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For Dual-Eligibles, Health Care Reform Is Already Here

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You can't open a newspaper--or a newsy website--these days without getting the latest update on two high-profile parts of the new health care law that are still months away from implementation.

The Medicaid Expansion, which has the potential of helping 17 million people get health insurance, and the state-based Exchanges, which will offer even more the opportunity to purchase affordable health insurance at a group rate, are both set to roll out in 2014. Both the expansion and the Exchanges are an important part of expanding access to quality, affordable health care and deserve the attention they are getting.

But it would be nice to see some column inches given to another reform effort from the Affordable Care Act, one that just launched in Massachusetts: an attempt to improve care and lower costs for those who are eligible for both Medicare and Medicaid.

Known as "dual-eligible beneficiaries" (or "dual-eligibles"), this group includes roughly 10 million people nationwide who represent some of the biggest challenges for medical service providers and program administrators.

A quick recap: Medicare is a federally-run program that provides senior citizens and people with disabilities access to valuable health care services, including acute care and prescription drugs. But its coverage is often incomplete, especially for those who cannot afford to pay its premiums or share costs, or those who require long-term care.

Medicaid--a federal-state partnership that provides coverage for some low-income people--steps into this breach and, depending on the circumstances, picks up some or all of these additional expenses. And the expenses can be significant. "Dual-eligibles" comprise roughly 15 percent of the national Medicaid enrollment but account for 39 percent of its expenses.

There are at least three reasons that costs associated with dual-eligibles are so comparatively high. The ACA tackles two of these reasons directly and, in doing so, hopes to impact the third.

The first issue the ACA takes on is the inconsistencies between the Medicaid and Medicare programs. For example, Medicaid covers wheelchairs for both in-home and out-of-home use, whereas Medicare only covers wheelchairs for in-home use. Each program provides a different set of standards for evaluating the quality of care, for appealing denials of service, and for covering home health services.

Sometimes the program rules actually work against each other. As the newly-created Medicare-Medicaid Coordination Office (MMCO) recently reported, "reimbursement policies between Medicare and Medicaid incentivize nursing homes to transfer dual-eligibles to hospitals and vice versa," resulting in less consistent care.

MMCO's report was part of an effort by the federal government to identify points of tension between the two programs and "realign" them if possible. It proposed 29 broad areas as candidates for regulatory fixes and is seeking additional input from the public on these.

The federal re-alignment initiative will only help so much, however. Sometimes valid reasons exist for the differences between the programs--and remember, many Medicaid administrative policies are set by the individual states, not the federal government.

The difficulty--and the second reason for high costs--lies in challenges of coordinating care. Right now, it is all too easy for a program administrator to apply the incorrect standard and wrongly deny care or delay payment. Add to this the fact that more than 43 percent of all dual-eligibles have a mental or cognitive impairment and are not well-positioned to navigate the system, and you have a recipe for a daunting bureaucratic labyrinth.

This brings me to MMCO's second initiative, and back to the state of Massachusetts: starting this year, the federal government will fund a series of demonstration, or pilot, programs across the country to better integrate Medicaid and Medicare services.

These programs will allow states and the federal government to experiment with ways to coordinate Medicaid and Medicare coverage to provide patients with quality, cost-effective care. Massachusetts' program, which began accepting enrollees at the beginning of April, is the first of several experiments that will be launching across the country over the coming months.

Given the complexity of the programs and the vulnerability of the populations they help, advocates will be watching closely to make sure the cure isn't worse than the disease. But if these two initiatives are effective, it will mean better care for millions of the sickest and poorest Americans, and better care will mean better health outcomes.

This leads me to the third--and biggest--reason that costs for dual eligible is so comparatively high: 60 percent of them have three or more chronic conditions--far more than the average Medicaid or Medicare enrollee.

It should come as no surprise that the oldest and sickest among us have higher medical bills than average; this would be the case even with perfect alignment and coordination. But many of these conditions, such as heart disease or diabetes, can be controlled, and costs lowered, with proper medical care.

I think you see where I'm going here. Better health care access for everyone is a win for us all.