In January, throughout a congressional listening to on his strategy to changing into secretary of the Division of Well being and Human Companies, Robert F. Kennedy Jr. received fundamental particulars fallacious 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 presents well being protection to tens of millions of disabled and low-income People. This system covers totally different providers for various individuals in numerous components of the nation — and enrollees might 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 funds proposals that might dramatically curtail this system. As that debate begins, here’s what you should find out 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 kids with disabilities.
Medicare, against this, usually 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 packages.
Who’s on Medicaid?
Greater than 79 million individuals obtain providers from Medicaid or the intently associated Youngsters’s Well being Insurance coverage Program. That represents about 20% of the full inhabitants of the US. 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 corresponding to 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 providers that enable them to reside independently in group settings, exterior of establishments corresponding to 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 revenue {qualifications}?
Eligibility usually is determined by whether or not an individual is low revenue, and states have alternative ways of defining that. For a four-adult family with out dependent youngsters, the present nationwide median protection degree is $44,367.
The Inexpensive Care Act, typically known as Obamacare, which handed in 2010, allowed extra individuals to qualify for Medicaid on the premise of revenue. That is what is called “Medicaid growth.”
The legislation supplied states a large incentive so as to add extra individuals to their packages: The federal authorities would pitch in extra money per enrollee to assist cowl them.
The intention behind the growth was to shut gaps in medical health insurance packages 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 may 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 increase this system could be left as much as particular person states. At this time, 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 12 months for a single-person family in 2025. Those that make extra aren’t 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 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 the moment, the federal authorities matches not less than 50% of state spending and presents states extra money for some providers and enrollees — for example, for kids and pregnant girls.
Much less rich states — decided by contemplating residents’ per capita incomes — obtain the next match, translating to the next share of federal {dollars}. In Mississippi, for example, the federal authorities picks up 77% of the associated fee 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 lots of of billions of federal {dollars} stream into states every year. 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 individuals with opioid use dysfunction. This system additionally covers many nursing and residential well being providers, although federal legislation permits these advantages to be clawed again after an enrollee’s demise.
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 every other sort of insurance coverage, public or non-public.
What’s Medicaid known as in my state?
Medicaid packages can go by many various names, even throughout the similar state, partially as a result of most states use non-public insurance coverage corporations to run them. This may be complicated for shoppers who might not understand they’re really enrolled in Medicaid.
In New York, for example, Medicaid plans are supplied by main corporations, corresponding to Anthem Blue Cross Blue Defend and UnitedHealthcare — and a few it’s possible you’ll not have heard of, corresponding 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 usually pays well being care suppliers corresponding to medical doctors and hospitals much less cash for providers than Medicare or non-public insurance coverage does. However it may be extra money 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 categorical 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 may take the type of cuts to federal funding. That would scale back the quantity of people that qualify, the providers accessible, or each. An identical push centered 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 concerning 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 massive take in main modifications to Medicaid, even when a rollout have been staggered?
