Why are millions of adults 65+ who are eligible for key federal benefits programs not enrolling?

That's the question a recent NCOA study sought to answer.

Why the research happened

In August 2024, NCOA’s Benefits Participation Map revealed that millions of older adults are eligible for but not enrolled in essential public benefits, including Medicare Savings Programs (MSPs), Supplemental Nutrition Assistance Program (SNAP), and Supplemental Security Income (SSI).

To address this issue, NCOA wanted to:

• Explore what is happening in communities with lower participation
• Understand the factors that differentiate one county from its neighboring county
• Understand and what makes high-participation possible in one place but not in the other, even within the same state

In 2025, NCOA launched a study, conducted in partnership with Social Policy Research Associates, to better understand the factors that influence county level participation rates, with the goal of identifying factors that increase participation and community-level innovations to address the participation gap.

What were the research questions and methods?

The study centered around two key questions:

1. What characteristics distinguish states and counties with higher participation from lstates and counties with lower participation in terms of outreach, enrollment processes, and administrative structures?
2. How do demographic, socioeconomic, and geographic factors relate to program participation rates among older adults at the county level?

The study's methods:

1. Analysis of older adult participation rate data from 2018 compared to the same data for 2023; this data was provided by NCOA and was created by the Urban Institute.
2. Review of administrative data, e.g., demographic information, benefits access and utilization, health care system stakeholders, funding sources, health disparities, and relevant policies and regulations.
3. Review of policy and program documents, e.g., state regulations, eligibility criteria, application materials, and publicly available funding allocations for outreach and enrollment assistance.
4. Key informant interviews and listening sessions.

The study included the following states and counties:

Findings, lessons learned, and recommendations

NCOA’s Benefits Participation Map revealed that in 2018:

• 5.8 million older adults were eligible for but not enrolled in MSP
• 8.9 million older adults were eligible for but not enrolled in SNAP
• 2.5 million older adults were eligible for but not enrolled in SSI

These numbers had increased in 2023, with:

• 6.6 million older adults eligible for but not enrolled in MSP
• 9.1 million older adults eligible for but not enrolled in SNAP
• 3.6 million  older adults elibigle for but not enrolled in SSI

The map also shows wide variations among counties within some states. Many policy changes occurred at the state and federal levels in this interval as the country responded to COVID-19 pandemic-induced needs, including skyrocketing unemployment, inflation, and declining health outcomes. Also, the older adult population increased significantly during this period, from approximately 52 million in 2018 to 59.2 million in 2023. Overall, MSP and SNAP participation rates increased, while the SSI participation rate decreased during this period.

Analysis of the quantitative data comparing high participation to low participation counties showed some clear differences in local demographic and socioeconomic contexts.

Namely, counties with higher participation had:

1. Higher overall populations and higher numbers of households
2. More urban areas with more public resources
3. More diverse communities
4. Fewer married residents

Key differences in participation appeared to hinge on county capacities and how they implement enrollment efforts. The following table summarizes these differences across states.

Counties with higher participation of older adults in benefits programs also consistently displayed these four characteristics:

1. High level of collaboration between local governmental agencies and service providers, such as SHIPs and AAA’s.
2. Effective implementation of tools, such as integrated application systems and data linkages.
3. High level of involvement of community-based organizations (CBOs) in outreach, screening, and application assistance.
4. Capacity building of staff resources for outreach and application assistance.

Based on the findings, recommendations for improving older adult participation include:

1. Fund CBOs with strong ties to older adult subgroups in a community to conduct benefits outreach and enrollment.
2. Promote strong implementation of state policies at the county level that facilitate older adult participation through staff training materials, local conference sessions and webinars.
3. Encourage state agencies and local county government partners to convene key partners to coordinate outreach resources and strengthen local partnerships.
4. Continuing to support research around best practices for improving older adult participation and ensuring findings are local, timely, and accurate.

More resources

Fact sheets based on the findings of the research project:

• Medicare Savings Programs (MSP)
• Supplemental Nutrition Assistance Program (SNAP)
• Supplemental Security Income (SSI)

Recorded webinar:

• “From Eligibility to Enrollment: Strategies to Increase MSP, SNAP, & SSI Participation” 

Photo copyright Douglas Yates for NCOA use only

Support for this project was provided by the Robert Wood Johnson Foundation (RWJF). The views expressed here do not necessarily reflect the views of the Foundation.