Academic journal article Health Care Financing Review

Excluded from Universal Coverage: ESRD Patients Not Covered by Medicare

Academic journal article Health Care Financing Review

Excluded from Universal Coverage: ESRD Patients Not Covered by Medicare

Article excerpt


In terms of morbidity, mortality, and economic costs, ESRD is among the most serious chronic diseases in the United States (Institute of Medicine, 1991). ESRD results from the permanent loss of kidney function and, without a regular course of dialysis or kidney transplantation, the disease is fatal. The Medicare ESRD program, established in 1973, grants a "near universal" entitlement to Medicare benefits for persons who require chronic dialysis or a kidney transplant to maintain life.

While this entitlement provides coverage for most Americans with irreversible kidney failure, it does not ensure coverage for all persons with ESRD. In 1991, Medicare insured approximately 93 percent of the 142,488 ESRD dialysis patients with kidney failure in the United States through the ESRD program (Health Care Financing Administration, 1993).

To receive a Medicare entitlement for ESRD, a physician must certify that a person requires continuous dialysis or a kidney transplant to maintain life. Additional requirements for entitlement include the following: eligibility for monthly insurance benefits under Title II of the Social Security Act; full or current insurance under Social Security; or to be the spouse or dependent child of a person who meets at least one of the two previous requirements. Approximately 10,000 ESRD dialysis patients, representing 7 percent of chronic dialysis patients nationally, did not meet these entitlement criteria in 1991 (Health Care Financing Administration, 1993). For these persons, Esrd-related services may have been paid for by other organizations, including State Medicaid agencies, the Department of Veterans Affairs (DVA), State kidney fund programs, the Indian Health Service, State and Federal prison systems, and private health insurance. According to the most recent survey, conducted by HCFA using 1981 data (Health Care Financing Administration, 1984), 70 percent of Medicare-ineligible ESRD patients were covered by State Medicaid, DVA, or State kidney programs. In light of an ever-expanding patient population and stable or declining DVA and State kidney program funding, State Medicaid agencies are increasingly becoming the primary financial support for ESRD patients who lack Medicare coverage (Institute of Medicine [IOM], 1991).

The IOM (1991), in its seminal study on kidney failure in the United States, reported that the existing data on the ineligible ESRD population are limited and do not include the extent and adequacy of other sources of support. In particular, the effects of ineligibility on access to or denial of treatment and differences between the benefits offered by Medicare versus other payers have not been examined. The IOM also reported that, "Although State Medicaid ESRD expenditures for .. reported non-eligibles are undoubtedly substantial, neither a direct count nor a good estimate exists." In light of the paucity of data, the IOM recommended that studies be conducted to ascertain the demographic characteristics, health status, and access to ESRD services for Medicare-ineligible ESRD patients.

To date, there are no published studies that have examined the Medicaid-only ESRD population. Using claims submitted to the Medicaid programs in California, Georgia, and Michigan, this study identifies Medicaid enrollees receiving chronic renal dialysis in 1991 who were not covered by Medicare or private insurance. The goals of this study are the following: (1) to quantify the health resource utilization of the Medicaid-only population, including dialysis treatments, inpatient and outpatient health care, pharmaceutical use, and long-term care; (2) to determine the total and per capita Medicaid health care expenditures for this population for calendar year 1991; and (3) to compare, to the extent possible, patient demographics, health resource utilization, and costs between the Medicaid and Medicare ESRD dialysis populations in each State.


We analyzed calendar year 1991 data on Medicaid and Medicare ESRD patients residing in California, Georgia, and Michigan. …

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