Eligibility for the Medicare buy-in programs, based on a survey of income and program participation simulation.

Medicare buy-in programs are designed to reduce out-of-pocket expenses of beneficiaries with modest income and assets. This article provides estimates of the size of the Medicare beneficiary population eligible for the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualified Individual-1 (QI-1) program. The buy-in programs use the same resource limits (twice those used in the Supplemental Security Income (SSI) program) but different thresholds for determining income eligibility. The QMB program uses 100 percent of the poverty line as the cutoff, QI-1 covers persons above 120 percent but at or below 135 percent of the poverty line, and the SLMB program is in between. Making informed judgments about the rate of participation in the buy-in programs and the need for outreach requires an accurate estimate of the size of the eligible population. If that population is underestimated, policymakers might come to unduly optimistic conclusions about current buy-in participation. In contrast, an overestimate may make current participation seem too low. If policymakers react to an upwardly biased estimate of the eligible population by increasing outreach, they are bound to be disappointed by the results of that effort. Estimates of the eligible population from past studies of the QMB and SLMB programs range from 5.1 million to 9.1 million. In the absence of new information, it is difficult to judge the accuracy of those estimates because the methodologies had substantial shortcomings that might bias the results. The most common shortcomings include the lack of high-quality, monthly income data and the lack of information on assets from the same data file that was used to estimate participation and income eligibility for Medicare. The current study uses the most recently available (as of August 2000) Survey of Income and Program Participation (SIPP) file that is matched to the Social Security Administration's (SSA's) administrative records. The data file covers 1995 information. Estimates were also obtained using 1991 data to assess the sensitivity of eligibility estimates to the year chosen. The SIPP has several major advantages over other data sources because it contains relevant, high-quality information on both income and assets for establishing financial eligibility for the buy-in programs. First, the SIPP collects detailed and conceptually appropriate information on monthly, rather than annual, income and therefore has more complete information about income than do other surveys. As a result, SIPP-based estimates of poverty are substantially lower than estimates based on the Current Population Survey. Second, the SIPP also collects information on assets at the individual level. Thus, the survey provides enough detail to measure the major income and asset exclusions directly. Finally, the SIPP data are matched to SSA administrative records: Medicare eligibility can therefore be accurately measured, and self-reported data on Social Security and SSI benefits can be replaced with more accurate monthly information. Our 1995 simulation estimates that approximately 4.8 million persons in the U.S. noninstitutionalized population were eligible for the QMB program and an additional 1.6 million for the SLMB program. The total--roughly 6.5 million--is within the range of estimates from past studies but is closer to the lower end, suggesting that the eligible population is smaller than was previously believed. When the estimated QI-1 eligible population of 0.9 million is added, the total for the three buy-in programs is 7.4 million. Because the QI-1 program did not exist in 1995, only the estimated 6.5 million QMBs and SLMBs would actually have been eligible to receive benefits. The 7.4 million figure represents the 1995 Medicare beneficiaries who would be eligible for buy-in under program rules for 2000. Adjusting that number to account for increases in the Medicare population between 1995 and 1999 yields an estimated eligible population of 7.8 million in 1999. Compared with other elderly Medicare recipients, eligible elderly QMBs and SLMBs have poorer health, more functional limitations, and higher rates of health care use. Thus, not only are their income resources relatively limited, but their need for potentially expensive medical care is also greater. Similar differences were not found in health, functional limitations, and health care use among disabled participants in the QMB and SLMB programs. Our estimates imply that about 2.5 million noninstitutionalized individuals were eligible for but not enrolled in the QMB and SLMB programs in 1999. That finding suggests that fewer eligibles may be available for targeting by outreach efforts than was previously believed. Outreach may be more difficult than it would be with a larger eligible population. (ABSTRACT TRUNCATED)     

Development and evaluation of a survey-based type of benefit classification for the Social Security program

This attempt to classify Social Security beneficiaries by type of benefit using the new Survey of Income and Program Participation (SIPP) has yielded promising results. Evaluations of the classification algorithm based on comparison of the estimated number of beneficiaries in each of the several categories to independent estimates of the number of beneficiaries indicate that in most instances a high percentage of each category has been identified. For the most part, age and monthly benefit amount size distributions seem reasonable. Furthermore, very few persons in the sample who were identified as Social Security beneficiaries could not be assigned to one or another of the benefit groups. The classification procedure also represents a marked improvement over earlier efforts to classify type of beneficiary that relied on data from the March Supplement to the Current Population Survey (CPS). Most importantly, the benefit classification scheme based on SIPP data appears to provide reasonably reliable distinctions between retired-worker and widow benefits for widowed women and permits the identification of retired-worker benefits for those women dually entitled to retired-worker and spouse benefits. In addition, the distinction between disabled- and retired-worker benefits for recipients aged 62-64 appears to be reasonably reliable, and for women under age 65, the classification procedure distinguishes between disabled-worker benefits on the one hand and widow and widowed mother benefits on the other. Finally, SIPP procedures for identifying minor child beneficiaries yield markedly better estimates than those available from the Current Population Survey. These improvements in the SIPP context are due entirely to the presence of information not collected in the CPS. The enhancement of the SIPP data set in turn resulted directly from an assessment of earlier work carried out by Projector and Bretz in the CPS context and on extensive research into the nature of Social Security reporting errors in the CPS. The superiority of the SIPP data set is linked principally to the presence of three pieces of information: the Medicare BIC, the direct question on reasons for benefit receipt asked of persons under age 65, and the direct measurement of recipiency and amount of benefits for minor children. Other items of some import include self-reported work disability, retirement status (ever retired from a job), previous marital status for currently married women, age first prevented from working due to a health condition, and Supplemental Security Income misreporting items.(ABSTRACT TRUNCATED AT 400 WORDS)     

How raising the age of eligibility for Social Security and Medicare might affect the disability insurance and Medicare programs

The normal age of retirement is scheduled to increase to 67 by 2022, and several proposals to increase it to age 70 are being considered. The Medicare eligibility age is not scheduled to increase under current law, but proposals to raise it in step with the retirement age were recently considered by the National Bipartisan Commission on the Future of Medicare (1999). This article examines how raising both the normal retirement age and the Medicare eligibility age would affect Social Security Disability Insurance (DI) eligibility, Medicare eligibility, and Medicare expenditures under two hypothetical policy scenarios. The first (the 2022 age-67 scenario) assumes that the eligibility age is raised to 67 by 2022, in step with the scheduled increase in the normal retirement age. The second (the 2040 age-70 scenario) assumes that the eligibility ages are increased to 70 by 2040. The findings are based on a summary of two reports. The earlier one (Wittenburg and others 1999) describes a series of microsimulation models developed from data in the Survey of Income and Program Participation (SIPP) and the Medicare Current Beneficiary Survey (MCBS). The base simulations in that report assume that the normal retirement and Medicare eligibility ages had already been increased in 1993, when the SIPP and MCBS respondents were observed. In the later report (Wittenburg, Stapleton, and Scrivner 2000), adjustment factors were developed to reflect future increases in Medicare expenditures, population growth, and increased participation in DI. The base simulations were then adjusted by those factors, yielding a final set of annual projections under the two policy scenarios. The hypothetical policy scenarios illustrate that the major cost reductions from jointly raising the Medicare eligibility age and the normal age of retirement would not be realized until after 2020, when the increases are fully phased in and a large portion of baby boomers have reached age 65. Although the projections provide important cost estimates, the equity and efficiency of those policies must be studied before the desirability of any specific proposal can be evaluated fully.     

Information, market government, and health policy: a study of health data organizations in the states.

Information is essential to the success of market-oriented policies. Information on health care costs and quality is collected and distributed by state governments through health data organizations (HDOs) to enhance competition and lower costs in the medical industry and to improve consumer choice among medical alternatives. This article examines the information collected, produced, and distributed by state health data organizations in Colorado and Pennsylvania. Findings reveal that information was not the objective determinant of choice and competition as market-oriented policy designers had hoped. Nor did market-oriented bureaucracies produce and distribute data readily accessible for public choice. Instead, information produced and distributed by these HDOs was the result of political and bureaucratic exercises that conform much more to classic interest group policymaking and captured bureaucracies than to contemporary market-oriented government ideals. The findings underscore the extraordinary difficulties facing federal-level policy designers as they contemplate introducing market-oriented health care policies on the national level.     

Expanding access to health care for Social Security Disability Insurance beneficiaries: early findings from the accelerated benefits demonstration

Most Social Security Disability Insurance (DI) beneficiaries must complete a 5-month waiting period before they become entitled to DI cash benefits and an additional 24-month waiting period before Medicare benefits begin. The Accelerated Benefits (AB) demonstration is a randomized experiment designed to test the effects of providing newly entitled DI beneficiaries who do not have health insurance with a generous health benefits package during the Medicare waiting period. This article presents early findings on the prevalence of health insurance coverage among newly entitled beneficiaries and the characteristics of those without health insurance. It also examines the effects of AB on health care utilization, the extent to which AB reduces unmet medical needs, and the costs of providing the AB health benefits package.     

Local labor markets and local area effects on welfare duration

The Survey of Income and Program Participation (SIPP) has become an important tool for studying how long people stay on welfare programs because it has monthly data on a variety of welfare programs. This article presents estimates of duration models for unmarried women with children who are on the Aid to Families with Dependent Children program (AFDC) using the 1984 and 1985 panels of SIPP. A weakness in previous welfare duration studies is that they do not include local labor market conditions or other local area effects; this omission may bias the estimated effects of policy variables (such as benefit levels) and labor market variables. This article incorporates relevant local area information from the City County Data Book and links this to SIPP welfare recipients based on county of residence. I find that local variables such as unemployment rates or per capita sales affect welfare exit rates, especially for blacks. Living in an urban area lengthens welfare spells for both whites and blacks.     

Toward a physician payment policy: Evidence from the Economic Stabilization Program

Concern over the rising cost of medical care has focused policy attention on methods of paying physicians. Unfortunately, limits placed on fees paid by public medical care financing programs, Medicare and Medicaid, adversely affect those programs' primary objective: making office-based physicians' services available to the poor and the elderly at affordable prices. This suggests that a second policy instrument, controls on physicians' private charges, may be needed. The Economic Stabilization Program (ESP) provides the only recent U.S. experience with a system which constrained both physicians' private charges and public payments. Using Medicare and Medicaid claims data for a large sample of California physicians, we simulate what physicians' private charges and supplies of services to Medicare assignment and Medicaid patients would have been in the absence of ESP. The simulations suggest that without ESP, private charges would have been higher and the quantities of services provided to poor and elderly patients lower than were actually observed. We believe, therefore, that the ESP experience supports the argument that controls over both public and private fees are needed in order to simultaneously contain costs of and maintain access to physicians' services by Medicare and Medicaid beneficiaries.The research for this paper was supported by Contract No. 600-76-0054 from the Social Security Administration, USDHEW. We wish to thank our colleagues Judith Feder, John Holahan, William Scanlon, and Judith Wagner for their helpful comments. James Bluck provided excellent research assistance. The findings and opinions expressed in this paper are solely those of the authors, and do not necessarily reflect the positions of either The Urban Institute or The Department of Health, Education, and Welfare.     

The erosion of retiree health benefits and retirement behavior: implications for the disability insurance program

The effects of retiree health insurance on the decision to retire have not been examined until recently. It is an area of increasing significance because of rising health care costs for retirees, the uncertain future of Medicare, and increased life expectancy. In general, studies suggest that individual retirement decisions are strongly responsive to the availability of retiree health insurance. Early retiree benefits and retirement behavior are also important because they may affect the Social Security Disability Insurance (DI) program. It is not apparent that if a person loses retiree health benefits, or if fewer people are eligible for retiree health benefits in general, claims for DI will increase. The potential 2-year loss of health benefits may be a deterrent to leaving the labor force and claiming DI, although persons who are unable to work would leave the labor force even without health benefits. In order to understand how the decline in retiree health benefits may affect enrollment in DI, analysts must at least incorporate the role of coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). That act provides many people with access to health insurance during the 2-year gap between eligibility for DI and Medicare. In fact, persons with sufficient means to retire early could use the income from Disability Insurance to buy COBRA coverage during the first 2 years of DI coverage. Determining the effect of the erosion of retiree health benefits on DI must account properly for the role of other factors that affect DI eligibility and participation. The financial incentives of Social Security, pension plans, retirement savings programs, health status, the availability of health insurance, and other factors influencing retirement decisions must be taken fully into account in order to isolate the precise effect of retiree health benefits.     

The weakness of strong policies and the strength of weak policies: Law,experimentalist governance,and supporting coalitions in European Union health care policy

The experience of European Union (EU) health care services policy shows the importance of supporting coalitions in any effort to effect policy change and the extent to which the presence or absence of such coalitions can qualify generalizations about policymaking. EU health care services law is substantively liberalizing and procedurally driven by the courts, with little legislative input. But the European Court of Justice (ECJ) has been much better at establishing an EU competency in law than in causing policy development in the EU or member states. Literature on courts helps to explain why: courts are most effective when they enjoy supporting coalitions and the ECJ does not have a significant supporting coalition for its liberalizing health care services policy. Based on interview data, this article argues that the hard law of health care services deregulation and the newer forms of health care governance, such as the Open Method of Coordination and the networks on rare diseases, depend on supporting coalitions in member states that are willing to litigate, lobby, budget, decide cases, and otherwise implement EU law and policy. Given the resistance that the Court has met in health care sectors, its overarching deregulatory approach might produce smaller effects than expected, and forms of experimentalist governance that are easy to deride might turn out to have supporting coalitions that make them unexpectedly effective.     

Comparing beneficiaries of the Medicare savings programs with eligible nonparticipants

This note focuses on participation in two entitlement programs that help reduce out-of-pocket expenses for low-income Medicare beneficiaries: the Qualified Medicare Beneficiary (QMB) program and the Specified Low-Income Medicare Beneficiary (SLMB) program. As of 1999, about 2.75 million eligible, noninstitutionalized individuals were not enrolled in these Medicare savings programs. The eligible nonparticipants differed substantially from the QMB and SLMB participants in that they were less likely to be Supplemental Security Income beneficiaries and more likely to be elderly, nonblack, and in relatively good health. These findings, which could help target future outreach efforts, are based on Survey of Income and Program Participation data matched with administrative records from the Social Security Administration.     

Medicaid matters: children's health and Medicaid eligibility expansions.

In the late 1980s, a series of federal laws were enacted which expanded Medicaid eligibility to more of the nation's children. States had a great amount of discretion in how fast and how far these expansions were implemented. As a result, there was great variation among the states in defining who was eligible for the program. This variation provides a rare opportunity to disentangle the effect of Medicaid from a child's socioeconomic status. Using data from the National Health Interview Survey, we address whether the Medicaid expansions improved the health and functional status of children. Econometric models were developed using fixed-effects regressions, and were estimated separately for white, black, and Hispanic children. White children experienced statistically significant reductions in acute health conditions and functional limitations. Black and Hispanic children showed some evidence of improved health conditions and functional status, but this evidence is inconclusive in the study sample. This may be due to differences in their access to appropriate health services or to the smaller sample size of minorities in each geographic area. The findings are also relevant to the implementation of the Children' Health Insurance Program (CHIP), the latest federal effort to expand access to health care to poor and near poor children. In many states, CHIP is being implemented in whole or in part through further Medicaid expansions.     

The tripartite regulation of America's health services

The Republican takeover of Congress suggests that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of our nation's health services. These "voluntary" alliances, frequently as an amalgamation of health providers and health insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies. The authors anticipate, as a result, the formation of state health services commissions that will regulate market share, the scope of health services, reimbursement rates and allowable profits. State departments of public health and insurance will have their own regulatory duties. Complex relationships will result as these groups will often have conflicting, politically-charged goals.     

The Continuing Evolution of Medicare Hospice Policy

This case study traces the creation and evolution of Medicare hospice policy. The Medicare hospice benefit, created in 1982, emphasizes palliative rather than curative care. It focuses on quality of life for the dying patient and family and encompasses medical, psychological, and spiritual care. Because no standard hospice care practices existed before this benefit was implemented, Medicare rules almost exclusively dictated the structure and delivery of services. Despite initial concerns about low use, spending averaged 17 percent per year between 1991 and 2001, largely driven by increased enrollment, covered days, services provided, and inflation. A rich accumulation of research studies and analyses of specific aspects of the hospice program provides an opportunity for a retrospective analysis of the program's genesis, impact on health care delivery, and implications for future policy decisions.     

What motivates adherence to medical recommendations? The procedural justice approach to gaining deference in the medical arena

Although it is within their long‐term interest, patients often fail to follow health care recommendations made by medical experts. This failure results in the widespread occurrence of preventable health problems and a significant increase in health care costs. Taking a new approach to confronting this issue, this paper examines whether the procedural justice model, which has been useful in explaining cooperation with legal and managerial authorities, can provide a basis for increasing patients' willingness to voluntarily adhere to health care recommendations. Three studies tested and supported this proposition. Study 1 experimentally manipulated physicians' procedural fairness or unfairness to explore its influence on patients' acceptance of doctors' recommendations. Study 2 used patients' reports about the fairness of their personal physicians and linked those evaluations to their willingness to follow their doctor's recommendations. Finally, study 3 explored the role of general procedural justice judgments in promoting willingness to accept health policies when they are advocated by private doctors and government health care authorities. The results of all three studies support the argument that when health care authorities use fair procedures, patients are more likely to accept their recommendations. Importantly, this procedural justice effect is distinct from, and in some cases stronger than, the influence of competence.     

The impact of child SSI enrollment on household outcomes

We use data from the Survey of Income and Program Participation (SIPP) to investigate the impact that child Supplemental Security Income (SSI) enrollment has on household outcomes, including poverty, household earnings, and health insurance coverage. The longitudinal nature of the SIPP allows us to control for unobserved, time‐invariant differences across households by measuring outcomes in the same household in the months leading up to and immediately following the first reporting of child SSI income. Our regression analyses demonstrate that for every $100 increase in household SSI income, total household income increases by roughly $72, reflecting some modest offset of other transfer income and conditional household earnings. Our analyses further demonstrate that child SSI enrollment is associated with a statistically significant and persistent reduction in the probability that a child lives in poverty of roughly 11 percentage points. Additional analyses suggest that program enrollment has virtually no impact on health insurance coverage because most new SSI recipients have health insurance from Medicaid or another source at the time of enrollment. © 2007 by the Association for Public Policy Analysis and Management     

Does Medicare Coverage Improve Cancer Detection and Mortality Outcomes?

Medicare is a large government health insurance program in the United States that covers about 60 million people. This paper analyzes the effects of Medicare insurance on health for a group of people in urgent need of medical care: people with cancer. We used a regression discontinuity design to assess impacts of near-universal Medicare insurance at age 65 on cancer detection and outcomes, using population-based cancer registries and vital statistics data. Our analysis focused on the three tumor sites for which screening is recommended both before and after age 65: breast, colorectal, and lung cancer. At age 65, cancer detection increased by 72 per 100,000 population among women and 33 per 100,000 population among men; cancer mortality also decreased by nine per 100,000 population for women but did not significantly change for men. In a placebo check, we found no comparable changes at age 65 in Canada. This study provides the first evidence to our knowledge that near-universal access to Medicare at age 65 is associated with improvements in population-level cancer mortality.     

Local government decentralization and the health sector in Tanzania

An evaluation of primary-level healthcare undertaken in Tanzania 1989-91 found that district health managers felt powerless to address health care performance weaknesses, although the district is the unit to which government management functions have been decentralized. In order to understand the managers views, this article analyses the pattern of decentralization within the health system from their perspective. It reviews the hislorical development of government structures and the theory and practice of decentralization within Tanzania. The matrix of accountability for health care has become very confusing, with multiple and cross-cutting flows of authority within and between levels of the system. District health managers have limited authority to take management action, such as managing resources, in ways that would begin to address problems of inefficiency and poor quality of care within primary care. District health management also suffers from weak resource allocation and financial management piocedures. The main obstacles preventing more effective management are: resource constraints; conflicts between the demands for central control and local discretion; limited institutional capacity; and political and cultural influences over the implementation of decentralization. Evaluation of past experience suggests that future policy influencing the organizational structure of government health services must be developed cautiously, recognizing the critical importance of complementary action to develop both institutional capacity and political and economic support for the health system.     

Medicare utilization by disabled-worker beneficiaries: a longitudinal analysis

Medicare eligibility for Social Security disabled-worker beneficiaries begins after 2 years of cash benefit receipt. Extension of the current coverage is often proposed as a way to encourage beneficiaries to return to work. Little is known, however, about the long-run Medicare costs for the disabled and how costs vary by demographic and health characteristics. This article describes Medicare utilization and reimbursement amounts for 1974-81 for a cohort of disabled-worker beneficiaries under age 62 and first entitled to cash benefits in 1972. The data come from a first-time linkage of Disability Insurance program data with data on Medicare utilization. The tables provide a detailed look at several factors that are associated with variation in Medicare costs among beneficiaries and over time.     

Physically demanding occupations, health, and work after retirement: findings from the New Beneficiary Survey

This article uses data on a recent cohort of Social Security retired-worker beneficiaries to examine the predictors of work after initial receipt of benefits. It focuses on two factors: an analysis of the effects of ill health and of employment in a physically demanding occupation in the year preceding receipt of benefits. Based on responses received during the Social Security Administration's New Beneficiary Survey, the employment of men in a physically demanding occupation is associated with a lower probability of work in retirement; the existence of a work-limiting health condition also lowers their probability of work. Full-time, full-year workers in 1979 who had changed jobs in the years just preceding the receipt of Social Security benefits were more likely to work after they became beneficiaries. It may be that workers anticipate constraints on their ability to continue working on a job and reduce the effect of those constraints through earlier job changes. The finding that the work effort of women beneficiaries is not affected by previous employment in occupations identified as physically demanding may signify the failure of customary physical demand indices to measure stress on those jobs in which women are most likely to be employed.