Mind the Activation Gap: Factors Associated With Low Patient Activation Among Dual-Eligible Versus Medicare-Only Beneficiaries.

OBJECTIVE

To assess how key risk factors contribute to differences in low patient activation between dual-eligible and Medicare-only beneficiaries and to examine whether these contributions vary by disability status or age-informing more equitable engagement strategies.

STUDY SETTING AND

DESIGN

This observational study used nationally representative data from the 2019-2022 Medicare Current Beneficiary Survey. Survey-weighted descriptive statistics assessed variation in risk factors between dual-eligible and Medicare-only beneficiaries. Survey-weighted logistic regression models with state, year, state, and regional fixed effects estimated associations between individual risk factors and low patient activation, defined as limited knowledge, skills, and confidence to manage one's health. Marginal effects were reported. The Fairlie decomposition method quantified the extent to which specific factors (e.g., spoken English proficiency, education, vision impairment) explained differences in low patient activation. Subgroup analyses examined whether these explanatory factors differed by age and disability status.

DATA SOURCES AND ANALYTIC SAMPLE: The analytic sample included 23,805 community-dwelling, continuously enrolled Medicare beneficiaries, representing 39,591 unweighted beneficiary-years.

PRINCIPAL FINDINGS: Among 189,843,094 weighted beneficiary-years, 14.4% were dual-eligible and 85.6% were Medicare-only. Low patient activation was more prevalent among dual-eligible (42.5%) than Medicare-only beneficiaries (32.1%). Among older beneficiaries, differences in activation were explained by limited English proficiency, poor perceived health, psychological distress, vision impairment, and difficulties with activities of daily living (ADL). Among disabled beneficiaries, differences were primarily driven by the presence of an intellectual disability and instrumental ADL (iADL) difficulties. Low educational attainment contributed to differences across both subgroups.

CONCLUSIONS

Different factors contribute to low patient activation among dual-eligible versus Medicare-only beneficiaries, with notable variation between older and disabled subgroups. These findings support the need for tailored engagement strategies and policy efforts focused on improving activation among high-need Medicare populations. Targeted interventions may help reduce activation gaps, promote equity, and improve health outcomes.