A and B. And all that said, there is robust literature now documenting low take up since the creation of the Medicare Savings Program. And take up is the percentage of the eligible population that's actually ends up enrolled in the program.
Rob Lott:I imagine there might also be some complexity around the fact that there's more than one program. Like you said, qualified Medicare beneficiary program, QMB represents I think about 80% of the beneficiaries in the Medicare savings program. Can you describe the different models and sort of explain why do we even need more than one? What's going on there?
J. Wyatt Koma:Yeah, that's a great question. So as we were talking about, the first and largest Medicare Savings Program eligibility group is the qualified Medicare beneficiary program. And so it's got an income limit of around 100% of the federal poverty level, which is about $1,300 per month for a person in 2025. And so the QMB program pays beneficiary premiums and their cost sharing, which we talked about before, which includes deductibles and coinsurance and co payments. And then the other three Medicare Savings Program eligibility groups really only help beneficiaries pay either their part A or their part B premiums, but don't help beneficiaries with their cost sharing.
Rob Lott:Do you have a sense that, so my understanding is that these were sort of created over time. And I mean, do you have a sense that maybe if someone kind of wiped the slate clean and wanted to create a program, a Medicare savings program from scratch today, it might not be quite as fragmented as the current status quo?
J. Wyatt Koma:Yeah, I'm sure that if people could go back, they would wipe the slate clean a little bit and make a more streamlined process for enrollment and as more streamlined program itself. They were introduced over about a decade and really they were each eligibility group was introduced as like a patchwork solution for a problem at the time that the legislation was introduced. You know, it's confusing just talking about it. There's a lot of words and a lot of word salad, and I think it kind of makes sense why people with Medicare are confused by the program and what is required to enroll.
Rob Lott:Okay. Well, against this backdrop, why don't you tell us about your paper? I know you looked at the Quimby model. What variables did you measure and what did you find?
J. Wyatt Koma:Yeah, so we assessed take up of the Quimby Medicare Savings Program using the most recent data of the Medicare Current Beneficiary survey from 2016 to 2022. And since the QMB eligibility group is the largest and most expansive in coverage, it's particularly of interest to policymakers. And so that's why we focused on that eligibility group in particular. And so in our analysis, we first identified Medicare beneficiaries who were likely eligible for the Quimby program based on their reported income and assets. And then among that group, we assessed Quimby enrollment using administrative enrollment data from CMS that's linked to the survey data.
J. Wyatt Koma:So we then compared who is enrolling and the cost related barriers to care among eligible beneficiaries who were enrolled versus those who were not enrolled in the program.
Rob Lott:Got it. Okay. And what'd you find?
J. Wyatt Koma:Yeah. So our first set of findings was really about the take up rate of the Quimby program. And we found that roughly two thirds of people who were eligible for the Quimby group were enrolled in 2022. We found that an additional 17% of low income people who were eligible for the Quimby program were enrolled in some other program, either a different Medicare Savings Program eligibility group, they were enrolled in full benefit Medicaid, or they were enrolled in the Medicare Part D Low Income Subsidy program by itself. And then the remaining 17%, so one in six eligible, QMB eligible beneficiaries were not enrolled in any of these programs in 2022.
J. Wyatt Koma:And so these people with low incomes were fully exposed to Medicare cost sharing and premiums.
Rob Lott:I wanna ask you a little more to look under the hood there in those findings. But before we do, let's take a quick break. And we're back. I'm here with Wyatt Coma talking about the Qualified Medicare Beneficiary Program. So Wyatt, I think one of the key findings in the paper is that there was actually a slight increase in the proportion of enrollees in this program.
Rob Lott:And I'm wondering if you can say a little more about how significant that was and what you might attribute that increase to.
J. Wyatt Koma:You're right. We do see a slight uptick in take up of the Quimby eligibility group over the study timeline from roughly sixty two percent in 2016 to sixty six percent in 2022. And so we don't specifically evaluate what contributed to these changes over time, but there were a couple of possible explanations. So for one, most states expanded Medicaid to low income childless adults under the ACA expansion pathway since 2014, and that included nine states during our study period. And our analysis finds that people who live in ACA expansion states are more likely to enroll in QMP than those who live in non expansion states.
Rob Lott:Is that sort of a kind of I think they call it the doormat effect kind of when when people are kind of seeing and hearing promotions about all kinds of different programs, they kind of start to do their own research and figure out what they're eligible for. Is that kind of your suspicion? What's going on there?
J. Wyatt Koma:Yeah, it could definitely be a piece of the welcome mat effect. It's worth noting though that while these low income Medicare beneficiaries aren't eligible for Medicaid through this ACA pathway, having Medicaid enrollment before they enter Medicare might end up increasing QMB take up if these enrollees have, like you said, a greater awareness of the available assistance or if they receive outreach or support to transition to a Medicare savings program once they enter Medicare.
Rob Lott:Got it. Okay. Any other theories or factors that you identified as sort of contributing to that increase?
J. Wyatt Koma:Yeah. So I would say the final reason that we were thinking through was we do see the highest QMV take up rates in our study period from 2020 to 2022, which was also when states halted Medicaid redeterminations during the COVID-nineteen public health emergency. And so more work is needed to really assess if these take up rates persist after the 2023 to 2025 Medicaid unwinding.
Rob Lott:Okay, great. A good future research question you and your colleagues to come back to. At this point, I'm wondering if you can tell us a little bit about the 2023 rule that came from CMS aimed at streamlining enrollment in these programs. What does the rule try to achieve and what's the timeline at this point for implementation?
J. Wyatt Koma:The 2023 CMS final rule was an attempt by the Biden administration to reduce these barriers to enrollment that we're seeing in the Medicare Savings Program for people with low incomes. And so really broadly, it does two things. One, the rule includes requirements for states that already automatically enroll supplemental security income or SSI recipients into Medicaid to then also automatically enroll these SSI recipients into the QMB program by October. And then two, the rule tries to streamline eligibility and enrollment information between the QMB program and the Medicare Part D Low Income Subsidy program, which lowers drug costs for enrollees. And so more specifically, the rule tries to encourage states to align eligibility criteria between the Medicare Part D LIS and the QMB QMB program.
J. Wyatt Koma:And then it requires states to use the income and assets data from the Part D LIS applications in new Medicare Savings Program applications by April. And so overall, back to our patchwork discussions of low income support for Medicare beneficiaries, this rule basically tries to streamline enrollment into the Quimby program and other Medicare Savings Eligibility Groups with other low income assistance programs that have a super large overlap in the eligible population. And it kind of requires states to auto enroll or use existing eligibility data where possible, which really could make it easier for people to enroll and then also could reduce costs for state Medicaid programs.
Rob Lott:Got it. Okay, seems like a pretty straightforward and reasonable attempt at reducing some of that bureaucratic burden and inefficiency to get people who are eligible into the system. How might your paper shed some light on the implementation process for this rule. In other words, is there relevance from your findings to the people at CMS who are charged with putting this rule into effect?
J. Wyatt Koma:Yep, we definitely hope so. We wrote this paper to try and inform policymakers who were trying to improve enrollment in the QMB program. So our findings do a few things. One, we provide the most recent estimates of QMB take up and find that while take up rates have increased, one in three eligible people have not enrolled. And then two, we provide some demographic characteristics of who is and is not enrolling in the Quimby program, which hopefully could inform some targeted outreach strategies.
J. Wyatt Koma:And three, our findings support prior evidence that shows that the Quimby eligibility groups really do help to reduce financial barriers to care. And additionally, these data help to provide estimates of the potential impact of the 2023 CMS final rule. So for example, in 2022, six percent of QMB eligible beneficiaries were enrolled in full benefit Medicaid and not enrolled in any MSP. Under the new rule, beneficiaries, the six percent of these beneficiaries who receive SSI would be automatically enrolled in the Quimby program in the 35 states that automatically enroll SSI recipients into Medicaid. And we also found that 3% of QMB eligible beneficiaries in 2022 were enrolled in Medicare Part D low income subsidy only.
J. Wyatt Koma:And so the CMS rule encourages, but doesn't require states to fully align income and asset counting rules between these two programs. And so greater state adoption of the LIS eligibility rules with the MSP eligibility rules could facilitate enrolling a greater share of these enrollees using data from the LIS applications. All that said though, the current administration's focus on cutting Medicaid costs could have a lot of implications for the future of the CMS rule. CDO estimates that repealing these streamlined enrollment provisions would result in reductions in enrollment in the Medicare Savings Program by potentially millions of beneficiaries by 02/1934. And so really these Medicaid eligibility and enrollment policies need to carefully weigh the potential impact on low income people with Medicare with any potential cost savings.
Rob Lott:Gotcha. You mentioned that CBO estimate. Is that because there are potential cuts in the Republican reconciliation package that's moving through Congress?
J. Wyatt Koma:One of the cuts would repeal the 2023 final rule.
Rob Lott:Okay. So before we wrap up, let's take a step back for our listeners thinking about where we go from here. What do you see as the next step in terms of policy? And if your paper were to sort of inspire concrete specific policy change going forward in this space, what would that be?
J. Wyatt Koma:So I think it's important to first say that Medicare covers sixty four million older adults and people with disabilities and that helps them access healthcare. But this coverage can be unaffordable, particularly for those with modest income and assets. And so the Medicare Savings Program and the Quimby Eligibility Group in particular can really help low income Americans with Medicare access healthcare by making it more affordable. So in terms of next steps for policy, we really see maintaining the twenty twenty three final rule as a critical first step to streamlining enrollment across these low income programs for Medicare beneficiaries. That said, we do have some additional recommendations as a way to build on the twenty twenty three final rule.
J. Wyatt Koma:So for example, stronger requirements for alignment between the Medicare Savings Program eligibility groups and the Medicare Part D Low Income Subsidy could really improve access to available assistance for low income beneficiaries and could reduce administrative costs for both beneficiaries and the state Medicaid programs. But it's important to underscore that this final rule really only impacts people with Medicaid who are already enrolled in one of the low income programs. And our analysis finds that nearly one in six of these eligible people are not enrolled in any of the low income programs. So additional outreach and education is really needed to beneficiaries who aren't impacted by the final rule and may be the least aware and to face the greatest barriers to enrolling in the Medicare Savings Program.
Rob Lott:Well, that's a great spot perhaps to wrap up. Wyatt Coma, thank you so much for making the time to chat with us today and for sharing your findings with us. Thank you
J. Wyatt Koma:so much for having me.
Rob Lott:To our listeners, if you enjoyed the episode, please share it with a friend, leave a review, subscribe, and of course tune in next week. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.