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. received fundamental particulars flawed about Medicaid — a program he now oversees.
He stated 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 provides well being protection to tens of millions of disabled and low-income Individuals. This system covers completely different companies for various folks in numerous components of the nation — and enrollees could work together with personal 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 finances 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 completely different from Medicare?
Medicaid and Medicare have 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 folks with low incomes and adults and kids with disabilities.
Medicare, against this, usually covers these 65 or older.
For older Individuals 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 folks obtain companies from Medicaid or the intently associated Kids’s Well being Insurance coverage Program. That represents about 20% of the full inhabitants of america. 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 companies akin 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 complicated medical wants and helps them afford companies that enable them to stay independently in group settings, outdoors of establishments akin 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 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 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 other ways of defining that. For a four-adult family with out dependent youngsters, the present nationwide median protection degree is $44,367.
The Reasonably priced Care Act, typically known as Obamacare, which handed in 2010, allowed extra folks to qualify for Medicaid on the premise of revenue. That is what is called “Medicaid growth.”
The regulation supplied states a large incentive so as to add extra folks 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 Individuals who don’t get protection by means of an employer. Medicaid would cowl folks with extraordinarily low incomes, and as their incomes rose, they might transfer to sponsored well being plans offered by means of the Reasonably priced Care Act’s exchanges.
In 2012, the U.S. Supreme Courtroom stated the choice of whether or not to broaden 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 12 months 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 also can 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.
At the moment, the federal authorities matches no less than 50% of state spending and provides states more cash for some companies and enrollees — as an example, for youngsters and pregnant ladies.
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, as an 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 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} stream into states annually. 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 applications to cowl sure companies, together with emergency medical transportation, X-rays and lab work, household planning, and medication-assisted remedy for folks 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 dying.
Past that, states have the pliability 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 every other kind of insurance coverage, public or personal.
What’s Medicaid known as in my state?
Medicaid applications can go by many alternative names, even throughout the identical state, partly as a result of most states use personal insurance coverage corporations 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 supplied by main corporations, akin to Anthem Blue Cross Blue Protect and UnitedHealthcare — and a few you could not have heard of, akin 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 akin to medical doctors and hospitals much less cash for companies than Medicare or personal 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 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 would scale back the quantity of people that qualify, the companies accessible, or each. An identical 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 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 position of presidency in folks’s well being: How large ought to the U.S. medical insurance coverage security web be? Who deserves authorities help? And the way will enrollees, states, suppliers, and the well being care system at massive soak up main modifications to Medicaid, even when a rollout have been staggered?
