Medicare's Invisible Populations on Syam Adusumilli

The LIS Landscape

Sun, 15 Mar 2026 00:00:00 +0000

The policy conversation about low-income Medicare beneficiaries almost always defaults to dual eligibles. That population is important, heavily studied, and reasonably well-served by an infrastructure of D-SNPs, FIDE SNPs, and state integration contracts designed to wrap services around their needs. But there is a population that is larger, less studied, and far less well-served by existing policy infrastructure: the low-income Medicare beneficiaries who receive Extra Help for Part D, or who qualify for Medicare Savings Programs, but who are not full dual eligibles. These are more than 13 million Americans navigating Medicare costs without the full protection of Medicaid, often unaware of the programs that exist to reduce their burden.

Summary: The LIS Landscape

Sun, 15 Mar 2026 00:00:00 +0000

The policy conversation about low-income Medicare beneficiaries defaults almost entirely to dual eligibles. That population is important and reasonably well-served by D-SNPs, FIDE SNPs, and state integration contracts. But a larger, less studied population falls outside the dual eligible framework: more than 13 million Americans who receive Extra Help for Part D or qualify for Medicare Savings Programs but who are not full dual eligibles. They are navigating Medicare costs without the full protection of Medicaid, often unaware of the programs that exist to reduce their burden. The problem is not that these programs do not exist. The problem is that millions of eligible beneficiaries are not enrolled, the enrollment processes are fragmented across federal and state agencies, and the policy conversation treats these populations as an afterthought.

Racial and Ethnic Health Equity in Medicare

Sun, 15 Mar 2026 00:00:00 +0000

Medicare is designed to be race-neutral. Payment rates, coverage rules, and beneficiary rights are uniform across racial and ethnic groups by statute. The outcomes are not uniform. Black Medicare beneficiaries are hospitalized for acute exacerbations of chronic disease at higher rates than white beneficiaries. Hispanic beneficiaries carry the highest uninsured rates and the most persistent cost-related barriers to care. American Indian and Alaska Native beneficiaries face access constraints that compound chronic disease burdens already three to five times the national average. The mechanisms driving these gaps are increasingly legible in CMS administrative data, in published research on HCC coding completeness, in OIG analyses of prior authorization denial rates, and in Health Affairs studies of MA network composition. What is changing in 2025 and 2026 is not the existence of these disparities but the systematic removal of the federal infrastructure that was designed to measure and address them.

Summary: Racial and Ethnic Health Equity in Medicare

Sun, 15 Mar 2026 00:00:00 +0000

Medicare is designed to be race-neutral. Payment rates, coverage rules, and beneficiary rights are uniform across racial and ethnic groups by statute. The outcomes are not uniform. Black Medicare beneficiaries are hospitalized for acute exacerbations of chronic disease at higher rates than white beneficiaries. Hispanic beneficiaries carry the highest uninsured rates and the most persistent cost-related barriers to care. American Indian and Alaska Native beneficiaries face access constraints that compound chronic disease burdens three to five times the national average. What is changing in 2025 and 2026 is not the existence of these disparities but the systematic removal of the federal infrastructure that was designed to measure and address them.

LGBTQ+ Seniors in Medicare

Sun, 15 Mar 2026 00:00:00 +0000

LGBTQ+ Medicare beneficiaries are not identified in CMS administrative data. There is no field in the Medicare enrollment record for sexual orientation or gender identity. There is no SOGI variable in the Master Beneficiary Summary File. There is no way, using CMS claims data alone, to determine how many LGBTQ+ beneficiaries are enrolled in Medicare, what their utilization patterns look like, or how their outcomes compare to the general Medicare population. The estimated population is approximately 1.1 million people age 65 and older, projected to double by 2030 as the generation that came of age during and after Stonewall ages into Medicare eligibility. The actual figure is unknown because the measurement system does not ask.

Summary: LGBTQ+ Seniors in Medicare

Sun, 15 Mar 2026 00:00:00 +0000

LGBTQ+ Medicare beneficiaries are not identified in CMS administrative data. There is no field in the Medicare enrollment record for sexual orientation or gender identity. The estimated population is approximately 1.1 million people age 65 and older, projected to double by 2030, but the actual figure is unknown because the measurement system does not ask. What is known from survey research and community-based studies consistently shows elevated rates of depression, anxiety, social isolation, chronic disease, and food and housing insecurity among LGBTQ+ older adults compared to heterosexual and cisgender peers. One-third of LGBTQ+ older adults live at or below 200 percent of the federal poverty level. For transgender older adults, the figure is 48 percent, reflecting lifetime disparities in earnings, employment discrimination, and decades of exclusion from the wealth-building mechanisms that married heterosexual couples accessed through employer-sponsored benefits, joint tax filing, and Social Security spousal benefits.

Native American and Tribal Medicare

Sun, 15 Mar 2026 00:00:00 +0000

Native American Medicare beneficiaries occupy a legal and operational space in the federal health system that has no parallel. They hold sovereign treaty rights to healthcare through the Indian Health Service, a system created to fulfill the federal government’s trust responsibility to tribal nations. They are simultaneously Medicare beneficiaries, entitled to the same coverage as every other person over 65 or qualifying through disability. The interaction between those two systems produces a coverage architecture that is more complex, more fragmented, and more dependent on administrative capacity at the facility level than anything in mainstream Medicare policy analysis. IHS serves approximately 2.6 million American Indian and Alaska Native people across 37 states. Among those who are Medicare-eligible, the question is not whether they have coverage in theory. It is what that coverage produces in practice when the system designed to serve them is funded at roughly half the level needed.

Summary: Native American and Tribal Medicare

Sun, 15 Mar 2026 00:00:00 +0000

Native American Medicare beneficiaries hold sovereign treaty rights to healthcare through the Indian Health Service and are simultaneously Medicare beneficiaries entitled to the same coverage as every other enrollee. The interaction between those two systems produces a coverage architecture more complex and more fragmented than anything in mainstream Medicare policy. IHS serves approximately 2.6 million American Indian and Alaska Native people across 37 states. For fiscal year 2024, projected third-party collections totaled approximately $1.8 billion, of which $252 million came from Medicare. IHS is funded at roughly half the level needed: the FY 2023 budget was approximately $6.96 billion against the Tribal Budget Formulation Workgroup’s estimate of $51 billion needed for adequate services. Per capita IHS spending remains roughly one-third of Medicare per capita spending and half of Veterans Health Administration per capita spending.

The Incarceration-to-Medicare Pipeline

Sun, 15 Mar 2026 00:00:00 +0000

Every year, thousands of people age 65 and older are released from state and federal prisons. They are Medicare-eligible. Most are not immediately enrolled in Medicare upon release. Many are also Medicaid-eligible but face separate enrollment delays for that program. They leave incarceration with chronic disease prevalence rates three to five times higher than the general Medicare population for conditions including diabetes, hypertension, hepatitis C, HIV, and COPD. Approximately 20 percent of incarcerated older adults have a serious mental illness. Substance use disorder, opioid use disorder in particular, creates immediate medication access needs at reentry that administrative delays interrupt. The policy infrastructure to manage this transition has improved in the last two years, but the gap between what exists on paper and what happens at the point of release remains wide.

Summary: The Incarceration-to-Medicare Pipeline

Sun, 15 Mar 2026 00:00:00 +0000

Every year, thousands of people age 65 and older are released from state and federal prisons. They are Medicare-eligible. Most are not immediately enrolled. They leave incarceration with chronic disease prevalence rates three to five times higher than the general Medicare population for conditions including diabetes, hypertension, hepatitis C, HIV, and COPD. Approximately 20 percent of incarcerated older adults have a serious mental illness. Substance use disorder, opioid use disorder in particular, creates immediate medication access needs at reentry that administrative delays interrupt. The policy infrastructure to manage this transition has improved, but the gap between what exists on paper and what happens at the point of release remains wide.

Housing-Insecure and Homeless Seniors

Sun, 15 Mar 2026 00:00:00 +0000

Medicare enrollment is designed for people who have a mailbox and a fixed address. The application process generates paper correspondence. CMS communications including enrollment decisions, appeals notices, and premium billing arrive by mail. The Part B premium must be paid by check, bank account, or Social Security withholding. Every interaction with the Medicare system assumes a stable residential address tied to a Social Security record. For the 41,292 seniors age 65 and older counted as experiencing homelessness on a single night in January 2024, and the much larger number living in doubled-up, transitionally housed, or otherwise precarious circumstances that the point-in-time count does not capture, these design assumptions are enrollment barriers. The population that has the least capacity to navigate a complex enrollment process is the one the process is least designed to accommodate.

Summary: Housing-Insecure and Homeless Seniors

Sun, 15 Mar 2026 00:00:00 +0000

Medicare enrollment is designed for people who have a mailbox and a fixed address. The application process generates paper correspondence. Enrollment decisions, appeals notices, and premium billing arrive by mail. The Part B premium must be paid by check, bank account deduction, or Social Security withholding. Every interaction with the Medicare system assumes a stable residential address tied to a Social Security record. For the 41,292 seniors age 65 and older counted as experiencing homelessness on a single night in January 2024, the highest recorded count in that age category since HUD began collecting age-disaggregated data, these design assumptions are enrollment barriers. Forty-three percent of those seniors were unsheltered. The National Alliance to End Homelessness estimates the number of older adults experiencing homelessness will triple between 2017 and 2030. The senior homeless population is growing faster than the overall homeless population, and it is growing into a healthcare system that was not built to find them.