Millions of ‘Near Dual’ Older Adults Are Financially Insecure, Have Limited Long-Term Care Options
New NORC research highlights middle-market crisis and points to actionable policy options.
CHICAGO, October 10, 2024 — Approximately 6.5 million older adults age 65 and older experience financial insecurity and complex health needs but have limited options for their long-term care, according to new research from NORC at the University of Chicago, funded by The SCAN Foundation.
Using 2021 data, researchers identified a new cohort of older adults called “Near Duals” (because they’re “near” dual eligibility for Medicare and Medicaid). They have similar financial, health, and functional needs and mobility limitations as older adults who are eligible for both programs. Yet, according to the study, Near Duals are ineligible for the Medicaid long-term services and support available to their dual-eligible counterparts.
The study shows that only a small portion of Near Duals transitioned to full dual-eligible status over a four-year period (2017-2020), indicating that this vulnerable population will likely continue to have limited options for their long-term care needs absent robust and timely policy reforms.
“As a growing number of Americans reach older age, future policy should be informed by data around the needs of the most vulnerable older adults.”
“This research exposes a critical gap in our current system of funding long-term care,” said Dianne Munevar, vice president of Health Care Strategy at NORC. “As a growing number of Americans reach older age, future policy should be informed by data around the needs of the most vulnerable older adults.”
This analysis expands upon NORC’s Forgotten Middle research, which has examined the characteristics and needs of middle-income older adults at the national level, in California, and among marginalized and minoritized populations. NORC found that few comprehensive and up-to-date studies cover the Near Dual population, which overlaps with the older adults with the fewest resources in the Forgotten Middle.
Leveraging data from the Medicare Current Beneficiary Survey (MCBS) and Medicare enrollment and claims files, researchers:
- Created a current profile of the Near Dual population
- Analyzed their transitions to full dual eligibility over time
- Examined trends in their health care coverage
Additionally, NORC and The SCAN Foundation convened an interdisciplinary expert panel of 20 leaders from the housing, health care, and aging sectors to weigh in on the challenges facing the middle market and corresponding policy actions. Four policy solutions to facilitate a more affordable, equitable, and accessible aging environment for middle-income older adults resulted from these discussions, including:
- Developing a Pathway for a New Home- and Community-Based Services (HCBS) Benefit under Medicare. Provides needs-based coverage in Medicare for HCBS as a permanent new benefit or a demonstration program so more Near Duals receive HCBS.
- Expanding and Harmonizing Medicaid Eligibility Requirements. Expands eligibility to Medicaid by incentivizing states to increase income eligibility limits so more Near Duals qualify for long-term services and supports.
- Expanding the Scope and Eligibility of Home Modification Programs. Increases funding for existing home repair and modification programs to help Near Duals stay in their homes for longer.
- Increasing Flexible National Funding for Community-Based Services. Increases funding for select programs and services that directly support vulnerable older adults like Near Duals.
“Nearly 7 million older adults live in a perilous financial situation, which can be hazardous to not just finances, but health care and access, too,” said Narda Ipakchi, vice president of policy at The SCAN Foundation. “Real policy change and relief for Near Duals is urgently needed so they can receive the necessary long-term care needed to age in their homes, safely and surrounded by community.”
Research findings and policy solutions will be featured in a webinar on October 25 from 1 to 2 pm ET. The webinar includes a presentation by NORC on the most recent Forgotten Middle and Near Duals research, followed by a fireside chat facilitated by Ipakchi and Munevar with expert panel members Amber Christ (Justice in Aging), Jennifer Molinsky (Joint Center for Housing Studies of Harvard University), and Sarah Steenhausen (California Department of Aging).
Methodology
Given the many pathways by which older adults may become eligible for full-benefit Medicaid and the variation in state eligibility requirements, NORC aimed to create a nuanced national definition for Near Duals. The target population included older adults age 65 and older who are unlikely to qualify for Aged, Blind, Disabled (ABD) Medicaid and have a level of financial resources that could lead to an imminent Medicaid spend down after one financial shock, such as the costs associated with a major fall and hospitalization. This analysis examined current resources in a given year and departs from the Forgotten Middle methodology, which calculated annuitized income and assets over the course of each individual’s projected life expectancy.
To set an income lower bound for the Near Duals, NORC identified the most generous ABD Medicaid income requirement for each state and then weighted this federal poverty limit (FPL) requirement by state based on each state’s proportion of the national total of Medicaid enrollees age 65+.
For the income upper bound, NORC implemented the most common income FPL requirement for Medicaid home- and community-based services (HCBS) waivers, which was 300 percent of Supplemental Security Income (SSI). Finally, NORC included an asset limit that represented the median assets of the bottom quartile of the Forgotten Middle, without annuitization.
NORC leveraged the MCBS to analyze the Near Duals, as this dataset allowed NORC to further link beneficiaries to their Medicare administrative claims. MCBS data were limited to home and community-based beneficiaries, leveraging the Income and Assets questionnaire section. NORC then recreated this group using Health and Retirement Study (HRS) data and compared population size, gender, race/ethnicity, and other demographic characteristics across both groups to validate the MCBS population.
NORC used the MCBS to analyze measures of demographics and reported health and functional status, while using the Master Beneficiary Summary File (MBSF) to examine enrollment patterns among the populations of interest. Plan Benefit Package (PBP) files were also linked to analyze enrollment in Medicare Advantage plans with a range of supplemental benefits and benefit generosity.
For specific methodologies, please see the Appendix of each analysis.
About NORC at the University of Chicago
NORC at the University of Chicago conducts research and analysis that decision-makers trust. As a nonpartisan research organization and a pioneer in measuring and understanding the world, we have studied almost every aspect of the human experience and every major news event for more than eight decades. Today, we partner with government, corporate, and nonprofit clients around the world to provide the objectivity and expertise necessary to inform the critical decisions facing society.
Contact: For more information, please contact Eric Young at NORC at young-eric@norc.org or (703) 217-6814 (cell).
About the SCAN Foundation
The SCAN Foundation is an independent public charity devoted to transforming care so that every older adult has the choices and opportunity to age well with purpose. For more information, visit www.TheSCANFoundation.org.