One of the most difficult aspects of reforming Medicaid in any state is answering the question, “what about the dual eligibles?” These are people who are eligible for Medicare due to their age (65+) and Medicaid due to being low income. The dual eligibles constitute about 1 in 10 Medicaid beneficiaries in North Carolina, but consume about one-fourth of the program costs.
Following are three interviews I conducted (in October 2011) with Marsha Gold, a researcher at Mathematica Policy Research, and one of the nation’s foremost experts on the dual eligibles:
The most important thing to remember when discussing Medicaid, is that it is not one, homogenous program in terms of who is covered. For example, the per capita Medicaid expenditures by Medicaid on dual eligible beneficiaries was around $10,600 in 2009; for the far more numerous children covered by the program, it was $2,800, in large part owing the cost of nursing home and other long term care services for the duals. And the number of dual eligibles will inevitably grow due to the movement of baby boomers into eligibility for Medicare. Keep in mind that most of the persons who would be covered by a Medicaid expansion under the ACA in North Carolina are childless and low income adults, not the more complicated (medically) groups of dual eligibles and the long term disabled.
Further, regarding the language used by the Governor to describe Medicaid as broken–and then using administrative costs as the prime example–the figures on administrative costs described in the in the N.C. Audit have been called into question. As noted in the post, some of the administrative costs in other Medicaid programs are contained in the amounts of dollars spent by managed care companies. So, the much discussed N.C. audit did not provide a complete picture of what proportion of other states Medicaid program was spent on administration. This is important only because this administrative “brokenness” was the logic provided by the Governor for not expanding Medicaid. Not only was this not the case, but the expansion would add people who are on average, much better health risks than the anecdotal examples of problems that have been provided in the debate–mostly of problems with dual eligible beneficiaries and the long term disabled (and there are many problems and difficulties, first and foremost about the health of these individuals).
What is broken in Medicaid are many of the beneficiaries, particularly the dual eligibles described above. These are elderly individuals, many living in Nursing Homes, often because they are widows or widowers, and who have many complicated acute and long term care needs. Medicaid provides care for “the least of these” and that will always be very hard and expensive.