Medicare and Medicaid: Meeting Needs of Dual Eligibles Raises Difficult
Cost and Care Issues (Testimony, 04/29/97, GAO/T-HEHS-97-119).

Pursuant to a congressional request, GAO discussed several issues that
arise in financing health care for people known as dual eligibles,
Medicare beneficiaries who are also eligible for some form of Medicaid
support, focusing on: (1) the health characteristics of those who are
eligible for both Medicare and Medicaid and the key structural
differences between the two programs that serve this population; (2)
benefit overlaps between these two programs and the associated shifting
of care and costs between federal and state levels; and (3) states'
efforts to use managed care to serve this population.

GAO noted that: (1) the dually eligible population consists of people
with a range of health needs, from the young to the very old and from
the healthy to the disabled or chronically ill in nursing homes; (2)
compared with Medicare-only beneficiaries, however, dually eligible
beneficiaries are more likely to have poorer health status and require
costly care, including long-term care; (3) meeting their needs under two
programs that are administered under different rules complicates matters
in both fee-for-service and managed care environments; (4) the potential
to cover posthospital and long-term care benefits under either program
has resulted in costs being shifted between programs; (5) because the
federal government pays the full cost of Medicare and shares the cost of
Medicaid with the states, the greater financial burden generally falls
on the federal government; (6) to better coordinate acute and long-term
care needs while holding down costs, some states are assessing the
potential for enrolling their dually eligible populations in a single
managed care plan; (7) however, differences in Medicare and Medicaid
requirements for commercial managed care participation can create
barriers to this approach; (8) because these barriers are largely
related to certain statutory beneficiary guarantees, including
beneficiaries' freedom to choose their own provider, granting waivers
from federal requirements to states that are designing comprehensive
managed care programs remains a delicate issue; (9) the implications of
managing the costs of care for this population are significant at both
the federal and state levels; (10) the issue is important to the federal
government because it pays for Medicare as well as for over half of
Medicaid's costs; (11) it is also important to state governments,
because they have little control over federal decisions, such as the
imposition of new Medicare cost-sharing requirements, that make their
budgets vulnerable to unplanned fiscal liabilities; and (12) as states
pursue greater flexibility to design more efficient and effective
service delivery programs for this population through waivers of certain
beneficiary protections guaranteed by federal statute, federal and state
governments' rigorous oversight of care delivery remains essential.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-97-119
     TITLE:  Medicare and Medicaid: Meeting Needs of Dual Eligibles 
             Raises Difficult Cost and Care Issues
      DATE:  04/29/97
   SUBJECT:  Health care programs
             Beneficiaries
             Eligibility criteria
             Cost sharing (finance)
             Long-term care
             Disadvantaged persons
             Managed health care
             Health care cost control
             State-administered programs
             Intergovernmental fiscal relations
IDENTIFIER:  Medicaid Program
             Medicare Program
             Minnesota Medicare Maximization Initiative
             
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Cover
================================================================ COVER


Before the Special Committee on Aging, U.S.  Senate

For Release on Delivery
Expected at 9:30 a.m.
Tuesday, April 29, 1997

MEDICARE AND MEDICAID - MEETING
NEEDS OF DUAL ELIGIBLES RAISES
DIFFICULT COST AND CARE ISSUES

Statement of William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services Division

GAO/T-HEHS-97-119

GAO/HEHS-97-119T


(101559)


Abbreviations
=============================================================== ABBREV

  HCFA - Health Care Financing Administration
  QMB - Qualified Medicare Beneficiaries
  SLMB - Specified Low-Income Medicare Beneficiaries
  SSI - Supplemental Security Income
  SNF - skilled nursing facility

MEDICARE AND MEDICAID:  MEETING
NEEDS OF DUAL ELIGIBLES RAISES
DIFFICULT COST AND CARE ISSUES
============================================================ Chapter 0

Mr.  Chairman and Members of the Committee: 

We are pleased to be here today to discuss several issues that arise
in financing health care for people known as dual eligibles--Medicare
beneficiaries who are also eligible for some form of Medicaid
support.  In 1995, Medicare and Medicaid spending for the roughly 6
million dual eligibles totaled an estimated $106 billion, or almost a
third of these programs' expenditures combined.  This dually eligible
population is expected to grow, resulting in ever greater health
financing expenditures and care challenges.  In addition, dual
eligibles are, by definition, poor, and many are in poor health, with
over 20 percent residing in nursing homes.  While the very poor and
very sick could benefit from a coordinated system of care, at times
they can encounter a fragmented and confusing array of services. 

My comments today will focus on three major areas:  (1) the health
characteristics of those who are eligible for both Medicare and
Medicaid and the key structural differences between the two programs
that serve this population, (2) benefit overlaps between these two
programs and the associated shifting of care and costs between
federal and state levels, and (3) states' efforts to use managed care
to serve this population.  Our work is based on our recent products
on efforts to reform Medicare posthospital benefit payments and
Medicare and Medicaid managed care issues, an analysis of federal
data on dually eligible beneficiaries, and other relevant research. 
(A list of related GAO products appears at the end of this
statement.)

In summary, the dually eligible population consists of people with a
range of health needs--from the young to the very old and from the
healthy to the disabled or chronically ill in nursing homes. 
Compared with Medicare-only beneficiaries, however, dually eligible
beneficiaries are more likely to have poorer health status and
require costly care, including long-term care.  Meeting their needs
under two programs that are administered under different rules
complicates matters in both fee-for-service and managed care
environments.  The potential to cover posthospital and long-term care
benefits under either program has resulted in costs being shifted
between programs.  Because the federal government pays the full cost
of Medicare and shares the cost of Medicaid with the states, the
greater financial burden generally falls on the federal government. 

To better coordinate acute and long-term care needs while holding
down costs, some states are assessing the potential for enrolling
their dually eligible populations in a single managed care plan. 
However, differences in Medicare and Medicaid requirements for
commercial managed care participation can create barriers to this
approach.  Because these barriers are largely related to certain
statutory beneficiary guarantees, including beneficiaries' freedom to
choose their own provider, granting waivers from federal requirements
to states that are designing comprehensive managed care programs
remains a delicate issue. 

The implications of managing the costs of care for this population
are significant at both the federal and state levels.  The issue is
important to the federal government because it pays for Medicare as
well as for over half of Medicaid's costs.  It is also important to
state governments, because they have little control over federal
decisions--such as the imposition of new Medicare cost-sharing
requirements--that make their budgets vulnerable to unplanned fiscal
liabilities.  As states pursue greater flexibility to design more
efficient and effective service delivery programs for this population
through waivers of certain beneficiary protections guaranteed by
federal statute, federal and state governments' rigorous oversight of
care delivery remains essential. 


   POOR HEALTH STATUS, PROGRAM
   DIFFERENCES POSE CHALLENGES IN
   SERVING DUALLY ELIGIBLE
   POPULATION
---------------------------------------------------------- Chapter 0:1

In concept, Medicare and Medicaid provide essential and complementary
services to dually eligible beneficiaries.  Medicare is the primary
provider of hospital, posthospital, and physician care, while
Medicaid provides benefits beyond those covered by Medicare, such as
prescription drugs and long-term care.  In practice, however,
Medicare and Medicaid's respective roles do not sort this out neatly,
and the health financing needs of the dually eligible population
surface numerous contradictions and policy conundrums when attempts
are made to mesh the two programs. 


      POOR HEALTH STATUS
      CHARACTERIZES THE CONDITION
      OF MANY OF THE DUALLY
      ELIGIBLE
-------------------------------------------------------- Chapter 0:1.1

Dual eligibles are among the most vulnerable Medicare beneficiaries. 
Within this population, however, individuals' health needs and
associated medical costs can vary substantially.  Although some
individuals incur few or no costs beyond those of the general
population, many have substantially greater health care needs and
fewer personal resources to meet those needs than the average
Medicare beneficiary.  By definition, dual eligibles are poor:  about
20 percent have annual income of less than $5,000 a year; 80 percent
have annual income of less than $10,000.  Compared with Medicare-only
beneficiaries, dually eligible beneficiaries are more likely to

  -- live in a nursing home or live alone;

  -- have a serious and chronic condition, and physical or cognitive
     impairment; and

  -- have less access to a regular source of care and preventive
     services, and higher use of emergency room care. 


      MEDICARE AND MEDICAID
      DISPLAY KEY STRUCTURAL
      DIFFERENCES
-------------------------------------------------------- Chapter 0:1.2

Medicare is a federally financed health insurance program
administered by the Department of Health and Human Services' Health
Care Financing Administration (HCFA).  It covers almost all Americans
65 years old and older and certain individuals under 65 who are
disabled or have chronic kidney disease.  The program provides
protection with an acute care focus under two parts.  Part A covers
inpatient hospital services, posthospital care in skilled nursing
facilities (SNF), and care in patients' homes.  Part B covers
primarily physician and other outpatient services.  In fiscal year
1996, Medicare covered an estimated 38 million beneficiaries at a
cost of $197 billion. 

Medicaid is a health insurance program financed and administered by
both the federal government and the states.  Its beneficiaries
include poor children and their parents as well as low-income
elderly, blind, and disabled individuals.  In addition to covering
primary and acute care, Medicaid covers outpatient prescription drugs
and long-term care both in the home and in nursing facilities. 

Medicaid, however, is not 1, but over 50 separate programs.\1
Although federal law mandates coverage of certain medical services
and population groups, it also permits states to choose whether to
cover additional services or low-income population groups.  Thus,
under Medicaid, the populations served and benefits provided vary
across states.  The percentage of Medicaid expenditures covered by
the federal government also varies by state, depending on the state's
per capita income, with a range from 50 to 83 percent.  In 1996, the
federal government paid 57 percent of the aggregate Medicaid costs of
about $160 billion, which provided health care coverage for about 37
million beneficiaries. 

Both programs have traditionally reimbursed providers through
fee-for-service arrangements, but both have been developing managed
care components in which beneficiaries obtain care from prepaid
health plans.  Managed care plans in both programs cover
beneficiaries under terms that are different from those under
fee-for-service arrangements.  For example, managed care
organizations are paid a fixed monthly amount for each enrollee to
provide or arrange for medical services, which are typically
coordinated through a primary care physician.  In addition, Medicaid
managed care programs differ among states.  To implement these
programs, states typically seek approval from HCFA to waive certain
federal requirements.  Named after sections of the Social Security
Act that authorize the waivers, 1915(b) program waivers and 1115
demonstration waivers permit states to conduct managed care programs
and experiment with plan participation and eligibility rules that
would otherwise be prohibited by law. 


--------------------
\1 There are 56 programs, 1 in each of the 50 states, the District of
Columbia, Puerto Rico, and the U.S.  territories. 


      DUAL ELIGIBLES QUALIFY FOR
      MEDICARE AND VARIOUS LEVELS
      OF MEDICAID SUPPORT
-------------------------------------------------------- Chapter 0:1.3

Dually eligible individuals are Medicare beneficiaries first. 
According to the level of support provided by Medicaid, the dually
eligible population is divided into two major groups:  (1) those
receiving Medicare cost-sharing support and additional Medicaid
health care benefits ("full-benefit" individuals) and (2) those
receiving help from Medicaid only to cover out-of-pocket costs after
payment by Medicare.  Collectively, both groups of dually eligible
beneficiaries represent about 16 percent of the Medicare population
but 30 percent of Medicare expenditures.  Similarly, they account for
about 17 percent of the Medicaid population but 35 percent of
Medicaid expenditures. 

States vary dramatically in the proportion of Medicare beneficiaries
also enrolled in their Medicaid programs.  According to one source,
in 1993, two states' Medicaid programs covered more than 20 percent
of their Medicare beneficiary populations, whereas eight states'
Medicaid programs covered fewer than 7 percent of their states'
Medicare beneficiaries.\2 These differences may reflect variation
across states in demographic composition, state eligibility criteria,
outreach efforts, and data reporting practices. 

Full-benefit individuals--an estimated 5.4 million in 1995--compose
the largest group of Medicare beneficiaries covered by Medicaid.\3
They qualify for Medicaid primarily because they are "categorically
eligible"--that is, they are eligible for such cash assistance
programs as Supplemental Security Income (SSI)--or because they are
"medically needy," which means they have incomes or assets above the
levels that would make them eligible for cash assistance but their
medical expenses relative to their incomes are so substantial that
states qualify them for assistance.\4

A much smaller group of Medicare beneficiaries--an estimated 562,000
in 1995\5 --receives Medicaid coverage for certain Medicare financial
obligations and includes two subgroups.  The first consists of
Qualified Medicare Beneficiaries--called QMBs.  These people have
incomes or assets that exceed the thresholds set for full-benefit
eligibility but have incomes that are nevertheless at or below the
federal poverty level.  Medicaid pays these beneficiaries' Medicare
monthly part B premiums and all copayments and deductibles required
under Medicare.  The second subgroup consists of Specified Low-Income
Medicare Beneficiaries--called SLMBs.  These people have incomes
slightly above the federal poverty level; Medicaid pays their
Medicare premiums but not copayments or deductibles. 

The Congress enacted the QMB and SLMB programs in 1988 and 1990,
respectively, out of concern for the financial hardship that Medicare
cost-sharing requirements could pose for low-income people not
eligible for Medicaid.  As we reported in 1994 and others have stated
more recently, since the programs were implemented, many individuals
eligible for Medicaid's cost-sharing support have not taken advantage
of it.\6

In 1995, an estimated 37 percent of people eligible for the QMB
program were not enrolled, and an estimated 90 percent of people
eligible for the SLMB program were not enrolled.\7


--------------------
\2 Katie Merrell and others, "Medicare Beneficiaries Covered by
Medicaid Buy-In Agreements," Health Affairs (Jan./Feb.  1997). 

\3 This testimony focuses primarily on the dual eligibles who qualify
for full benefits. 

\4 States may also choose to provide Medicaid benefits to people with
incomes up to 300 percent of SSI levels in nursing homes or receiving
home and community-based services under a waiver, or to people with
income between SSI levels and 100 percent of the poverty level who
may not be receiving cash assistance. 

\5 Precise numbers for these individuals are not readily available. 
For a recent estimate, see Judith Feder, "Medicare/Medicaid Dual
Eligibles:  Fiscal and Social Responsibility for Vulnerable
Populations" (Georgetown University:  Mar.  25, 1997). 

\6 Medicare and Medicaid:  Many Eligible People Not Enrolled in
Qualified Medicare Beneficiary Program (GAO/HEHS-94-52, Jan.  20,
1994). 

\7 Marilyn Moon and others, Protecting Low-Income Medicare
Beneficiaries (The Urban Institute:  Nov.  1996). 


   BENEFIT OVERLAPS FOSTER
   SHIFTING OF FEE-FOR-SERVICE
   COSTS BETWEEN PROGRAMS
---------------------------------------------------------- Chapter 0:2

Both Medicare and Medicaid devote substantial resources to providing
care to the dually eligible population.  At the same time, both
programs are under pressure to contain cost growth in their
respective programs.  This makes the substitution of services
provided--and the resulting shifting of costs between federal and
state levels--one alternative for limiting a program's fiscal
liability.  The net burden is likely to fall more heavily on the
federal government, as the payer for all Medicare and more than half
of Medicaid expenditures. 

Dual eligibles can obtain similar services from both Medicare and
Medicaid, especially home health and nursing facility care.  Since
1989, when coverage guidelines were liberalized in response to court
decisions, the home health care benefit has been essentially
transformed from one focused on patients needing short-term care
after hospitalization to one that serves chronic, long-term care
patients as well.  Between 1989 and 1996, Medicare's part A home
health care payments rose sevenfold, from $2.4 billion to $17.7
billion.  As we testified before congressional committees earlier
this year,\8 not only has the number of Medicare beneficiaries
receiving home health care increased dramatically, but so has the
intensity of visits for each beneficiary.\9

Medicaid, as a payer for long-term and home-based care, can take
advantage of Medicare's liberalized guidelines to help cover the
costs of long-term care for dual eligibles.  This practice, often
referred to as "Medicare maximization," involves Medicaid's billing
of Medicare first--where feasible--on behalf of dual eligibles.  This
practice is consistent with the Social Security Act, which requires
that, when a service is covered by both programs, Medicare is the
primary payer.  A recent example is the enactment in 1996 of
Minnesota's Medicare Maximization Initiative, a program designed to
teach providers how to use Medicare for home care services and
supplies and equipment for recipients who are dually eligible.  In
this way, Medicaid has been able to reduce its costs by capitalizing
on the movement of Medicare's home health benefit from a post-acute
focus to include long-term care benefits. 

Alternatively, when Medicare's SNF coverage criteria for daily
skilled care are applied more stringently, Medicare's coverage of a
dually eligible patient's SNF stay may end earlier and Medicaid
becomes the primary payer.  Such a strict application of Medicare
coverage criteria, while advantageous to Medicare, shifts some of the
burden of financing SNF care to Medicaid. 


--------------------
\8 We have testified before the Subcommittee on Health and
Environment, House Committee on Commerce:  Medicare:  Home Health
Cost Growth and Administration's Proposal for Prospective Payment
(GAO/T-HEHS-97-92, Mar.  5, 1997) and before the Subcommittee on
Health, House Committee on Ways and Means:  Medicare Post-Acute Care: 
Home Health and Skilled Nursing Facility Cost Growth and Proposals
for Prospective Payment (GAO/T-HEHS-97-90, Mar.  4, 1997). 

\9 The number of Medicare beneficiaries receiving home health care
more than doubled, from 1.7 million in 1989 to about 3.9 million in
1996.  During the same period, the average number of visits to home
health beneficiaries also more than doubled, from 27 to 72.  In
addition, we found that the proportion of home health users receiving
more than 30 visits increased from 24 percent in 1989 to 43 percent
in 1993, and, during the same period, the proportion of those
receiving more than 90 visits tripled, from 6 percent to 18 percent. 


   STATES' DESIRE TO USE MANAGED
   CARE MAY CONFLICT WITH FEDERAL
   GUARANTEES TO MEDICARE
   BENEFICIARIES
---------------------------------------------------------- Chapter 0:3

States are beginning to explore the use of managed care to serve
their dually eligible populations.  However, using managed care
prepaid health plans presents another set of dilemmas.  On the one
hand, managed care, in principle, offers the potential for a single
system of coordinated care to serve a population particularly likely
to benefit from such a system.  On the other hand, managed care
plans--both in Medicare and Medicaid--have little experience serving
a population with expensive medical and extensive long-term care
needs.  In addition, each of the respective programs has different
terms for beneficiary and plan participation.  Thus, as states
consider enrolling dual eligibles in their managed care programs,
they face certain barriers that require federal and state cooperation
to overcome.  With federal waivers from some statutory requirements,
several states have removed key administrative obstacles, permitting
the enrollment of the dually eligible population. 


      DIFFERENCES IN MANAGED CARE
      PARTICIPATION TERMS
      COMPLICATE STATES' EFFORTS
      TO COORDINATE CARE
-------------------------------------------------------- Chapter 0:3.1

Medicare and Medicaid managed care programs are characterized by two
key differences: 

  -- "Freedom-of-choice" guarantees.  Under Medicare, beneficiaries
     can enroll in any managed care plan with a Medicare contract and
     are free to disenroll every 30 days and reenter the
     fee-for-service system or join another managed care plan.  Under
     Medicaid, with HCFA-granted waivers a state can require
     beneficiaries to enroll in a limited number of state managed
     care plans and can also "lock in" their enrollment for as long
     as 12 months. 

  -- Plan participation requirements.  In both programs, managed care
     plans must enroll a certain number of commercial members because
     of the hypothesis that a health plan's ability to attract
     private enrollees can serve as one assurance of quality. 
     Medicare's commercial membership threshold of 50 percent is
     higher than Medicaid's, which is 25 percent--or waived
     altogether in the case of states that have obtained special
     approval from HCFA.\10

As states seek greater control of their health financing and care
delivery obligations, these program differences may serve as barriers
to enrolling dual eligibles in a single managed care plan. 
Medicare's liberal disenrollment policy, coupled with its requirement
to enroll beneficiaries in plans meeting the 50-percent commercial
membership level, complicates states' ability to use managed care for
their Medicaid beneficiaries with Medicare status. 

For example, a state's ability to lock beneficiaries into a prepaid
plan providing both Medicare and Medicaid benefits for an extended
period may have the benefit of stabilizing the state's fiscal
liability for health care, while offering the potential to coordinate
care within a single network of providers.  But dually eligible
beneficiaries who exercise their Medicare right to leave the plan
during the Medicaid lock-in period may expose the state to the
cost-sharing obligations incurred with a fee-for-service or Medicare
managed care provider and preclude the Medicaid plan's potential to
organize a system of coordinated services.  In addition, states may
have existing contractual relationships with Medicaid managed care
organizations that could serve the states' dual eligibles, but their
public program membership exceeds the 50-percent threshold needed to
comply with Medicare's rules for plans eligible to serve Medicare
beneficiaries. 


--------------------
\10 The administration has proposed replacing Medicare and Medicaid's
commercial enrollment requirements with enhanced quality monitoring
and measurement systems, yet to be defined. 


      BENEFICIARY PROTECTION IN
      MANAGED CARE MORE CRITICAL
      FOR DUALLY ELIGIBLE
      POPULATION
-------------------------------------------------------- Chapter 0:3.2

With its focus on coordinated care, managed care provides states an
option for moving their dually eligible population into a single plan
providing all or most required services.  However, a Medicaid
program's policy may preclude incorporating certain Medicare
provisions--such as the freedom to choose among all participating
plans and to disenroll monthly--which have been considered important
beneficiary protections in managed care.  As our recent testimony
before this Committee indicated, the ability of plans to satisfy and
retain beneficiaries is highly variable.\11

The more complex and extensive needs of the dually eligible
population accentuate the importance of beneficiary protections. 
However, limited experience on the part of states and plans
serving--in a managed care setting--people with the demographic and
health status traits of dual eligibles makes it difficult to identify
beneficiary protections that will be effective and will minimize
problems in coordinating these two programs.  For example, we
recently reviewed states' prepaid Medicaid programs serving disabled
beneficiaries\12 and found that, of 17 states making managed care
available to disabled people, 12 had less than 20 percent of their
disabled beneficiaries enrolled.  Of the six state programs requiring
some or all of their disabled population to enroll in prepaid managed
care, only one was more than 3 years old. 

We also found that oversight mechanisms designed to track a plan's
performance in delivering services to the average enrollee are not
well-suited to monitor service delivery to the severely disabled, who
may represent a small number of enrollees in a plan.  About half of
the 17 states enrolling disabled beneficiaries in prepaid managed
care continued to rely on mechanisms such as beneficiaries' freedom
to disenroll from or switch plans or on their access to grievance
systems in lieu of more carefully targeted formal quality assurance
systems. 


--------------------
\11 Medicare Managed Care:  HCFA Missing Opportunities to Provide
Consumer Information (GAO/T-HEHS-97-109, Apr.  10, 1997). 

\12 Medicaid Managed Care:  Serving the Disabled Challenges State
Programs (GAO/HEHS-96-136, July 31, 1996). 


   SEVERAL CONCERNS ABOUT DUAL
   ELIGIBLES REMAIN ISSUES FOR THE
   FUTURE
---------------------------------------------------------- Chapter 0:4

Several factors highlight the importance of dual eligibility in the
coming years:  a growing dually eligible population, the potential
for new cost-sharing obligations, and states' continued requests for
waivers to implement innovative managed care programs. 

The demographics of the dually eligible beneficiaries will
undoubtedly continue to focus attention on the respective federal and
state roles in serving this population.  The numbers of dual
eligibles are expected to increase, and the two groups that are
likely to be dually eligible--the oldest elderly and the nonelderly
disabled--are growing segments of the Medicare population.\13

Among the various approaches being considered to contain the
unsustainable growth in Medicare costs is the option to increase
beneficiary cost sharing.  However, if Medicare premiums and cost
sharing are increased, these costs will consequently rise for the
states, as payers of the dually eligibles' financial obligations
under Medicare. 

Finally, states are likely to continue seeking flexibility under
HCFA's waiver approval process to overcome existing barriers to dual
eligibles' enrollment in managed care.  How HCFA will treat
freedom-of-choice issues, such as the beneficiaries' right to
disenroll monthly, and the "50-50" public/private membership rule
remains an open question.  Regardless of the approaches taken, our
recent work in both Medicare and Medicaid managed care stresses
repeatedly that, to ensure program accountability for the interests
of both beneficiaries and the federal government, rigorous federal
and state oversight of care and effective quality monitoring systems
are essential. 


--------------------
\13 Nonelderly disabled beneficiaries made up about 10 percent of the
Medicare population in 1991 but are expected to make up nearly 18
percent in 2010.  Similarly, beneficiaries aged 85 or older made up 8
percent of the Medicare population in 1991 but are expected to
compose 11 percent of the Medicare population in 2010. 


-------------------------------------------------------- Chapter 0:4.1

Mr.  Chairman, this concludes my prepared statement.  I will be happy
to answer any questions you or the other Committee Members may have. 


   CONTRIBUTORS
---------------------------------------------------------- Chapter 0:5

For more information on this testimony, please call Kathryn G. 
Allen, Acting Associate Director, on (202) 512-7059.  Other major
contributors included Hannah F.  Fein and Sally J.  Kaplan. 


RELATED GAO PRODUCTS
=========================================================== Appendix 1

Medicaid Managed Care:  Challenge of Holding Plans Accountable
Requires Greater State Effort (GAO/HEHS-97-86, forthcoming). 

Medicare:  Home Health Cost Growth and Administration's Proposal for
Prospective Payment (GAO/T-HEHS-97-92, Mar.  5, 1997). 

Medicare Post-Acute Care:  Home Health and Skilled Nursing Facility
Cost Growth and Proposals for Prospective Payment (GAO/T-HEHS-97-90,
Mar.  4, 1997). 

Medicare HMOs:  Potential Effects of a Limited Enrollment Period
Policy (GAO/HEHS-97-50, Feb.  28, 1997). 

Medicare:  HCFA Should Release Data to Aid Consumers, Prompt Better
HMO Performance (GAO/HEHS-97-23, Oct.  22, 1996). 

Medicaid Managed Care:  Serving the Disabled Challenges State
Programs (GAO/HEHS-96-136, July 31, 1996). 

Medicare:  Increased HMO Oversight Could Improve Quality and Access
to Care (GAO/HEHS-95-155, Aug.  3, 1995). 

Medicaid:  Spending Pressures Drive States Toward Program Reinvention
(GAO/HEHS-95-122, Apr.  4, 1995). 

Medicare and Medicaid:  Many Eligible People Not Enrolled in
Qualified Medicare Beneficiary Program (GAO/HEHS-94-52, Jan.  20,
1994). 


*** End of document. ***