US HEALTH REFORM-MONITORING AND IMPACT Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Analysis of Alternative Approaches to Increasing Part B Financial Assistance to Medicare Beneficiaries with Low Incomes Anuj Gangopadhyaya, John Holahan, Adele Shartzer, and Bowen Garrett December 2022 Medicare Savings Programs (MSPs) provide financial assistance with premium obligations and cost-sharing expenses to many low-income Medicare beneficiaries who are not eligible for full Medicaid benefits. However, these programs have income and asset limits that are often less generous than federal laws allow, and even in the most generous programs, low-income beneficiaries may still face very high financial burdens from premiums, deductibles, and copayments. In this brief, we estimate the effects and costs of three national policies that would limit the financial burdens faced by low- income Medicare enrollees. Unlike MSPs, none of the three approaches uses asset tests to determine eligibility. The first approach would cap Part B premiums for all Medicare enrollees at 8.5 percent of income. The second would cap Part B premiums using the Inflation Reduction Act (IRA) income cap schedule, which fully subsidizes premiums for people with incomes up to 150 percent of the federal poverty level (FPL) and then gradually increases household spending on Part B premiums to 8.5 percent of income for those with incomes at or above 400 percent of FPL. The third approach would also use the IRA premium schedule but eliminate Part B cost sharing for beneficiaries with incomes at or below 100 percent of FPL. We find an 8.5 percent cap would provide some financial assistance to nearly all enrollees with incomes below the poverty level and many with incomes between 100 and 200 percent of FPL without substantially raising Medicare payments. Applying IRA income caps would provide financial assistance to all Medicare enrollees with incomes below 200 percent of FPL and nearly half of enrollees with incomes between 200 and 400 percent of FPL, but doing so would raise total Medicare Part B program spending by 9 percent. About US Health Reform-Monitoring and Impact With support from the Robert Wood Johnson Foundation, the Urban Institute has undertaken US Health Reform-Monitoring and Impact, a comprehensive monitoring and tracking project examining the implementation and effects of health reforms. Since May 2011, Urban Institute researchers have documented changes to the implementation of national health reforms to help states, researchers, and policymakers learn from the process as it unfolds. The publications developed as part of this ongoing project can be found on both the Robert Wood Johnson Foundation's and Urban Institute Health Policy Center's websites. Introduction Medicare beneficiaries with low incomes-like all other beneficiaries-are required to pay premiums for Part B that cover 25 percent of the costs of services, unless they enroll in one of the MSPs that Congress established to provide financial help. However, these MSPs are not easily accessible because they are administered by state Medicaid programs, have eligibility requirements that can vary by state, and have low participation. For example, for most enrollees, the 2023 monthly premium for Part B coverage will be $164.90 ($1,979 annually). At this level, Part B premiums alone would represent about 15 percent of the annual income of an unmarried beneficiary over the age of 65 with an income right at the FPL.1 Because federal financial assistance through an MSP is not available to any beneficiary with income above 135 percent of FPL, the burden of these premiums is quite substantial for beneficiaries with incomes just above that cutoff. Beyond the financial burden these Part B premiums represent, low- income enrollees without MSP protections also face a $226 deductible and 20 percent cost-sharing for Part B services, unless they have protection from a supplemental plan. Policymakers took a very different approach when providing subsidies for nongroup coverage purchased through the Marketplaces established under the Affordable Care Act. Under the Affordable Care Act, subsidies covered the full premium for people with incomes at 100 percent of FPL and gradually phased out until incomes reach 400 percent of FPL, where payments were capped at 8.5 percent of income. Under the American Rescue Plan Act, the subsidy schedule was made more generous and the 8.5 percent cap was extended through the entire income distribution. The IRA, passed in August 2022, extends the American Rescue Plan subsidy schedule through 2025. Why Medicare and the Marketplaces take such different approaches to providing financial help with the costs of coverage for those with low and moderate incomes has never been seriously debated. 2 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES In this brief, we explore alternative approaches to providing premium and cost-sharing assistance to Medicare beneficiaries to overcome some of the existing challenges of MSPs. We first provide background describing the level of Part B premiums, the income burden these premiums represent, and how the various state-administered MSPs provide protection for certain low-income Medicare enrollees. We then explore three alternative national policies to limit burdens on low-income people:  Policy alternative 1: Cap Part B premiums for all Medicare enrollees at 8.5 percent of income.  Policy alternative 2: Cap Part B premiums using the IRA income caps that have no premiums for people with incomes up to 150 percent of FPL, and then gradually increase premiums to 8.5 percent of income for those with incomes above 400 percent of FPL.  Policy alternative 3: Cap Part B premiums using the IRA income caps that have no premiums for people with incomes up to 150 percent of FPL, gradually increase premiums to 8.5 percent of income for those with incomes above 400 percent of FPL, and eliminate cost sharing for those with incomes at or below 100 percent of FPL. Each of these policy alternatives retains the MSP premium and cost-sharing subsidies under current law but goes further by expanding income eligibility ranges and not requiring asset tests. Background Most Medicare enrollees qualify for premium-free Part A through their work history, but Part B has monthly premiums that increase with income.2 In 2023, the monthly premium for Part B will start at $164.90 and increase to $560.50 for individuals with incomes over $500,000 (or couples with incomes over $750,000). Table 1 shows the current annual premium amounts by income level and the financial burden of those premiums at income levels within each band for married and unmarried beneficiaries. In addition to premiums, both Parts A and B have cost-sharing obligations (copayments and deductibles) that can create financial burdens for Medicare beneficiaries with low or modest incomes without additional assistance. In traditional Medicare in 2023, the Part A deductible for a hospital stay is $1,600. The deductible for physician and other services under Part B is $226, and after the deductible is met beneficiaries are responsible for 20 percent of allowable charges for Part B covered services. State-run Medicaid programs wrap around Medicare coverage for eligible beneficiaries, and those enrolled in both Medicare and Medicaid are called "dual eligibles." Medicaid provides different levels of assistance for different types of dual eligibles. Some beneficiaries can enroll in MSPs for financial help that may only cover premiums or may also cover deductibles, coinsurance, and copayments ("partial benefit Medicaid"). Other beneficiaries may qualify for full Medicaid benefits including additional services and help with Medicare cost sharing under separate non-MSP pathways. INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 3 TABLE 1 Part B Premiums and Premiums as a Share of Income for Married and Unmarried Medicare Beneficiaries, by Income Range, 2023 Premium as a percentage of Marital status and income level Annual premium ($) income at middle of range Married beneficiaries Income range Less than or equal to $194,000 1,979 2.0 $194,000–246,000 2,770 1.3 $246,000–306,000 3,956 1.4 $306,000–366,000 5,143 1.5 $366,000–750,000 6,330 1.1 Greater than or equal to $750,000 6,726 0.9 Unmarried beneficiaries Income range Less than or equal to $97,000 1,979 1.0 $97,000–123,000 2,770 2.5 $123,000–153,000 3,956 2.9 $153,000–183,000 5,143 3.1 $183,000–500,000 6,330 1.9 Greater than or equal to $500,000 6,726 1.4 Source: Centers for Medicare & Medicaid Services, "2023 Medicare Parts A and B Premiums and Deductibles 2023 Medicare Part D Income-Related Monthly Adjustment Amounts," news release, September 27, 2022, https://www.cms.gov/newsroom/fact- sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related- monthly#:~:text=The%20standard%20monthly%20premium%20for,deductible%20of%20%24233%20in%202022. Notes: Annual premiums for married beneficiaries are reported at the individual level. For married couples who are both enrolled in Medicare Part B, the household annual premium total and the premium as a percentage of income will be twice the amounts reported here. There are four main types of MSPs. Under the Qualified Medicare Beneficiary (QMB) program, people receive full subsidies for Part A premiums (if required, which is not common), Part B premiums, and Medicare cost sharing. The federal income eligibility limit for the QMB program is 100 percent of FPL. People eligible for the Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) programs both receive full subsidies for Part B premiums but not Medicare's cost-sharing requirements. Because the QI program is funded through a block grant, once a state's annual QI funding is exhausted no additional eligible individuals can enroll. Qualified Disabled and Working Individual programs are for individuals who lost Medicare Part A benefits because of a return to work but are eligible for Part A and not otherwise eligible for Medicaid (table 2).3 In 2022, the asset limit for the QMB, SLMB, and QI programs was $8,400 for an individual and $12,600 for a couple.4 4 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES TABLE 2 Medicare Savings Program Eligibility Pathways and Benefits (Partial Benefit Medicaid) Federal income Medicare Savings eligibility (% of FPL)a Program Benefits At or below 100% Qualified Medicare  Parts A and B premiums Beneficiary  Medicare deductibles, coinsurance, and copayments 101–120% Specified Low-  Part B premiums Income Medicare Beneficiary 121–135% Qualifying Individual  Part B premiums At or below 200% Qualified Disabled  Part A premiums and Working Individuals Source: "Medicare Savings Programs," Medicare.gov, accessed November 8, 2022, https://www.medicare.gov/basics/costs/help/medicare-savings-programs. Notes: FPL = federal poverty level. a States set income limits that may be up to but not exceed the federal limits. Thus, state eligibility rules may be more strict than federal limits allow. To qualify for an MSP, beneficiaries must apply through their state and have income and resources below certain limits. States vary in income limits for MSPs and which types of income and resources are counted. Enrollment in MSPs differs across states-from 7 percent of the Medicare population in North Dakota to 33 percent in Washington, DC-in part because of differences in eligibility requirements and poverty rates among the Medicare population (Freed et al. 2022). States with higher enrollment in MSPs generally either eliminated the asset test or established income limits higher than the federal limit. The Medicaid and CHIP Payment and Access Commission has pointed out several shortcomings of MSPs.5 Enrollment is low relative to the number of eligible Medicare beneficiaries-participation rates are 53 percent for the QMB program, 32 percent for the SLMB program, and 15 percent for the QI program. To enroll, beneficiaries must have knowledge of the MSPs and submit an application that includes information on income and assets. In addition, eligibility for MSPs is separate from the low- income subsidy for Medicare Part D and other federal programs providing assistance with health insurance coverage, which can create more confusion. The federal income limit for assistance with Medicare premiums (135 percent of FPL) also leaves many low- and moderate-income Medicare beneficiaries without assistance. Data and Methods We use the Urban Institute's Medicare policy simulation model, MCARE-SIM, to estimate 2023 Part B premium spending and Part B service use under current law and to predict the effects of implementing policy options that would provide enhanced subsidies for Part B premiums and, in one scenario, provide additional cost-sharing protections to enrollees with low-income (Arnos et al. 2020). MCARE-SIM uses INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 5 data from the 2015–18 Medicare Current Beneficiary Survey (MCBS) and projects Medicare enrollment and spending estimates to 2023. We estimate 2023 Part B enrollment by reweighting each wave of the MCBS to match 2020 enrollment, reported in the Centers for Medicare & Medicaid Services (CMS) program statistics,6 and then applying population growth rates from the Urban Institute's Mapping America's Futures database.7 We determine enrollee Part B premium spending by applying 2023 CMS Part B premium rules8 based on enrollee family income, marital status, and enrollment in any MSP. Medicare premiums and cost-sharing rules are applied on an individual basis. Accordingly, our analysis focuses on affordability for individual enrollees. A family with two enrollees would pay the premium amount we report twice and face twice the burden. Policy alternative 3 provides additional cost-sharing protections to low-income beneficiaries. We determine the effect of this policy on 2023 spending for Part B services among traditional Medicare enrollees. (We do not include Medicare Advantage enrollees in this analysis of cost-sharing protections because Medicare Advantage cost and use data are unavailable in the MCBS, but the policy would be designed to assist these enrollees as well, noting that Medicare Advantage enrollees often already benefit from reduced cost sharing.) We do this in two steps. First, we identify administratively reported outpatient or medical provider events and their associated Medicare costs, adjust these estimates to match 2020 Part B aggregate spending reported in CMS program statistics, and apply per capita spending growth rates (actual through 2021, then projected) for Part B reported in the 2022 Medicare Trustees report (Medicare Trustees 2022). Second, we apply empirically based price-response elasticities to estimate the increase in Part B service use resulting from lowering the out-of-pocket price for services delivered to low-income enrollees.9 For additional detail on our approach, see the appendix. Results Current Subsidies Do Not Help All Low-Income Enrollees and Phase Out at Relatively Low Incomes Table 3 provides estimated 2023 data for Medicare beneficiaries, including the number of people in each income category, the share of each income group receiving MSP benefits, and annual premiums with and without MSP benefits for each income group. Overall, 17 percent of Medicare beneficiaries (10.5 million people) have incomes at or below 100 percent of FPL, and 26 percent (16.2 million) have incomes between 100 and 200 percent of FPL. About 18.1 million have incomes between 200 and 400 percent of FPL, and 16.9 million have incomes above 400 percent of FPL. CMS has set the full 2023 Part B premium without MSP subsidies to $1,979 for most enrollees, before income-based surcharges apply.10 The average premium, across both those with and without MSP benefits, was $706 for beneficiaries with incomes at or below 100 percent of FPL, $1,550 for those with incomes between 100 and 200 percent of FPL, and $1,979 for those with incomes between 200 and 400 percent of FPL. 6 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES TABLE 3 Average Annual Part B Premium, by Medicare Savings Program Participation and Income Group, 2023 Above At or below 100–200% of 200–400% 400% of 100% of FPL FPL of FPL FPL All enrollees Full Part B premiums (excluding MSP benefits) $1,979 $1,979 $1,979 $2,417 Average annual Part B premiums paid (including MSP benefits) $706 $1,550 $1,946 $2,409 Average family income (2022 estimate) $11,219 $23,112 $46,436 $134,766 Share receiving MSP benefits 64.3% 21.7% 1.6% 0.2% Number of enrollees (millions) 10.5 16.2 18.1 16.9 Enrollees with MSP benefits Full Part B premiums (excluding MSP benefits) $1,979 $1,979 $1,979 $2,839 Average annual Part B premiums paid (including MSP benefits) $0 $0 $0 $0 Average family income (2022 estimate) $10,850 $19,128 $38,532 $123,243 Number of enrollees (millions) 6.8 3.5 0.3 < 0.1 Enrollees without MSP benefits Average annual Part B premiums paid $1,979 $1,979 $1,979 $2,309 Average family income (2022 estimate) $11,883 $24,214 $46,568 $134,795 Average premiums as a share of family income 16.7% 8.2% 4.2% 1.7% Number of enrollees (millions) 3.8 12.7 17.8 16.9 Source: MCARE-SIM 2023 projected estimates using 2015–2018 Medicare Current Beneficiary Survey. Note: MSP = Medicare Savings Program. The second panel of table 3 provides data on those receiving MSP benefits. By design, MSP benefits are not available for beneficiaries with incomes above 135 percent of FPL. Though the full annual Part B premium is $1,979, those eligible for and receiving MSP benefits pay nothing. About 6.8 million of the 10.5 million beneficiaries with income at or below 100 percent of FPL (64.3 percent) receive MSP benefits. Another 3.5 million beneficiaries with incomes between 100 and 200 percent of FPL receive MSP benefits (21.7 percent of this income range), and 298,000 beneficiaries with incomes between 200 and 400 percent of FPL (1.6 percent in this income range) do as well. Slightly more than one-third of enrollees with incomes below 100 percent of FPL and about 78 percent of those with incomes between 100 and 200 percent of FPL do not receive MSP benefits under current law. Those without MSP benefits pay the full $1,979 annual premium and thus pay substantially more than those with MSP benefits. For those with incomes below 100 percent of FPL, the full premium averages about 17 percent of income. For those with incomes between 100 and 200 percent of FPL, the full premium averages about 8 percent of income. When MSPs phase out for most beneficiaries at 135 percent of FPL, there is a sharp cliff at which individuals who are no longer subsidized must pay the full INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 7 premium. The full Part B premium averages about 4 percent of income for beneficiaries with incomes between 200 and 400 percent of FPL. These figures only represent the burden of Part B premiums. Enrollees who use services may also face the burden of cost-sharing expenses (the Part B deductible and coinsurance), depending on what supplemental coverage or Medicare Advantage plan they may have. Alternative Policies Can Eliminate Gaps and Provide Better Financial Support for Low-Income Enrollees Table 4 shows the share and number of beneficiaries by income group receiving premium subsidies under current law and under the alternative policies, the average annual savings on Part B premiums for those receiving subsidies, and the aggregate subsidy amount for all beneficiaries in that income range. Under current law (first shown in table 3 and reported in the first column of table 4 for reference), the share of Medicare beneficiaries receiving MSPs declines with income. The number of enrollees receiving premium subsidies declines by income group. For those who receive the subsidy (shown in the third panel of table 4), the average amount of the subsidy is the full Part B premium-meaning these beneficiaries pay nothing. About 64 percent of enrollees who receive subsidies have incomes below 100 percent of FPL. About $13.4 billion in subsidies go to enrollees in this income group. Another $6.9 billion go to those with incomes between 100 and 200 percent of FPL. The total subsidy amount paid by MSPs under current law among all enrollees is $21.1 billion. TABLE 4 Changes in per Capita and Total Expenses for Part B Premiums, by Beneficiary Income Group and Policy Alternative Policy Policy Policy Current Law Alternative 1 Alternative 2 Alternative 3 MSP sole Part B premiums Applying IRA PTC source of subject to 8.5% schedule to Applying IRA PTC support for Part income cap (in Medicare schedule to B premium addition to MSP enrollees (with Medicare enrollees payments support) MSP support) (with MSP support) Share receiving premium subsidy, by income range (%) At or below 100% of FPL 64.3 99.2 100.0 100.0 100–200% of FPL 21.7 59.6 100.0 100.0 200–400% of FPL 1.6 1.6 45.8 45.9 Above 400% of FPL 0.2 0.2 0.2 0.2 Number of enrollees receiving premium subsidy (including MSPs), by income range (millions) At or below 100% of FPL 6.8 10.4 10.5 10.5 100–200% of FPL 3.5 9.6 16.2 16.2 200–400% of FPL 0.3 0.3 8.3 8.3 Above 400% of FPL < 0.1 < 0.1 < 0.1 < 0.1 8 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES Policy Policy Policy Current Law Alternative 1 Alternative 2 Alternative 3 MSP sole Part B premiums Applying IRA PTC source of subject to 8.5% schedule to Applying IRA PTC support for Part income cap (in Medicare schedule to B premium addition to MSP enrollees (with Medicare enrollees payments support) MSP support) (with MSP support) Subsidy amount ($), among those receiving subsidy, by income range At or below 100% of FPL 1,979 1,633 1,979 2,003 100–200% of FPL 1,979 938 1,864 1,888 200–400% of FPL 1,979 1,979 816 837 Above 400% of FPL 3,118 3,118 3,118 3,156 Total subsidy amount ($ millions), by income range At or below 100% of FPL 13,398 17,052 20,828 21,080 100–200% of FPL 6,934 9,053 30,151 30,538 200–400% of FPL 590 590 6,769 6,968 Above 400% of FPL 130 130 130 131 Total subsidy amount ($) 21,052 26,825 57,877 58,718 Source: MCARE-SIM 2023 projected estimates using 2015–2018 Medicare Current Beneficiary Survey. Notes: MSP = Medicare Savings Program. IRA = Inflation Reduction Act. PTC = premium tax credit. FPL = federal poverty level. AN 8.5 PERCENT OF INCOME CAP A policy that caps premiums at 8.5 percent of income (policy alternative 1) substantially increases the number of people receiving financial assistance relative to current law. The number of people with incomes at or below 100 percent of FPL receiving financial help is 10.4 million, which is nearly all Medicare beneficiaries in this income group. Without assistance, the amount these individuals would pay for Part B premiums is well above 8.5 percent of income. A total of 9.6 million beneficiaries with incomes between 100 and 200 percent of FPL would receive subsidies, 6.1 million more than under current law. As a result, 60 percent of enrollees in this income range receive some financial help for Part B premium payments, compared with 22 percent under current law. No individuals with incomes above 200 percent of FPL would benefit from an 8.5 percent of income cap (i.e., the number of beneficiaries in these income groups receiving premium subsidies is unchanged relative to current law). The average amount of assistance for beneficiaries in each income range is lower than under current law, because many beneficiaries newly receiving assistance would only be getting partial assistance. In this policy alternative, all beneficiaries receiving MSPs continue to get the full premium benefit of $1,979. Additional enrollees benefit from the 8.5 percent cap, but subsidies can be small for these enrollees, bringing down the average subsidy received. The average subsidy for those receiving either MSPs or tax credits is $1,633 for those with incomes at or below 100 percent of FPL, $938 for those with incomes between 100 and 200 percent of FPL, and $1,979 for those with incomes between 200 and 400 percent of FPL. Because the percent increase in the number receiving subsidies is greater than the percent drop in average subsidies, the total amount spent on premium subsidies for each income group increases to $17.1 billion for those with incomes at or below 100 percent of FPL and $9.1 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 9 billion for those with incomes between 100 and 200 percent of FPL. Overall spending on subsidies for Part B premiums increases to $26.8 billion. INFLATION REDUCTION ACT SUBSIDIES We estimate even greater benefits to lower-income enrollees under policies applying the IRA premium tax credit schedule to Part B premiums (policy alternatives 2 and 3). As with policy alternative 1, all beneficiaries with income at or below 100 percent of FPL receive premium assistance under policy alternatives 2 and 3. But for those with incomes between 100 and 200 percent of FPL, the percentage receiving subsidies under policy alternatives 2 and 3 also reaches 100 percent. Under the IRA premium schedule, people with incomes up to 150 percent of FPL have fully subsidized premiums. The percentage of incomes that individuals with incomes between 150 and 200 percent of FPL are expected to pay increases from 0 to 2 percent. The full Medicare Part B premium exceeds these IRA-based income caps for everyone in these income groups. The IRA premium schedule phases out as incomes increase, but a cap at 8.5 percent of income remains. Slightly fewer than half (46 percent) of individuals with incomes between 200 and 400 percent of FPL receive some financial assistance, up from 2 percent under current law and policy alternative 1. Under policy alternatives 2 and 3, the number of people receiving subsidies increases to 16.2 million among those with incomes between 100 and 200 percent of FPL and to 8.3 million among those with incomes between 200 and 400 percent of FPL. The average value of premium subsidies also is higher. All beneficiaries with incomes below 100 percent of FPL save the full premium amount, $1,979. Beneficiaries with incomes between 100 and 200 percent of FPL save nearly the full premium (on average $1,864 under policy alternative 2). For those with incomes between 200 and 400 percent of FPL, premium subsidies average $816. With an increase in both the number of people receiving subsidies and the average value of the subsidies, the total amount in subsidies increases to $57.9 billion, a $36.8 billion increase relative to current law. Of this, $20.8 billion goes to those with incomes at or below 100 percent of FPL, and $30.2 billion goes to those with incomes between 100 and 200 percent of FPL. With this policy, an additional amount, $6.8 billion, goes to those with incomes between 200 and 400 percent of FPL. The premium estimates for policy alternative 3 are similar to those for policy alternative 2, given the identical IRA subsidy in both policies. However, policy alternative 3 includes additional cost-sharing subsidies, which cause the use of and expenditures for Part B services to rise. Because Part B premiums are tied to total Part B expenditures, policy alternative 3 will lead to a small increase in overall premiums. As a result, both average and total subsidies increase to $58.7 billion, compared with $57.9 billion in policy alternative 2. GRAPHICAL REPRESENTATION OF FINANCIAL BURDENS OF PREMIUMS BY INCOME AND HOW POLICIES REDUCE THEM Figures 1A and 1B provide a graphical view of how each policy alternative would benefit enrollees relative to current law. In figure 1A, we present the share of income spent on Part B premiums against income as a percentage of FPL for unmarried enrollees who do not qualify for MSP benefits. The 10 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES horizontal line indicates the 8.5 percent cap (policy alternative 1). Under policy alternative 1, all enrollees whose Part B premium spending as a share of income exceeds this line will see savings. In figure 1A, this is all enrollees with incomes to the left of point A. The shaded region between the horizontal line and the premium payments made under current law represents the aggregate savings to enrollees under an 8.5 percent income cap. In figure 1B, the additional dashed line represents the IRA premium tax credit schedule. Under an IRA-type premium schedule, enrollees with incomes below 150 percent of FPL would be fully subsidized. All enrollees with current-law Part B premium spending as a share of income above the dashed line (i.e., all enrollees with incomes as a percentage of FPL to the left of point B) would see savings under policy alternatives 2 and 3 that are equivalent to the vertical distance between the current-law spending line and the IRA premium schedule. Thus, the shaded region between these two lines in figure 1B represents the aggregate savings to enrollees under an IRA-type premium schedule. FIGURE 1A Savings to Enrollees under an 8.5 Percent Cap Part B premium spending as a percentage of income under current law Cap on Part B spending at 8.5% of income A INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 11 FIGURE 1B Savings to Enrollees under an IRA-Type Premium Tax Credit Schedule Part B premium spending as a percentage of income under current law Cap on premium spending as a percentage of income under IRA-type premium schedule B URBAN INSTITUTE Source: Authors' calculations. Note: IRA = Inflation Reduction Act. Policies Can Also Reduce Cost-Sharing Obligations for Beneficiaries with Incomes at or below 100 Percent of FPL Without assistance, beneficiaries pay cost-sharing amounts in traditional Medicare that are determined by Medicare Part B: a deductible of $226 in 2023 and 20 percent cost sharing for Part B services. Beneficiaries who qualify for the QMB program (with incomes at or below 100 percent of FPL) receive cost-sharing assistance. Table 5 shows beneficiary total spending on Part B services by income and the amount spent by Medicare, categorizing remaining spending into expenditures by households, Medicaid, and supplemental insurance or employer plans. The 8.5 percent premium cap and the IRA premium schedule each (policy alternatives 1 and 2) do not affect cost sharing, as shown in the second panel. In the bottom panel, we illustrate the effect of policy alternative 3. The cost-sharing assistance incorporated in this policy supplements MSPs by providing full subsidies for cost sharing for all enrollees with incomes at or below 100 percent of FPL- that is, all those not already receiving MSPs. 12 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES Table 5 shows that total Part B spending per capita increases to $9,975 for the lowest-income group, which reflects new Medicare expenditures to fully subsidize cost sharing for all those with incomes at or below 100 percent of FPL, regardless of receipt of MSP benefits. With the shift in spending from households, Medicaid, and supplemental insurance plans to Medicare, total Medicare spending on Part B services increases from $7,417 to $9,975. Spending also increases because we assume that a lack of cost sharing would result in increased use of services. This policy has no effect on people with incomes above 100 percent of FPL, as their cost sharing is unaffected by this policy. TABLE 5 Per Capita Spending on Part B Services among Traditional Medicare Enrollees, by Income Group and Policy Alternative In dollars 200– Above At or below 100–200% 400% of 400% of 100% of FPL of FPL FPL FPL Current law Total spending on Part B services 9,321 8,502 8,733 7,724 Medicare spending 7,417 6,726 6,876 6,043 Other spending 1,904 1,776 1,856 1,681 Households 282 403 381 267 Medicaid 1,301 385 41 9 Supplemental plans/ESI 321 989 1,435 1,405 Policy alternatives 1 and 2 Total spending on Part B services 9,321 8,502 8,733 7,724 Medicare spending 7,417 6,726 6,876 6,043 Other spending 1,904 1,776 1,856 1,681 Households 282 403 381 267 Medicaid 1,301 385 41 9 Supplemental plans/ESI 321 989 1,435 1,405 Policy alternative 3 (fully subsidized cost sharing for those with incomes at or below 100% of FPL) Total spending on Part B services 9,975 8,502 8,733 7,724 Medicare spending 9,975 6,726 6,876 6,043 Other spending 0 1,776 1,856 1,681 Households 0 403 381 267 Medicaid 0 385 41 9 Supplemental plans/ESI 0 989 1,435 1,405 Source: MCARE-SIM 2023 projected estimates using 2015–2018 Medicare Current Beneficiary Survey. Notes: ESI = employer-sponsored insurance. FPL = federal poverty level. The Increase in Federal Spending Needed to Implement an 8.5 Percent Cap Is Modest, but an IRA-Type Premium Tax Credit Schedule Would Raise Federal Spending on Medicare by about 9 Percent of Total Part B Expenditures Table 6 provides data on aggregate expenditures on Part B premiums (panel 1) and Part B spending for traditional Medicare enrollees only (panel 2) under current law and each policy alternative. Under INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 13 current law, $129.6 billion is spent on Part B premiums (panel 1). Of this, beneficiaries spend $108.5 billion and MSPs the remaining $21.1 billion. Under the 8.5 percent of income cap in policy alternative 1, beneficiary premium spending falls from $108.5 billion to $102.8 billion. Medicare pays an additional $5.8 billion to offset premiums that exceed 8.5 percent of income. This represents 4 percent of total Part B premium spending. Under IRA premium tax credit subsidies without cost-sharing subsidies (policy alternative 2), beneficiary spending falls from $108.5 billion to $71.7 billion. Medicare expenditures to finance the new subsidies increase by $36.8 billion (28 percent of total Part B premium spending). TABLE 6 Total 2023 Expenditures for Part B Premiums under Current Law and Policy Alternatives and Total Expenditures for Part B Services among Traditional Medicare Enrollees, by Payer and Policy Alternative Billions of dollars Policy alternative 3: Policy Applying IRA PTCs alternative 1: Policy and fully subsidized 8.5% of alternative 2: cost sharing for income cap on Applying IRA individuals with Current Part B PTCs for Part B incomes < 100% of law premiums premiums FPL Expenditures for Part B premiums (all enrollees) Total expenditures on Part B premiums 129.6 129.6 129.6 131.1 Beneficiary spending on Part B premiums 108.5 102.8 71.7 72.4 MSP expenditures 21.1 21.1 21.1 21.3 Additional Medicare expenditures to support Part B premiums N/A 5.8 36.8 37.4 Expenditures for Part B care (traditional Medicare enrollees only) Total Part B expenditures for care 266.0 266.0 266.0 269.2 Medicare spending 209.6 209.6 209.6 222.2 Other spending 56.3 56.3 56.3 47.0 Households 10.5 10.5 10.5 9.1 Medicaid 9.6 9.6 9.6 3.2 Supplemental/ESI plans 36.2 36.2 36.2 34.7 Source: MCARE-SIM 2023 projected estimates using 2015–2018 Medicare Current Beneficiary Survey. Notes: IRA = Inflation Reduction Act. MSP = Medicare Savings Program. PTC = premium tax credit. ESI = employer-sponsored insurance. N/A = not applicable. The final column of table 6 presents effects of policy alternative 3, the IRA premium tax credit subsidies combined with fully subsidized cost sharing for enrollees with incomes below 100 percent of FPL. Estimates for this scenario are slightly higher than for policy alternative 2, since the increase in overall Part B service use leads to a small increase in overall premiums. Medicare spending to support 14 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES the premium subsidies under policy alternative 3 rises to $37.4 billion (panel 1). For context, this represents about 9 percent of total Part B spending in 2021.11 The bottom panel of table 6 shows the effect of cost-sharing subsidies for beneficiaries in traditional Medicare. Policy alternative 3 is the only policy modeled with additional cost-sharing subsidies, so expenditures are unchanged relative to current law under both an 8.5 percent of income cap on premiums and the IRA premium tax credits (policy alternatives 1 and 2). Medicare spending on Part B services increases to $222.2 billion under policy alternative 3, a $12.6 billion (6 percent) increase relative to current law. Total spending on Part B services increases, reflecting the increased use of services associated with lower cost sharing for some people. Households only save $1.4 billion because all the reduction in cost-sharing expenditures is limited to those with incomes at or below 100 percent of FPL, many of whom already have cost-sharing protections under Medicaid. Under policy alternative 3, Medicaid would save $6.4 billion, and these savings would accrue to the federal government and state governments. An Alternative to Policy Alternative 3 Could Eliminate the MSPs and Have the Federal Government Cover the Costs of Providing Premium and Cost-Sharing Subsidies Replacing MSPs with a fully federal subsidy would increase federal expenditures on premiums from $37.4 billion to $58.7 billion (calculated by adding $21.3 billion in MSP expenditures to the $37.4 billion). These expenditures could be mitigated by establishing a "clawback" program similar to that in Medicare Part D (Schneider 2004). With a clawback program, the cost of a 100 percent federal subsidy for low-income people would not exceed spending in policy alternative 3, as states would be expected to continue to pay for premium subsidies and cost-sharing protections on behalf of enrollees who previously had MSP benefits under current law. However, elimination of the MSP eligibility verification and enrollment processes could further generate administrative savings to states. Discussion In 2023, Medicare Part B will have an annual premium of $1,979 and a deductible of $226 and will require beneficiaries to pay 20 percent of remaining expenditures. In response to the effects of these costs on low-income beneficiaries, MSPs were established to provide beneficiaries with financial assistance. Depending on a beneficiary's income, premiums can be fully subsidized; and for those with incomes at or below 100 percent of FPL, cost sharing is eliminated. While these programs are potentially generous, they are limited by income cutoffs and an asset test that eliminates many people with low incomes from eligibility. States do not always aggressively implement these programs, and individuals are not always well informed about their availability. In this paper, we show that slightly more than one-third of enrollees with incomes below 100 percent of FPL do not receive MSP benefits, nor do about 77 percent of those with incomes between 100 and 200 percent of FPL. MSPs provide assistance differently than the Affordable Care Act, which INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 15 offers help to a larger share of low- and moderate-income people, but at declining rates. Here we examine three alternatives for enhancing financial assistance for lower-income enrollees beyond what the MSPs provide. The first would cap Part B premiums at 8.5 percent of income, the second would use the IRA premium subsidy schedule, and the third would use the IRA premium schedule but also eliminate all cost sharing for those with incomes below 100 percent of FPL. We show that an 8.5 percent of income cap would assist virtually all individuals with incomes at or below 100 percent of FPL and most individuals with incomes between 100 and 200 percent of FPL. In the latter income group, the percentage receiving at least some financial help increases from 22 percent under current law to 60 percent. In addition to helping more people, premium savings would average $1,633 for those with incomes at or below 100 percent of FPL. For those with incomes between 100 and 200 percent of FPL, premium subsidies would be $938. The policy that uses the IRA premium tax credit schedule provides even greater benefits to enrollees with low incomes. All beneficiaries with incomes below 200 percent of FPL would receive at least some assistance. Part B premiums for all people with incomes below 150 percent of FPL are eliminated. The IRA premium schedule phases out as incomes increase but retains the cap at 8.5 percent of income for all incomes. Premium savings are $1,979 for those with incomes at or below 100 percent of FPL, $1,864 for those with incomes between 100 and 200 percent of FPL, and $816 for those with incomes between 200 and 400 percent of FPL. We also examine one policy that would eliminate cost sharing for those with incomes below 100 percent of FPL. This reduces out-of-pocket cost-sharing expenditures from $282 to $0. These policy alternatives are not overly expensive. The 8.5 percent of income cap on Part B premiums would add $5.8 billion dollars to Medicare spending. The policy that uses the IRA premium subsidies would cost the federal government $36.8 billion in additional spending (9 percent of total Part B spending). Eliminating cost sharing for those with incomes at or below 100 percent of FPL would add $13.0 billion to Medicare expenditures and greatly increase affordability for people living in poverty. We conclude that these policy alternatives would correct major weaknesses in the current Part B program at a relatively low additional cost to the federal government. Appendix. Detailed Methods We use the Urban Institute's Medicare policy simulation model, MCARE-SIM, to estimate 2023 Part B premium spending and Part B service use under current law and to predict the effects of implementing policy options that would provide subsidies for Part B premiums and, in one scenario, additional cost- sharing protections to low-income enrollees. MCARE-SIM uses data from the 2015–18 MCBS and projects Medicare enrollment and spending estimates to 2023. We estimate 2023 Part B enrollment by reweighting enrollee groups by survey year in a combined 2015–18 MCBS analytic file to match 2020 Medicare Advantage and traditional Medicare Part B enrollment, separately among enrollees who are and are not supported by MSPs, as reported in CMS program statistics. We then apply population growth rates for each age and racial-ethnic group, 16 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES calculated from 2010 and projected 2030 estimates from the Urban Institute's Mapping America's Futures database. We preserve each enrollee's income as a percentage of FPL in their survey year and assign their 2022 nominal income as the equivalent needed to maintain the same income-to-poverty ratio based on the most recently available poverty guidelines. We use this calculated income as an estimate for enrollee income in 2023. To calculate each enrollee's annual Part B premium spending, we apply 2023 CMS Part B premium rules based on enrollee family income and marital status. Nearly all MSPs fully subsidize Part B premium payments; therefore, for beneficiaries enrolled in an MSP, we impute beneficiary spending on Part B premiums as $0. For each policy alternative, we assume MSPs remain in place. Because MSP protections for those eligible are always at least as generous as any of the policy alternatives discussed here, we assume that those enrolled in an MSP under current law will continue to receive MSP benefits under each policy alternative and are therefore unaffected by each new option. Eligibility for MSPs is generally based on income and assets; in most states, these programs are unavailable for those with incomes above 135 percent of FPL. Among enrollees with reported income above 200 percent of FPL, we impute those who are not in an institutionalized setting or with end-stage renal disease as not having MSP benefits. Policy alternative 3 provides additional cost-sharing protections to beneficiaries with incomes below 100 percent of FPL. We cannot assess this policy's impact on Part B spending among all Medicare enrollees because the MCBS does not provide information on Part B services spending and use among Medicare Advantage enrollees. However, this information is available for enrollees in traditional Medicare, and for these enrollees we assess how such a policy would affect enrollee spending on and use of Part B services. Doing so requires first establishing 2023 Part B spending under current law. MCARE-SIM adjusts MCBS-reported Part B spending to align with total expenditures in the 2020 CMS program statistics. Medicare spending is then projected to 2023 by applying per capita spending growth rates for Part B reported in the 2022 Medicare Trustees report's expanded and supplementary materials. To determine total Medicare cost-sharing payments, we apply 2023 Part B cost-sharing rules for traditional Medicare enrollees. In 2023, all Part B enrollees will be subject to a $226 deductible and a 20 percent coinsurance rate for covered services.12 For enrollees with either supplemental (i.e., Medigap or employer-sponsored insurance coverage) or Medicaid coverage, we assume the secondary plan pays for cost-sharing expenses. Reducing out-of-pocket prices for Part B covered services has been shown to increase the use of services (Manning et al. 1987). Recognizing this, we estimate the increase in the use of Part B services due to behavioral responses to subsidized cost sharing for low-income enrollees. This "induced demand" is estimated by applying a price-elasticity demand response, tied to empirical findings, to the percentage of change in out-of-pocket prices relative to current law that each enrollee faces under policy alternative 3. For Part B services, we assume a 1 percent decrease in prices leads to a 0.2 percent increase in the use of services. Finally, because Part B premiums are tied to expected changes in Part B expenditures, we model the rise in premiums following the rise of Part B services as leading to a similar increase in Part B premiums. INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 17 Thus, under policy alternative 3, we calculate the percent change in total expenditures for services between the policy option and current law and apply the same percent change to Part B premiums. Notes 1 The 2022 poverty guideline is $13,590 for a one-person household and $18,310 for a two-person household ("Poverty Guidelines," US Department of Health and Human Services, accessed November 8, 2022, https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines). 2 The Part B premium is determined by modified adjusted gross income as reported on the IRS tax return two years prior-that is, 2022 premiums are determined by the 2020 modified adjusted gross income. 3 State Medicaid programs must provide full benefits for individuals receiving Supplemental Security Income, which is about 74 percent of FPL. Many states have also adopted optional eligibility pathways for seniors and people with disabilities. As a result, most low-income Medicare enrollees who qualify for MSPs also qualify for full benefits. See Musumeci, Chidambaram, and Watts (2019). 4 "Medicare Savings Programs," Medicare.gov, accessed November 8, 2022, https://www.medicare.gov/basics/costs/help/medicare-savings-programs. Income and asset limits for 2023 were not available at the time of writing. 5 "Medicare Savings Programs," Medicaid and CHIP Payment and Access Commission, accessed November 3, 2022, https://www.macpac.gov/subtopic/medicare-savings-programs/. 6 "CMS Program Statistics," Centers for Medicare & Medicaid Services, accessed November 4, 2022, https://data.cms.gov/collection/cms-program-statistics. 7 "Mapping America's Futures," Urban Institute, updated December 1, 2017, https://apps.urban.org/features/mapping-americas-futures/. 8 Centers for Medicare & Medicaid Services, "2023 Medicare Parts A and B Premiums and Deductibles 2023 Medicare Part D Income-Related Monthly Adjustment Amounts," news release, September 27, 2022, https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023- medicare-part-d-income-related- monthly#:~:text=Each%20year%20the%20Medicare%20Part,%245.20%20from%20%24170.10%20in%20202 2. 9 For elasticities of demand for outpatient services covered by Part B, we apply a -0.2 elasticity. This estimate is based on evidence from the RAND Health Insurance Experiment, which randomized health insurance plans to enrollees to evaluate the demand for health care. See Manning and colleagues (1987). 10 The annual premium was $170.10 in 2022 and actually went down for 2023. As CMS has described, the 2022 premium projected the spending on a new drug, Aduhelm, but actual spending on this drug was lower than expected and led to an increase in the reserves for the Supplementary Medical Insurance trust fund that funds program payments for Part B. CMS opted to pass the excess reserves in the trust fund back to beneficiaries in the form of lower premium payments. See Centers for Medicare & Medicaid Services, "2023 Medicare Parts A and B Premiums and Deductibles and Deductibles 2023 Medicare Part D Income-Related Monthly Adjustment Amounts." 11 Part B expenditures totaled $406 billion in 2021. See table II.B1 in Medicare Trustees (2022). 12 Centers for Medicare & Medicaid Services, "2023 Medicare Parts A and B Premiums and Deductibles and Deductibles 2023 Medicare Part D Income-Related Monthly Adjustment Amounts." 18 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES References Arnos, Diane, Bowen Garrett, Anuj Gangopadhyaya, and Adele Shartzer. 2020. "Calibrating a Microsimulation Model of Medicare Policy Reform to Match Administrative Benchmarks for Enrollment and Spending." Washington, DC: Urban Institute. Freed, Meredith, Juliette Cubanski, Anthony Damico, and Tricia Neuman. 2022. "Help with Medicare Premium and Cost-Sharing Assistance Varies by State." San Francisco: Kaiser Family Foundation. Manning, W. G., J. P. Newhouse, N. Duan, E. B. Keeler, A. Leibowitz, and M. S. Marquis. 1987. "Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment." American Economic Review 77 (3): 251– 77. Medicare Trustees (Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds). 2022. 2022 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC: Medicare Trustees. Musumeci, MaryBeth, Priya Chidambaram, and Molly O'Malley Watts. 2019. "Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey." San Francisco: Kaiser Family Foundation. Schneider, Andy. 2004. "The 'Clawback': State Financing of Medicare Drug Coverage." Washington, DC: Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured. About the Authors Anuj Gangopadhyaya is a senior research associate in the Health Policy Center at the Urban Institute. His research focuses on the impact of safety net programs on health and well-being, family income, and education achievement outcomes for children in low-income families. He has focused on the impact of Medicaid eligibility expansion on children's education achievement, maternal and child health effects of the earned income tax credit program, and the impact of the Affordable Care Act Medicaid expansion on adult labor supply and fertility rates of women of reproductive age. He also helps lead Urban's Medicare simulation model (MCARE-SIM), estimating potential impacts of proposed policy changes on program spending, beneficiary spending, and use of services. Gangopadhyaya received his PhD in economics from the University of Illinois at Chicago. John Holahan is an Institute fellow in the Health Policy Center, where he previously served as center director for over 30 years. His recent work focuses on health reform, the uninsured, and health expenditure growth, developing proposals for health system reform most recently in Massachusetts. He examines the coverage, costs, and economic impact of the Affordable Care Act (ACA), including the costs of Medicaid expansion as well as the macroeconomic effects of the law. Holahan has also analyzed the health status of Medicaid and exchange enrollees, and the implications for costs and exchange premiums. He has written on competition in insurer and provider markets and implications for premiums and government subsidy costs as well as on the cost-containment provisions of the ACA. Holahan has conducted significant work on Medicaid and Medicare reform, including analyses on the recent growth in Medicaid expenditures, implications of block grants and swap proposals on states and the federal government, and the effect of state decisions to expand Medicaid in the ACA on federal and state spending. Recent work on Medicare includes a paper on reforms that could both reduce budgetary impacts and improve the structure of the program. His work on the uninsured explores reasons for the 19 INCREASING FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES growth in the uninsured over time and the effects of proposals to expand health insurance coverage on the number of uninsured and the cost to federal and state governments. Adele Shartzer is a senior research associate in the Health Policy Center, where her work focuses on health coverage, access to care, and the health care delivery system; her research has been published in notable health policy journals. Before joining Urban, she worked as a program analyst in the Office of Health Policy in the Office of the Assistant Secretary of Planning and Evaluation at the US Department of Health and Human Services. She has also worked in health policy at several nonprofits in the Washington, DC, area. Shartzer holds a bachelor's degree in bioethics from the University of Virginia and an MPH in health policy from George Washington University. She received her PhD in health services research from the Johns Hopkins Bloomberg School of Public Health. While there, she received a doctoral dissertation award in patient-reported outcomes and was a National Research Service Award trainee. Bowen Garrett is an economist and senior fellow in the Health Policy Center. His research focuses on health reform and health policy topics, including health insurance and labor markets and Medicare financing. He leads the development of the Urban Institute's Medicare policy simulation model (MCARE-SIM). Previously, Garrett was chief economist of the Center for US Health System Reform and McKinsey Advanced Health Analytics at McKinsey and Company. Garrett received his PhD in economics from Columbia University and was a postdoctoral research fellow in the Robert Wood Johnson Foundation's Scholars in Health Policy Research Program at the University of California, Berkeley. 20 INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. The authors thank Avani Pugazhendhi for research assistance, Katherine Hempstead and Stephen Zuckerman for helpful comments, and Rachel Kenney for editorial assistance. ABOUT THE ROBERT WOOD JOHNSON FOUNDATION The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity, that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people's lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness 500 L'Enfant Plaza SW and enhance the well-being of people and places. Washington, DC 20024 Copyright © December 2022. Urban Institute. Permission is granted for www.urban.org reproduction of this file, with attribution to the Urban Institute. INCREASING PART B FINANCIAL ASSISTANCE TO LOW-INCOME MEDICARE BENEFICIARIES 21