In January, throughout a congressional listening to on his option to changing into secretary of the Division of Well being and Human Providers, Robert F. Kennedy Jr. obtained primary particulars flawed 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 complicated. The $880 billion-a-year state-federal program provides well being protection to tens of millions of disabled and low-income People. This system covers totally different companies for various individuals in numerous elements of the nation — and enrollees might work together with non-public insurance coverage firms 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 funds proposals that might dramatically curtail this system. As that debate begins, here’s what you could learn about Medicaid.
What’s Medicaid, and the way is it totally different from Medicare?
Medicaid and Medicare have 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 individuals with low incomes and adults and youngsters with disabilities.
Medicare, in contrast, typically covers these 65 or older.
For older People with low incomes, Medicaid covers out-of-pocket prices for Medicare. Such individuals are generally known as “twin eligibles,” as a result of they qualify for each applications.
Who’s on Medicaid?
Greater than 79 million individuals obtain companies from Medicaid or the carefully associated Youngsters’s Well being Insurance coverage Program. That represents about 20% of the full inhabitants of the USA. Most enrollees qualify due to low incomes.
About 40% of all kids within the nation are coated by Medicaid or CHIP, created in 1997. Each pay for companies equivalent to routine checkups, vaccinations, and hospital stays. Medicaid additionally covers pregnant individuals earlier than and after they provide start and pays for greater than 40% of all births.
Medicaid additionally covers individuals with disabilities or complicated medical wants and helps them afford companies that permit them to reside independently in neighborhood settings, exterior of establishments equivalent to nursing properties 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 individuals.
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 very 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 determined by whether or not an individual is low earnings, and states have alternative ways of defining that. For a four-adult family with out dependent kids, the present nationwide median protection degree is $44,367.
The Inexpensive Care Act, usually known as Obamacare, which handed in 2010, allowed extra individuals to qualify for Medicaid on the idea of earnings. That is what is called “Medicaid growth.”
The legislation provided states a large incentive so as to add extra individuals to their applications: 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 applications for the tens of millions of People who don’t get protection by an employer. Medicaid would cowl individuals with extraordinarily low incomes, and as their incomes rose, they might transfer to backed well being plans offered by the Inexpensive Care Act’s exchanges.
In 2012, the U.S. Supreme Court docket mentioned the choice of whether or not to develop this system can be left as much as particular person 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 degree is $5,947 a yr for a single-person family in 2025. Those that make extra should not eligible.
Adults in these states who make an excessive amount of for Medicaid may 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.
At present, the federal authorities matches not less than 50% of state spending and provides states more cash for some companies and enrollees — for example, for youngsters 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, for example, the federal authorities picks up 77% of the price of Medicaid.
States additionally obtain a 90% match from the federal authorities for enrollees eligible for Medicaid beneath the ACA’s growth.
There is no such thing as a restrict on how a lot states can spend on this system, and tons of of billions of federal {dollars} circulation 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 applications to cowl sure companies, together with emergency medical transportation, X-rays and lab work, household planning, and medication-assisted remedy for individuals with opioid use dysfunction. This system additionally covers many nursing and residential well being companies, although federal legislation permits these advantages to be clawed again after an enrollee’s loss of life.
Past that, states have the flexibleness to decide on the companies their Medicaid applications cowl. All states cowl pharmaceuticals, and most cowl eyeglasses, some dental care, and bodily remedy.
Medicaid covers extra psychological well being and long-term care companies than some other kind of insurance coverage, public or non-public.
What’s Medicaid known as in my state?
Medicaid applications can go by many various names, even throughout the similar state, partly as a result of most states use non-public insurance coverage firms to run them. This may be complicated for shoppers who might not notice they’re truly enrolled in Medicaid.
In New York, for example, Medicaid plans are provided by main firms, equivalent to Anthem Blue Cross Blue Protect and UnitedHealthcare — and a few it’s possible you’ll 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 companies 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 People 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 modifications, which may take the type of cuts to federal funding. That would scale back the quantity of people that qualify, the companies 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 largest obstacles to altering Medicaid is its reputation: 77% of People — 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 individuals’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 take in main modifications to Medicaid, even when a rollout have been staggered?
