Defining and Examining the Near Duals

Older man and woman leaning on the railing of a porch and smiling

Problem

The Near Duals are among the most vulnerable groups within the older adult middle market.

For over five years, NORC has been at the forefront of research identifying and understanding the Forgotten Middle—middle-income older adults who are unlikely to qualify for Medicaid long-term care but are also unlikely to have the financial resources to pay for certain housing and care supports. Our work has uncovered an impending policy crisis with no clear solution: the majority of middle-income older adults will not be able to afford the housing and care they require as they age. Within the middle market older adult population, the Near Duals are among the most vulnerable. Near Duals are defined as adults ages 65 and over who are on the cusp of full-benefit Medicaid financial eligibility and at risk of spending down to Medicaid within one to two years.

There are few comprehensive, up-to-date studies on the Near Duals, creating a gap in understanding of this vulnerable population and their needs. This lack of up-to-date analysis leaves policymakers and industry leaders with little evidence to inform future policies and programs to support this population.

Solution

NORC conducted three in-depth analyses of the Near Dual population to establish a comprehensive profile and understand trends over time.

Each of our Near Duals analyses uses the Medicare Current Beneficiary Survey (MCBS) and Medicare administrative claims data to better understand the under-researched population of the Near Duals.

Profile of the Near Duals: The first analysis develops a profile of the Near Duals in 2021, providing a deeper understanding of their health needs and care gaps. This analysis compares the Near Duals to full duals and other Medicare beneficiaries, providing important context to the demographics, health status, and functional needs of this newly defined Near Dual population.
Near Duals Over Time: The second analysis assesses Near Dual and full dual demographic and health care utilization trends from 2017-2020 to understand differences between those who remain Near Duals and those who transition into full dual eligibility. This work provides insights on the patterns and trends among those who transition to full dual status.
Middle Market Health Care Coverage: The third analysis takes a deep dive into middle market health care coverage to understand how full duals, Near Duals, middle-moderate, and high-income populations vary in their choice of health plans. This research also includes a focused look on Medicare Advantage (MA) and the drivers of consumer choice within MA.

Result

Findings from our analyses highlight key insights important for future programs and policies.

Each analysis contains important findings:

Profile of the Near Duals

Near Duals are similar to full duals in their health and functional needs, yet lack access to the Medicaid long-term services and supports (LTSS) to help meet those needs. Near Duals have a similar number of chronic conditions, require assistance with a similar number of instrumental activities of daily living, and have a similar rate of mobility limitations as full duals.

Near Duals Over Time

While only 6 percent of Near Duals transitioned to full dual status within the four-year study period; those who do transition are sicker, less mobile, and are more likely to have experienced a fall resulting in hospitalization. This study also found that a greater proportion of individuals who transition to full dual status switch from MA to Fee-For-Service before or at the point of transition compared to those that remain Near Dual.

Middle Market Health Care Coverage

By 2021, nearly two-thirds of the Near Duals and full duals were enrolled in MA, far surpassing that of other beneficiaries. Near Duals and full duals also are more likely to be enrolled in MA plans that offer supplemental benefits compared to higher income beneficiaries, indicating that supplemental benefits could be a factor in plan selection criteria for lower-income groups.

Policy Implications

Findings from this work indicate that policy changes are needed to meet the growing housing and care needs of the middle market. In response, NORC and The SCAN Foundation convened an interdisciplinary expert panel comprising experts in older adult housing, health care, and aging services to identify potential policy options to support these populations. Grounded in our Near Duals and Forgotten Middle research, this effort culminated in the development of four policy solutions, which can be downloaded along with the Near Duals chart packs. The four solutions are:

Develop a pathway for a new benefit under Medicare for home and community-based care services
Expand Medicaid eligibility and facilitate Medicaid Savings Programs enrollment
Expand the scope and eligibility of home modification programs
Increase flexible national funding for community-based services