In January, throughout a congressional listening to on his solution to changing into secretary of the Division of Well being and Human Providers, Robert F. Kennedy Jr. acquired fundamental particulars fallacious about Medicaid — a program he now oversees.
He mentioned that Medicaid is absolutely 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 gives well being protection to hundreds of thousands of disabled and low-income People. This system covers totally different companies for various individuals in numerous elements of the nation — and enrollees could 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 price range proposals that might dramatically curtail this system. As that debate begins, here’s what you could find out about Medicaid.
What’s Medicaid, and the way is it totally different from Medicare?
Medicaid and Medicare had been created by the identical laws — an addition to the Social Safety Act — that was signed into regulation 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 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 individuals obtain companies from Medicaid or the intently associated Kids’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 kids within the nation are lined by Medicaid or CHIP, created in 1997. Each pay for companies resembling routine checkups, vaccinations, and hospital stays. Medicaid additionally covers pregnant individuals earlier than and after they offer 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 stay independently in group settings, exterior of establishments resembling nursing properties and state-run hospitals.
This system serves a various cross part of the nation. About 40% of individuals underneath 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 relies on whether or not an individual is low earnings, and states have other ways of defining that. For a four-adult family with out dependent kids, the present nationwide median protection stage is $44,367.
The Reasonably priced Care Act, typically referred to as Obamacare, which handed in 2010, allowed extra individuals to qualify for Medicaid on the premise of earnings. That is what is named “Medicaid growth.”
The regulation provided states a large incentive so as to add extra individuals 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 hundreds of thousands of People who don’t get protection via an employer. Medicaid would cowl individuals with extraordinarily low incomes, and as their incomes rose, they might transfer to backed well being plans offered via the Reasonably priced Care Act’s exchanges.
In 2012, the U.S. Supreme Courtroom mentioned the choice of whether or not to increase this system could be left as much as particular person states. At present, 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 12 months for a single-person family in 2025. Those that make extra usually are not eligible.
Adults in these states who make an excessive amount of for Medicaid can even make too little to qualify for assist shopping for plans on the Reasonably priced 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 at the very least 50% of state spending and gives states more cash for some companies and enrollees — as an example, for youngsters and pregnant girls.
Much less rich states — decided by contemplating residents’ per capita incomes — obtain the next match, translating to the next proportion of federal {dollars}. In Mississippi, as an 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 underneath the ACA’s growth.
There isn’t any restrict on how a lot states can spend on this system, and a whole lot of billions of federal {dollars} circulate into states every year. In 2023, states spent about 15% of their very own budgets on Medicaid.
What does that cash pay for?
Federal regulation requires all state Medicaid packages to cowl sure companies, together with emergency medical transportation, X-rays and lab work, household planning, and medication-assisted therapy for individuals with opioid use dysfunction. This system additionally covers many nursing and residential well being companies, although federal regulation permits these advantages to be clawed again after an enrollee’s loss of life.
Past that, states have the pliability to decide on the companies 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 companies than another kind of insurance coverage, public or non-public.
What’s Medicaid referred to as in my state?
Medicaid packages can go by many alternative names, even throughout the identical state, partly as a result of most states use non-public insurance coverage firms to run them. This may be complicated for customers who could not understand they’re really enrolled in Medicaid.
In New York, as an example, Medicaid plans are provided by main firms, resembling Anthem Blue Cross Blue Protect and UnitedHealthcare — and a few you might not have heard of, resembling 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 resembling 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 could be uninsured.
Like states, suppliers and hospitals have come to depend on this cash and specific issues 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 might take the type of cuts to federal funding. That might cut back the quantity of people that qualify, the companies out there, or each. The same 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 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 in regards to the position of presidency in individuals’s well being: How huge 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 up main modifications to Medicaid, even when a rollout had been staggered?
