The US Medicaid Program

Abstract

ImportanceMedicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.ObjectiveTo describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.Evidence ReviewAnalyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.FindingsMedicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.Conclusions and RelevanceMedicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Association Between Hospital Adoption of an Emergency Department Treatment Pathway for Opioid Use Disorder and Patient Initiation of Buprenorphine After Discharge

“…However, we applied codes commonly used in related literature. [37][38][39] Sixth, our DD analysis assumes that there are no unmeasured characteristics that differed between attesting and nonattesting hospitals associated with changes over time in the incidence of buprenorphine treatment. If such an unmeasured confounder exists, our estimates would be biased.…”

Medicaid as a Driver of Health Equity

“…As Donohue et al 2 highlight, Medicaid expansion has not only been associated with improved health care access and outcomes (including mortality) for its enrollees, but also with gains in social outcomes such as lower rates of high school dropout, home eviction, and crime. 2 In addition, given the long history of structural racism in the US resulting in racialized poverty, Medicaid disproportionately serves racial and ethnic minority groups, who account for more than half of enrollees. While Medicaid expansion has clearly reduced racial and ethnic disparities in coverage and improved health outcomes, persistent disparities within Medicaid deserve attention, particularly in the wake of COVID-19.…”

“…While Medicaid expansion has clearly reduced racial and ethnic disparities in coverage and improved health outcomes, persistent disparities within Medicaid deserve attention, particularly in the wake of COVID-19. 2 The history of Medicaid is one of slow but steady expansion, fundamentally shaped by its financing and administrative structure, whereby the federal government sets the broad parameters for how much it is willing to pay, for what services, and for whom, but states have great discretion within those general bounds. This includes the ability to receive "waivers" that allow states to test new approaches to coverage and care not otherwise allowed under federal rules.…”

“…6 At this juncture, Medicaid covers approximately 1 in 5 people in the US, more than 40% of births, and more than 60% of nursing home residents. 2 While state autonomy presents challenges to creating a uniform safety net, the relative nimbleness of states has enabled policy and program experimentation focused on access, cost, population health, care management, value-based payment, and more. These are issues that are relevant to the entire health care system, but are more pressing and visible for Medicaid given public financing and the vulnerable populations covered.…”

“…In this issue of JAMA , Donohue and colleagues provide a timely and valuable overview of Medicaid, including a synthesis of its key characteristics and an analysis of its potential to improve health equity. In their comprehensive, evidence-based Special Communication, the authors provide detailed data on the population insured by Medicaid and the financial aspects of the program; examine evolving areas of Medicaid policy, including managed care, payment, and delivery system reforms; review the status of ACA Medicaid expansion; and discuss potential Medicaid policy reforms to reduce racial and ethnic disparities and advance health equity.…”