In January, throughout a congressional hearing on his solution to turning into secretary of the Division of Well being and Human Providers, Robert F. Kennedy Jr. received primary particulars improper about Medicaid — a program he now oversees.
He mentioned that Medicaid is totally funded by the federal authorities (it’s not) and that many enrollees are unhappy with excessive out-of-pocket prices (enrollees pay restricted, if any, out-of-pocket prices).
Medicaid is complex. The $880 billion-a-year state-federal program provides well being protection to thousands and thousands of disabled and low-income Individuals. This system covers completely different providers for various folks in several elements of the nation — and enrollees could work together with non-public insurance coverage corporations with out “Medicaid” of their names, leaving some unaware that they’re on this system in any respect.
Though President Donald Trump promised to “love and cherish” Medicaid, Republicans in Congress final week introduced federal price range proposals that would dramatically curtail this system. As that debate begins, here’s what you have to learn about Medicaid.
What’s Medicaid, and the way is it completely different from Medicare?
Medicaid and Medicare had been created by the identical laws — an addition to the Social Safety Act — that was signed into legislation by President Lyndon B. Johnson in 1965.
Medicaid is a authorities medical health insurance program for folks with low incomes and adults and kids with disabilities.
Medicare, in contrast, typically covers these 65 or older.
For older Individuals with low incomes, Medicaid covers out-of-pocket prices for Medicare. Such persons are generally referred to as “twin eligibles,” as a result of they qualify for each packages.
Who’s on Medicaid?
Greater than 79 million folks obtain providers from Medicaid or the intently associated Youngsters’s Well being Insurance coverage Program. That represents about 20% of the overall inhabitants of the USA. Most enrollees qualify due to low incomes.
About 40% of all youngsters within the nation are lined by Medicaid or CHIP, created in 1997. Each pay for providers equivalent to routine checkups, vaccinations, and hospital stays. Medicaid additionally covers pregnant folks earlier than and after they provide delivery and pays for greater than 40% of all births.
Medicaid additionally covers folks with disabilities or advanced medical wants and helps them afford providers that permit them to stay independently in neighborhood settings, exterior of establishments equivalent to nursing houses and state-run hospitals.
This system serves a various cross part of the nation. About 40% of individuals beneath 65 who use Medicaid are white, 30% are Hispanic, 19% are Black, and 1% are Indigenous folks.
Federal Medicaid {dollars} can’t be used to cowl immigrants who’re within the U.S. with out authorized permission, although some states, in addition to Washington, D.C., have used their own funds to increase Medicaid protection to such people. California was the primary state to take action.
What are the earnings {qualifications}?
Eligibility typically is dependent upon whether or not an individual is low earnings, and states have other ways of defining that. For a four-adult family with out dependent youngsters, the present nationwide median protection stage is $44,367.
The Inexpensive Care Act, typically referred to as Obamacare, which handed in 2010, allowed extra folks to qualify for Medicaid on the premise of earnings. That is what is called “Medicaid growth.”
The legislation supplied states a large incentive so as to add extra folks to their packages: The federal authorities would pitch in more cash per enrollee to assist cowl them.
The intention behind the growth was to shut gaps in medical health insurance packages for the thousands and thousands of Individuals who don’t get protection via an employer. Medicaid would cowl folks with extraordinarily low incomes, and as their incomes rose, they might transfer to sponsored well being plans bought via the Inexpensive Care Act’s exchanges.
In 2012, the U.S. Supreme Courtroom mentioned the choice of whether or not to increase this system can be left up to individual states. Immediately, 40 states and the District of Columbia — led by Democrats and Republicans alike — have opted in.
Within the 10 states that haven’t expanded Medicaid to extra low-income adults, the median earnings qualification stage is $5,947 a yr for a single-person family in 2025. Those that make extra are usually not eligible.
Adults in these states who make an excessive amount of for Medicaid may also make too little to qualify for assist shopping for plans on the Inexpensive Care Act exchanges, leaving some unable to afford protection. An estimated 1.5 million fall into this protection hole.
The place does the cash to pay for it come from?
The federal authorities pays most of the price of Medicaid by matching a portion of what states spend.
Presently, the federal authorities matches no less than 50% of state spending and provides states more cash for some providers and enrollees — as an example, for kids and pregnant girls.
Much less rich states — decided by contemplating residents’ per capita incomes — obtain a better match, translating to a better share of federal {dollars}. In Mississippi, as an example, the federal authorities picks up 77% of the cost of Medicaid.
States additionally obtain a 90% match from the federal authorities for enrollees eligible for Medicaid beneath the ACA’s growth.
There isn’t any restrict on how a lot states can spend on this system, and lots of of billions of federal {dollars} movement into states annually. In 2023, states spent about 15% of their very own budgets on Medicaid.
What does that cash pay for?
Federal legislation requires all state Medicaid packages to cowl sure providers, together with emergency medical transportation, X-rays and lab work, household planning, and medication-assisted therapy for folks with opioid use dysfunction. This system additionally covers many nursing and residential well being providers, although federal legislation permits these advantages to be clawed back after an enrollee’s loss of life.
Past that, states have the flexibleness to decide on the providers their Medicaid packages cowl. All states cowl prescribed drugs, and most cowl eyeglasses, some dental care, and bodily remedy.
Medicaid covers extra psychological well being and long-term care providers than another sort of insurance coverage, public or non-public.
What’s Medicaid referred to as in my state?
Medicaid packages can go by many different names, even throughout the identical state, partially as a result of most states use non-public insurance coverage corporations to run them. This may be complicated for shoppers who could not notice they’re really enrolled in Medicaid.
In New York, as an example, Medicaid plans are supplied by main corporations, equivalent to Anthem Blue Cross Blue Defend and UnitedHealthcare — and a few you might not have heard of, equivalent to Amida Care and MetroPlusHealth. In Wisconsin, enrollees could also be in BadgerCare Plus; in Connecticut, Husky Well being; in Texas, STAR; and in California, Medi-Cal.
How does Medicaid have an effect on hospitals and medical doctors in my state?
Medicaid typically pays well being care suppliers equivalent to medical doctors and hospitals much less cash for providers than Medicare or non-public insurance coverage does. However it may be more cash than they’d get caring for people who find themselves uninsured — and with out Medicaid, many extra Individuals can be uninsured.
Like states, suppliers and hospitals have come to depend on this cash and categorical considerations that even phasing it out over time would require main changes.
What’s going to occur to Medicaid?
It’s not clear. Republicans in Washington are once more pushing for main adjustments, which might take the type of cuts to federal funding. That might cut back the quantity of people that qualify, the providers obtainable, or each. An analogous push targeted on repealing and changing Obamacare in 2017, throughout Trump’s first time period, was unsuccessful.
Maybe one of many greatest obstacles to altering Medicaid is its popularity: 77% of Individuals — and majorities of Democrats, independents, and Republicans — view this system favorably.
On the coronary heart of all of it are key questions concerning the function of presidency in folks’s well being: How large ought to the U.S. medical insurance coverage security internet be? Who deserves authorities help? And the way will enrollees, states, suppliers, and the well being care system at giant soak up main adjustments to Medicaid, even when a rollout had been staggered?
