Public Health Insurance Programs: Cost Containment, Equity, and Care Burden Among Aging and Disabled Populations

Session Submission Type: Panel

Abstract

Public health insurance programs in the United States serve as crucial safety nets for aging and disabled populations. Yet, their design features, such as reimbursement structures, cost-containment mechanisms, administrative arrangements, and eligibility rules, may lead to unintended outcomes. The four studies in this panel examine how program design and policy reforms across Medicare, Medicaid, and Social Security disability programs are associated with financial security, equity, and care burden among older adults and people with disabilities. Together, they show that cost-containment efforts and inequities embedded in public insurance programs may lead to consequences that spill over into family caregiving, household financial hardship, and unmet care needs.

A central theme across the papers is that cost-containment policies, while fiscally motivated, are associated with redistributive consequences that extend beyond their intended targets. One study provides causal evidence that the effects of Medicare hospice payment reforms on patients with Alzheimer's disease and related dementias, transfer care burden onto unpaid family members when formal support was withdrawn. Descriptive evidence further suggests that Medicaid estate recovery, which was enacted to recoup long-term care costs, recovers modest amounts relative to administrative costs while disproportionately targeting families of modest means. Taken together, these findings suggest that the burden of cost containment is not eliminated but displaced onto the vulnerable populations.

The papers also collectively document how program structure is linked to inequity. Access to Medigap supplemental insurance, which provides protection against out-of-pocket cost risk, has become stratified by socioeconomic status, while rising premiums driven by state regulatory environments are associated with lower-income seniors shifting toward Medicare Advantage. Meanwhile, descriptive evidence on SSDI and SSI beneficiaries, a population with significant personal care needs, points to distinct gaps in access to paid care, and raises questions about whether disability benefit programs adequately support functional independence.

Taken together, four studies show that program design choices about reimbursement rates, administrative arrangements, supplemental coverage markets, and benefit structures are associated with disparities in equity and well-being that extend beyond their immediate fiscal targets. As the U.S. confronts rising long-term care costs and a growing population of older adults and people with disabilities, the design of public insurance programs will be an increasingly important determinant of population health and economic security.

Policy Area

• Health Policy

Chair

• Afsana Alam, University of Massachusetts Boston

Discussants

• Ngoc Dao, Kean University

• Yonatan Ben-Shalom, Mathematica

Organizer

• Soohyun Kim, Syracuse University

Individual Presentations

• Medicare Hospice Reform andthe Reallocation of End-of-Life Care - Presenting Author: Soohyun Kim, Syracuse University

• Medicaid Estate Recovery: Is there value to keeping it "in house"? - Presenting Author: Amanda Spishak-Thomas, Rutgers University

• Who Pays for Care? Disability, Public Programs, and the Sources of Home Care at Midlife - Presenting Author: Na Yin, Baruch College (City University of New York); Non-Presenting Co-Author: Yinuo Guo, The City University of New York