Because of its size and cost, Medicaid has been called the “workhorse” of the U.S. health system. Now it’s front and center in the debate on overhauling the U.S health system and expanding coverage to the uninsured.
With 60 million enrollees, Medicaid dwarfs other insurance programs, including its cousin, Medicare, which covers 44 million elderly and disabled people.Medicaid is a joint federal-state program, with the federal government picking up about 57 percent of the overall Medicaid tab. But the federal contribution varies by state, ranging from 50 percent to 73 percent, with poorer states getting a bigger matching rate.
Medicaid isn’t a one-size-fits-all program; after meeting certain federal requirements, each state has the flexibility to shape coverage and benefits. As a result, the Medicaid program in Pennsylvania bears little resemblance to the one in Louisiana. For example, non-working parents in Pennsylvania qualify for Medicaid if their incomes are below twice the federal poverty level ($44,100 for a family of four). But in Louisiana, non-working parents qualify only if their incomes are below 11percent of the poverty level ($2,426 for a family of four). States frequently experiment with new concepts in benefit design, eligibility and delivery systems.
In general, Medicaid covers about 45 percent of poor Americans, defined as those with incomes below the federal poverty level (about $22,000 for a family of four). To be eligible for coverage, individuals must fall below certain income thresholds, which vary by state, and belong to certain categories, such as having dependent children, or being pregnant or disabled. In 20 states, a parent in a family of four who gets paid the federal minimum wage makes too much to qualify. Only 18 states cover adults without dependent children.
Medicaid benefits include mental health services, transportation-to-health services, and comprehensive screenings and treatment for children. In addition, Medicaid enrollees have much lower out-of-pocket costs than people with private coverage. There are typically no monthly premiums and no, or very low, co-payments
However, in many states, specialists and dentists don’t see Medicaid patients. Providers typically blame low reimbursement rates as the main reason for not accepting Medicaid patients. In Kentucky, Medicaid pays doctors $210for a colonoscopy; Medicare pays $333. Private insurers usually pay more. In Pennsylvania, Medicaid pays doctors $300 for an appendectomy, while Medicare pays $575.
About 76 percent of all enrollees are children and their parents. And 65 percent of people on Medicaid come from working families. About three quarters of Medicaid spending is for the elderly and disabled, even though the two groups make up only about one quarter of the program’s enrollees. Medicare provides little coverage for long-term care, so many elderly, after depleting their savings, rely on Medicaid to pay their costly nursing home bills.
Administrative costs of Medicaid are less than 7 percent, or half the rate that’s typically seen in the private sector. Medicaid holds down costs in part by paying providers lower fees and doing little marketing.