The Relationship Between Take-up of Prescription Drug Subsidies and Medicaid Among Low-Income Medicare Beneficiaries
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J Gen Intern Med DOI: 10.1007/s11606-020-06241-y © Society of General Internal Medicine 2020
rates,5 highlighting opportunities for policy reforms to increase participation in both programs.
METHODS INTRODUCTION
Medicare premiums and cost-sharing can pose a substantial financial burden on beneficiaries, half of whom have incomes below $26,200.1 Beneficiaries with low incomes and assets may qualify for assistance with these costs through full Medicaid, the Medicare Savings Programs (MSPs, which are limited Medicaid benefits), and the Part D Low-Income Subsidy (LIS).2,3 However, a substantial proportion of individuals who qualify for these programs are not enrolled.3–5 These programs are linked in ways that may be unknown to Medicare beneficiaries. All beneficiaries who are eligible for full or limited Medicaid qualify for the LIS, which eliminates premiums and lowers cost-sharing in the Medicare Part D program. Moreover, beneficiaries who receive Medicaid are automatically enrolled in the LIS. Because auto-enrollment is the main pathway into the LIS,2 there is concern that low take-up of Medicaid could contribute to low LIS take-up. Foregoing the LIS may have adverse consequences for patients: CMS has estimated that this program reduces average annual outof-pocket prescription drug spending by $4000 and receiving the LIS has been linked to improved medication adherence.3,6 In this study, we examined take-up of the LIS and Medicaid among Medicare beneficiaries who qualified for both programs. We go beyond prior analyses that report average enrollment by program by examining whether LIS take-up mirrors Medicaid enrollment at income levels where individuals qualify for limited Medicaid benefits that have low take-up
Received May 19, 2020 Accepted September 11, 2020
We analyzed Medicare beneficiaries in the 2008–16 waves of the Health and Retirement Study (surveyed biennially) and linked administrative indicators of Medicaid and LIS enrollment. We restricted our sample to financial respondents (i.e., individuals most knowledgeable about a household’s finances) who qualified for Medicaid and the LIS based on their income and assets. In primary analyses, we examined LIS and Medicaid take-up as a function of income relative to the federal eligibility threshold for the Qualified Medicare Beneficiary MSP (100% of FPL). Beneficiaries whose income is below this threshold qualify for assistance with outof-pocket costs in Medicare Parts A and B (provided they have low assets) while those with incomes of 101– 135% of FPL only qualify for Medicaid assistance with the Part B premium. In secondary analyses, we assessed take-up above and below state-specific income eligibility thresholds for full Medicaid. Finally, we estimated adjusted differences in LIS take-up above and below these thresholds, controlling for beneficiaries’ demographic and socioeconomic characteristics, health status, disability, Medicare Advantage enrollment, and state and year fixed effects. We adjusted for survey weights to produce estimates that are natio
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