Dual Eligibles in the U.S.: Statistics and Facts

There’s a peculiar fact concerning health care in the United States today: one specific group of patients makes up a disproportionate amount of federal and state health care spending.

There’s a peculiar fact concerning health care in the United States today: one specific group of patients makes up a disproportionate amount of federal and state health care spending.

These patients, known as the dual eligibles or dual eligible beneficiaries, are people who qualify for both Medicare and Medicaid. As a population, they tend to be mainly seniors who have poorer health and lower income than other beneficiaries. Because they often have complicated health statues and multiple chronic conditions, they also tend to utilize costly services, which substantially drives up spending.

With higher rates of sickness and hospitalization, the dual eligibles present a major challenge for the future of health care in America. Here are some statistics and facts about dual eligible beneficiaries in the U.S., to provide a better understanding of the situation:

• There are over 9.7 million dual eligible beneficiaries in the United States

• Over half earn an income less than $10,000, have cognitive or mental impairment, and are in “poor or fair health”.

• These patients account for 16% and 15% of Medicare and Medicaid beneficiaries respectively, but make up 27% and 39% of costs.

• Health care costs of dual eligible totals roughly $300 billion of the $900 billion spent on Medicare and Medicaid total.

• In 2005, among 5.6 million dual eligible beneficiaries, 27% had at least one hospitalization; with an average hospitalization cost of $10,226

• About 25% of the hospitalizations for dual eligible beneficiaries in 2005 were potentially avoidable. Medicare and Medicaid spending for those potentially avoidable totaled nearly $6 billion.

• Five conditions are responsible for over 80% of the potentially avoidable hospitalizations: Congestive heart failure, chronic obstructive pulmonary disease/asthma, pneumonia, dehydration, and urinary tract infections

• Congestive heart failure was the leading condition associated with a potentially avoidable hospitalization.

It’s clear that dually eligible Medicare/Medicaid beneficiaries present a number of problems for the American health system and that new solutions are needed. What can be done to improve care for this segment of patients and drive down costs?