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Medicaid

MEDICAID

Millions of elderly people in the United States have extensive health care needs and expenses, but many have limited incomes or savings to help them cover the cost of care. Virtually all elderly Americans have Medicare, the federal health insurance program for elderly and disabled Americans, to help pay medical bills. However, limits in the scope of benefits, coupled with financial obligations for coverage, can impose a serious financial burden. Elderly persons with low incomes are particularly vulnerable to these burdens because they are more likely to have health problems than higher-income Medicare beneficiaries, yet are less able to afford care. In addition, they are less likely to be able to access or afford the supplemental coverage that many Medicare beneficiaries purchase to help fill in Medicare's gaps.

Medicaid, a means-tested entitlement program that provides health coverage to low-income Americans, serves as an important complement to Medicare by assisting low-income Medicare beneficiaries with Medicare premiums and cost-sharing, and by providing coverage for prescription drugs and long-term care services not available through Medicare. Medicaid's supplemental coverage helps many low-income elderly persons gain access to needed health services and provides financial security from the high cost of care.

The need for medical assistance

In general, elderly persons are less healthy and have greater health care needs than the general population. Nearly a third of people age sixty-five and over report that their health status is poor or fair, compared to 18 percent of people age 55 to 64 and just 6 percent of those age 25 to 44. A significant percent of elderly persons live with serious or disabling health problems, such as arthritis (56 percent), hypertension (53 percent), and heart disease (36 percent), and many live with multiple chronic conditions (69 percent). These are all conditions that require increased contact with the health care system and ongoing care, including frequent visits with a health care provider, prescription medications, and, at times, hospitalization or other inpatient medical services.

Medicare coverage

The Medicare program provides basic health coverage to most persons age 65 and older, regardless of income, assuring them access to the health system and protection from financial catastrophe when illness strikes. Medicare consists of two parts: Hospital Insurance (Part A), which covers inpatient hospital care, limited skilled nursing facility care, and home health and hospice services, and Supplementary Medical Insurance (Part B), which covers physician and outpatient hospital services, as well as some other screening, laboratory, and home health services. However, the program does not cover all medical services that elderly people need (most notably, prescription drugs and nursing home care) and requires beneficiaries to pay monthly premiums and some portion of the cost of services at the point of care. For example, in 2002 the deductible for Part A was $812 and beneficiaries had to pay some portion of the charge for extended hospital stays. Medicare also requires a monthly ($100 in 2002) premium for Part B coverage ($54 in 2002) and 20 percent co-insurance after the Part B deductible ($100 in 2002) is met.

While many Medicare recipients purchase supplemental insurance to help with these cost-sharing obligations, these requirements can impose a substantial financial burden on the more than eleven million elderly Medicare beneficiaries (36 percent) who are poor or near-poor (see Figure 1). Not only do many Medicare beneficiaries live on modest incomes, but most rely on Social Security benefits as their main source of income. Social Security benefits are often quite modestthe average in 2001 was about $800 per month. However, these benefits are the major source of income for nearly two-thirds of beneficiaries. Living on fixed incomes with little potential for additional earnings leaves these beneficiaries with minimal cushion to absorb additional medical costs.

The potential burden of medical costs is particularly important to low-income elderly people because they are more likely to need medical services than higher-income beneficiaries. Poor elderly Medicare beneficiaries are nearly twice as likely as higher-income beneficiaries to report their health status as fair or poor, and they are more likely to live with multiple chronic conditions and functional limitations than elderly people with higher incomes. Poor health status and chronic medical conditions translate into higher costs due to the increased need for medication and physician supervision, as well as the need for nonmedical support services such as transportation and personal care assistance with daily tasks such as bathing and cooking.

note: In 1999, the federal poverty level was $8,240 for individuals, $11,060 for couples.

To provide assistance in covering the cost of uncovered Medicare services and Medicare cost-sharing, many elderly persons have supplemental coverage in addition to Medicare. There are different types of supplemental coverage, and the cost and scope of benefits vary. Thirty-six percent of Medicare beneficiaries have employer-sponsored retiree coverage. This type of coverage is typically very generous, covering a wide range of benefits and limiting beneficiaries' out-of-pocket costs. Another source of supplemental coverage is individually purchased Medigap policies, which about a quarter of Medicare beneficiaries hold. Beneficiaries pay monthly premiums for Medigap coverageon average $100 per month, though policies range in cost from about $1,400 to $4,700 per year, depending on where a person lives, the level of coverage they obtain, and their age.

Supplemental coverage of Medicare beneficiaries varies significantly by income (see Figure 2). Higher-income beneficiaries are more likely to have worked in jobs that offer retiree coverage, and higher- and moderate-income beneficiaries are also more likely to purchase Medigap policies. Lower-income beneficiaries, in contrast, are more likely to rely solely on Medicare. This difference in coverage exists because low-income elderly people are less likely to have worked in jobs that offer private supplemental coverage after retirement. In addition, though many purchase Medigap policies, the high cost of such coverage is unaffordable for some.

Ultimately, poor Medicare beneficiaries bear a disproportionate burden in out-of-pocket health care costs, spending more than a third of their income on health care, compared to 10 percent for higher-income beneficiaries. These costs may lead some elderly people into impoverishment or force them to choose between covering their health care costs and paying for other basic necessities.

Medicaid coverage for elderly persons

Medicaid, the nation's major public financing program for providing health and long-term care coverage to low-income people, fills in Medicare's gaps for millions of low-income elderly people. Medicaid is jointly funded by federal and state governments and administered by the states. Enacted as Title XIX of the Social Security Act in 1965, the program has evolved from one that primarily covered people receiving cash assistance to being an essential provider of health and long-term care coverage for over forty million low-income Americans.

Medicaid coverage is targeted to people who have low incomes, few assets, and who fall into particular categories, such as low-income children, some poor parents, pregnant women, people with disabilities, and elderly persons. In 1998, the program covered over four million elderly people, accounting for about 10 percent of total Medicaid enrollment and about 12 percent of elderly people on Medicare.

There are several pathways through which elderly people can become eligible for Medicaid assistance, and the scope of coverage varies according to which pathway is used (see Table 1). The poorest Medicare beneficiariesthose who are receiving or eligible for cash assistance through the Supplemental Security Income (SSI) programreceive assistance with all of Medicare's financial requirements and are also covered for the full range of Medicaid benefits. These benefits wrap around and supplement Medicare coverage. People who have exhausted their personal resources paying for health and long-term care services to the point that their available incomes fall below cash assistance income standards are also eligible for the same level of benefits. States also have the option to provide this level of coverage to elderly persons with slightly higher incomes or assets.

The majority of elderly people receiving Medicaid assistance fall into one of these groups and receive full Medicaid benefits. Because Medicaid supplements Medicare benefits, these beneficiaries (known as dual eligibles ) rely on Medicaid primarily for services not covered by Medicare, such as prescription drugs and long-term care, and for coverage of Medicare's premiums and cost-sharing.

Other low-income beneficiaries are eligible to receive assistance primarily limited to Medicare financial requirements (most notably, Part B premiums and cost-sharing), through four related programs, which are often referred to as the buy-in programs or "Medicare savings programs." Since the programs' inception in 1965, states have had the option to buy-in the poor to Medicare by paying their Part B premium and cost-sharing. In the late 1980s and the 1990s, the federal government expanded the Medicaid buy-in to assist low-income Medicare beneficiaries with the growing cost of Medicare premiums and cost-sharing. The first initiative was the Qualified Medicare Beneficiary (QMB) program, through which Medicaid pays the Medicare cost-sharing requirements and the Part B premium for beneficiaries with incomes below the federal poverty level (in 2000, the poverty level was $8,350 for an individual and $11,250 for couples) and limited assets. The Specified Low-Income Medicaid Beneficiary (SLMB) program pays the Part B premium for people with incomes between 100 and 120 percent of the federal poverty level and limited assets. Finally, the Qualified Individual (QI) programs provide a set amount of money to provide some assistance to Medicare beneficiaries with higher incomes (up to 175 percent of poverty) on a first come, first served basis.

note: Columns may not sum to 100 percent; employer/retiree includes both beneficiaries who have supplemental insurance from a former employer or union and those who are still working and whose current employer is their primary source of insurance.

Delivering Medicaid services to elderly persons

Because of the more extensive health care needs of elderly Medicaid beneficiaries, the elderly population accounts for a substantial share of spending under Medicaid. Of the $169 billion in total Medicaid expenditures in 1998, $46 billion (27 percent) was spent on services for the 10 percent of beneficiaries who were low-income elderly persons. Nearly three-quarters of Medicaid spending on the elderly population was for long-term care services, primarily nursing-home care; about 7 percent was for prescription drugs; and nearly 6 percent was payments to the Medicare program for premiums or cost-sharing. Largely due to the high cost of long-term care, elderly beneficiaries had the highest per capita expenditures of any Medicaid eligibility group (see Figure 3).

One of the most important roles that Medicaid plays for elderly Americans is financing long-term care. With nursing-home care averaging more than $50,000 per year and regular assistance in the community costing more than $10,000 per year in 2001, long-term care can be quite costly and can drain private resources quickly. Medicaid is the major public program that covers nursing-home care; the program finances care for over two-thirds of the nation's nursing-home residents and pays nearly half of all nursing-home costs in the nation. However, because Medicaid coverage is available only to low-income individuals, many people in nursing homes who receive Medicaid assistance must spend down, or deplete, their personal resources before Medicaid assistance is available. They must also continue to contribute any available income from Social Security or pensions toward the monthly cost of their care.

note:The first three programs are entitlements; the last two are block grants available on a first-come, first-serve basis.

In response to the high cost of nursing-home care and people's desire to remain in their community, all states also offer home health and home and community-based services (HCBS) under their Medicaid programs; some states also offer personal care services. These services provide assistance to people in the community and may target a specific mix of noninstitutional long-term care services to a distinct population or geographic area. While community-based services are crucial to enabling many elderly persons with long-term care needs to remain in their homes, they represent less than 10 percent of Medicaid spending and have not been shown to reduce nursing-home utilization. A 1999 Supreme Court decision (Olmstead v. L.C. ) has helped to promote the broader use of home care as an alternative to institutionalization for people with disabilities, and it may create pressure to increase the amount and share of Medicaid resources devoted to community-based long-term care.

Medicaid's role in covering the cost of prescription drugs to Medicare beneficiaries with low incomes is another key function of the program for elderly persons. Outpatient drug therapy has become an increasingly important part of the therapeutic regimen for millions of elderly Americans. In 1996, eight out of ten Medicare beneficiaries utilized prescription drugs on an ongoing basis as a way of managing chronic conditions, delaying or even preventing the onset of serious illness, or substituting for more invasive methods of care. Prescription drugs come at a substantial cost, however, and, on average, range from $800 to $1,400 per person, per year (as of 2001). People who do not have insurance to help with these costs are less likely to fill prescriptions, and they may pay more for some drugs because they cannot participate in pharmacy discounts negotiated by insurers. All states cover prescription drugs under their Medicaid programs, a benefit that accounted for over 8 percent of total program spending in 1998. One-quarter of Medicaid spending on drugs is on behalf of elderly beneficiaries.

note: Expenditures do not include DSH, adjustments, or administrative costs.

For both long-term and acute care services, elderly persons receiving Medicaid face particular challenges in receiving health services from both Medicare and Medicaid programs. Medicare remains the primary source of insurance for elderly people, while Medicaid covers wraparound services. Depending on how a state's Medicaid program works, dual eligibles may have to see different providers for different services one for their acute care needs and one for their long-term care needs. This situation creates confusion among beneficiaries, is administratively difficult for providers, and may encourage the programs to try to shift the cost of care to each other. The growing use of managed care, which relies on a restricted network of providers for services, in both Medicare and Medicaid programs for the elderly population, brings yet another layer of complexity to coordination of services. However, without the services in Medicaid to complement Medicare coverage, the four million elderly dual eligibles would have their substantial health needs go unmet. Medicaid functions as a true safety net for Medicare's most vulnerable and sickest beneficiaries.

Medicaid's impact

Medicaid supplemental assistance makes a difference in the lives of the elderly people enrolled in the program. Problems in getting medical care are often tied to financial barriers: If people cannot afford to pay their share for services, they often delay or avoid seeking care, which ultimately compromises their health status and results in greater suffering and mortality. Medicaid coverage helps remove financial barriers to care and substantially improves access to health care for Medicare beneficiaries. Despite their greater health care needs, dual eligibles are much more likely than beneficiaries without any supplemental coverage (Medicare only) to have regular check-ups and to obtain care in a timely manner (see Figure 4). People who receive both Medicare and Medicaid are also more likely to have a usual source of care than are those who have no supplemental coverage, an indicator that Medicaid helps people gain entry into the primary health care system and receive basic health services.

Dual eligibles also have lower out-of-pocket spending than other beneficiaries, spending four to five times less of their income on health care than the average Medicare beneficiary (see Figure 5). While other types of supplemental insurance may also moderate Medicare beneficiaries' out-of-pocket costs, people receiving Medicaid assistance are in the lowest income group, but they also spend far less of their income on medical care.

note: *Community residents only.

Future challenges in Medicaid coverage of elderly persons

Medicaid has made great strides in assuring access to care and alleviating financial burdens for elderly Americans. The program is a critical source of assistance to four million low-income elderly people. However, despite its importance as a complement to Medicare, Medicaid still faces many challenges in serving current and future beneficiaries.

One of the biggest challenges facing Medicaid is the aging of the general population, which will increase demand for Medicaid services in the future and place a larger financial burden on the program. The elderly population in the United States is expected to double to 70 million people by 2030, and the population over age eighty-five is expected to grow more than fourfold by 2050 to over 18 million people. These demographic changes are not only likely to lead to a greater number of people relying on Medicaid, but also are likely to greatly increase expenditures, as elderly Medicaid beneficiaries are high users of some of the most costly services in the programlong-term care and prescription drugs.

Medicaid's growing role in caring for the poorest elderly Americans and filling in Medicare's gaps occurs at a time when the federal and state governments, with limited resources, are likely to be addressing other, often competing, policy issues. For example, future changes to the Medicare program that add benefits (i.e., prescription drugs) or enact changes to the structure of the program could lead to increased costs for Medicaid and strain state financing. Many state governments operate under very tight budgets and do not have additional resources to cover these costs. Responsibility for financing the care of the growing elderly population remains a major policy challenge.

Future additional burdens on Medicaid coverage of elderly Americans are especially problematic in light of the fact that the existing program still needs several improvements. Currently, Medicaid's coverage of the low-income Medicare population is limited. In 1997, the program reached only half of all poor, and 13 percent of near-poor, Medicare beneficiaries. States have the option to extend full Medicaid benefits to Medicare beneficiaries at higher income levels or use more liberal methods for determining income and assets for eligibility, but levels and allowable assets generally remain low. In addition, many Medicare beneficiaries who are eligible for Medicare premium assistance through the buyin programs, particularly the SLMB and QI programs, are not enrolled. Lack of significant outreach efforts, complex and burdensome enrollment processes, and limited benefits all contribute to limited enrollment. Simplified or automatic eligibility determination and a meaningful benefit would help expand the scope of Medicaid coverage for low-income elderly persons.

note: *Noninstitutionalized beneficiaries age sixty-five and older. **Not enrolled in Medicaid. The 1997 federal poverty level of people over age sixty-five was $7,698 for individuals and $9.712 for couples.

The Medicaid program must also work to assure access to high quality health services for this vulnerable population. With rising prescription drug costs and utilization, states are looking into various methods to control spending in this area, including restricting access to expensive brand-name drugs or limiting the number of prescriptions a beneficiary can fill. Such efforts could lead Medicaid to restrain, rather than expand, its role in providing prescription drug coverage at a time when prescription drugs' importance to maintaining health is growing.

Medicaid can also improve the provision of long-term care to elderly persons. Despite improvements in nursing-home quality following comprehensive nursing-home reforms in the late 1980s, serious problems persist in many facilities. In addition, the supply of community-based services falls far short of demand. Increases in payment levels to levels that allow facilities to properly care for elderly persons and a greater commitment to providing community-based services can enhance the quality of care and the quality of life for elderly Medicaid beneficiaries.

Medicaid is critical to making Medicare work for over four million elderly people in the United States. Despite the importance of Medicare's universal coverage, millions of elderly Americans struggle to gain access to the health care they need. To assure Medicare's adequacy for coverage of elderly persons in future years, it is important to maintain and improve the assistance with financial obligations and additional benefits that Medicaid provides today.

Rachel Garfield Diane Rowland

See also Long-Term Care; Long-Term Care Financing; Medicare Medigap; Poverty.

BIBLIOGRAPHY

Health Care Financing Administration. "Medicare Savings Programs: Medicare/Medicaid Dual Eligible Home Page." World Wide Web document, 2001. http://www.hcfa.gov/medicaid/dualelig/default.htm.

Hoffman, E. D., Jr.; Klees, B. S.; and Curtis, C. A. "Overview of the Medicare and Medicaid Programs." Health Care Financing Review 22 (2000): 175193.

Lamphere, J. A., and Rosenbach, M. L. "Promises Unfulfilled: Implementation of Expanded Coverage for the Elderly Poor." HSR: Health Services Research 35, no. 1, Part II (2000): 207217.

Moon, M., and Mulvey, J. Entitlements and the Elderly. Washington, D.C.: Urban Institute Press, 1995.

Moon, M.; Brennan, N.; and Segal, M. "Options for Aiding Low-Income Medicare Beneficiaries." Inquiry 35 (1998): 346356.

Nemore, P. B. Variations in State Medicaid Buy-In Practices for Low-Income Medicare Beneficiaries, A 1999 Update. (Publication # 1566.) Washington, D.C.: The Kaiser Family Foundation, 1999.

Niefield, M.; O'Brien, E.; and Feder, J. Long-Term Care: Medicaid's Role and Challenges. (Publication #2172.) Washington, D.C.: The Kaiser Commission on Medicaid and the Uninsured, 1999.

United States General Accounting Office. Low-Income Medicare Beneficiaries: Further Outreach and Administrative Simplification Could Increase Enrollment. (Publication #GAO/HEHS-99-61.) Washington, D.C.: USGAO, 1999.

Weiner, J. M., and Stevenson, D. G. "State Policy on Long-Term Care for the Elderly." Health Affairs 17, no. 3 (1998): 81100.

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Medicaid

MEDICAID

Enacted in 1965, Medicaid is the major public financing program for providing health and long-term care coverage to the low-income population of the United States. It was originally enacted as a means of providing funds to help states provide health care for welfare recipients and has evolved into a program that finances care for more than one in seven Americans. Medicaid enables millions of Americans to gain access to needed health services, helping to close the gaps in care between the poor and nonpoor, ease the financial burdens of health care, and provide a health care safety net for the nation.

Authorized under Title XIX of the Social Security Act, Medicaid is a means-tested entitlement program financed by the states and the federal government and administered by the states. Federal financial assistance is provided to states for coverage of specific groups of people, and benefits are paid for by the states and through federal matching payments based on each state's per capita income. The federal share ranges from 50 to 80 percent of Medicaid expenditures and averaged 56.5 percent in 1998. State participation in the Medicaid program is voluntary, but all states have chosen to participate.

MEDICAID COVERAGE

Although Medicaid was created to assist low-income Americans, coverage is dependent upon several other criteria in addition to income. Eligibility is primarily for those persons falling into particular categories, such as low-income children, pregnant women, elderly people, people with disabilities, and parents not exceeding specific income thresholds. Single adults are generally ineligible, no matter how poor, unless they are disabled. Within federal guidelines, states set their own income and asset eligibility criteria for Medicaid, resulting in large variations in coverage among states.

In 1998, 40.4 million people were enrolled in Medicaid. This included 20.7 million low-income children and 8.6 million low-income adults in families with children. The vast majority of adults were women. Historically, most women and children have been eligible for Medicaid because they received cash assistance through Aid to Families with Dependent Children (AFDC). Over time, eligibility was expanded to women and children not receiving welfare. The Temporary Assistance to Needy Families (TANF) welfare reforms implemented in 1996 officially severed the automatic link between Medicaid coverage and cash assistance for families.

There were 4.1 million elderly persons covered by Medicaid in 1998. Some elderly persons are eligible because they receive cash assistance through Supplemental Security Income (SSI), and others have incomes too high to qualify for cash assistance but spend-down to Medicaid by incurring high health care expenses. Many elderly Medicaid beneficiaries are "dual eligibles," or people who receive both Medicare and Medicaid. These people rely on Medicaid for assistance with Medicare's cost-sharing requirements and premiums, and sometimes for coverage of services not included in the Medicare benefits package (i.e., long-term care or prescription drugs).

Medicaid also covered 7.0 million blind and disabled persons in 1998. Most disabled persons

Figure 1

are eligible for Medicaid because they receive SSI cash assistance, though some spend-down to eligibility. Some disabled Medicaid beneficiaries are also dual eligibles.

From the perspective of whom is served, Medicaid is predominantly a program assisting low-income families, but from the perspective of how Medicaid dollars are spent, Medicaid funds primarily serve the low-income aged and low-income disabled populations. Adults and children in low-income families make up nearly three quarters (73%) of enrollees, but account for only 25 percent of spending (see Figure 1). In contrast, the elderly and disabled account for 27 percent of enrollees and the majority (67%) of spending, largely due to their intensive use of acute care services and the costliness of long-term care in institutional settings. In 1998, the average per capita cost for a child on Medicaid was $1,225, almost all of which went to basic acute care, while the corresponding figures for the disabled and elderly were $9,558 and $11,235, respectively, a significant portion of which went to long-term care services.

Although Medicaid is a key source of coverage for the low-income population, in 1998 it covered

Figure 2

only about a quarter of nonelderly Americans with incomes below 200 percent of the poverty level. Limits on coverage were largely due to limits on eligibility, especially for adults, and enrollment obstacles for those who are eligible. The decoupling of Medicaid and welfare, as well as the 1997 State Children's Health Insurance Program to extend coverage additional low-income children, offers states new opportunities to extend Medicaid coverage to millions of low-income children and their parents. Many states, however, have yet to draw on this new flexibility to extend Medicaid.

COVERED SERVICES

Medicaid covers a broad range of services with nominal, if any, cost sharing by beneficiaries. Every individual entitled to Medicaid is guaranteed a minimum package of federally mandated services, including:

  • Inpatient and outpatient hospital care
  • Physician, midwife, and certified nurse practitioner services
  • Laboratory and X-ray services
  • Nursing home care and home health care

Figure 3

  • Early and periodic screening, diagnosis, and treatment (EPSDT) for children under twenty-one years of age
  • Family planning
  • Rural health clinic/federally qualified health center services

States also have the option to cover additional services and still receive federal matching funds. Commonly offered services include prescription drugs, clinic services, case management, hearing aids, dental care, and intermediate care facilities for the mentally retarded (ICF/MR).

Because they are so costly, long-term care services account for a significant amount of Medicaid spending. Of the $169.3 billion spent in 1998 (see Figure 2), 38 percent was spent on long-term care services, primarily nursing home care. Acutecare services were about half (53%) of total spending, with nearly half of all acute-care spending allocated for premiums to managed care organizations (MCOs). About 9 percent of Medicaid spending does not go directly to benefits for enrollees, but provides supplemental payments for hospitals with a disproportionately large population of indigent patients; these are called disproportionate share hospital payments (DSH). These additional payments are intended to enable these hospitals to

Figure 4

offset some of the costs of providing services to uninsured patients.

CARE DELIVERY

Traditionally, Medicaid services have been delivered on a fee-for-service basis. Beginning in the 1990s, however, many states began to look to managed care as a model of service delivery in an effort to decrease costs and emphasize primary care and care coordination. Medicaid managedcare models range from health maintenance organizations (HMOs) that use prepaid capitated contracts to loosely structured networks that contract with selected providers for discounted services and use gatekeeping to control utilization.

States initially targeted low-income families for managed-care enrollment, but efforts to enroll aged or disabled beneficiaries increased in the late 1990s. In 1997, states were given more latitude in using Medicaid managed care under the Balanced Budget Act (BBA) of 1997, including the authority to mandate managed-care enrollment for most Medicaid populations. AS of June 1999,17.8 million Medicaid beneficiariesover half of all Medicaid beneficiarieswere enrolled in managed care, a sixfold increase from the 2.7 million enrolled in 1991.

States may also seek waivers of federal Medicaid rules to design new service delivery models for Medicaid beneficiaries. Home and community-based service (HCBS) waivers (also called 1915(c) waivers) are often used by states to deliver targeted community-based care for frail elderly or disabled individuals. Although all states have such waivers, the population served remains small.

TRENDS IN ENROLLEE AND EXPENDITURE GROWTH

Medicaid enrollment rose dramatically in the early 1990s, peaking at 41.7 million beneficiaries in 1995 (see Figure 3). This growth was mostly attributable to expanded coverage of low-income pregnant women and young children and increases in the number of blind and disabled beneficiaries. However, from 1995 to 1998, enrollment declined, especially for low-income adults and children eligible for Medicaid based on receipt of cash assistance under welfare programs, due in part to state and federal changes in welfare and immigration policy.

During the early 1990s, Medicaid expenditures grew nearly 30 percent annually, due to a combination of health care inflation, state use of alternative financing mechanisms, and an increase in enrollment. Only a small fraction of spending growth was due to the expansions in coverage of low-income pregnant women and children (see Figure 4). Legislation enacted to limit the states' capacity to raise funds through provider taxes and to limit DSH payments played a role in slowing Medicaid spending growth during these years. By 1995, growth in annual expenditures had dropped to under 10 percent, and it had nearly leveled off by 1998 rising less than 4 percent annually from 1995 to 1998.

MEDICAID'S IMPACT

Since the mid-1960s, Medicaid has been a major force in shaping health and long-term care services for the most vulnerable and needy Americans. In the year 2000, Medicaid covered more Americans than any other health insurer, accounted for 15 percent of the nation's spending on health care, and was the major source of federal financial assistance to the states, accounting for 40 percent of all federal grant-in-aid payments to states. It covers one-quarter of all American children, 40 percent of all births, and is the single largest source of public financing for HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) care. Medicaid is also the only significant public program providing financing for long-term care, covering 70 percent of nursing home residents and nearly half of nursing home costs nationwide. It has impacted every sector of health care in America, from hospital care to nonmedical support services.

More importantly, Medicaid has a significant impact on the individuals it serves. Before Medicaid, the poor saw providers less often than the nonpoor, and they faced serious financial burdens in obtaining care. Medicaid has reshaped the availability and provision of care to the poor, raising access to levels similar to those with private coverage. In contrast, poor Americans who do not have Medicaid coverage continue to face significant barriers to care.

Diane Rowland

Rachel Garfield

(see also: Access to Health Services; Medicare; National Health Systems; Poverty and Health; Uninsurance )

Bibliography

Coughlin, T. A.; Ku, L..; and Holahan, J. (1994). Medicaid Since 1980. Washington, DC: The Urban Institute Press.

Hurley, R.; Freund, D.; and Paul, J. (1993). Managed Care in Medicaid: Lessons for Policy and Program Design. Chicago: The Health Administration Press.

Iglehart, J. (1994). "The American Health Care SystemMedicaid." New England Journal of Medicine 340(5): 403408.

(1995). "Medicaid and Managed Care." New England Journal of Medicine 332(25):17271731.

Kaiser Commission on Medicaid and the Uninsured (1999). Medicaid: A Primer. Washington, DC: The Kaiser Family Foundation.

Lillie-Blanton, M.; Martinez, R. M.; Lyons, B.; and Rowland, D., eds. (1999). Access to Health Care: Promises and Prospects for Low-Income Americans. Washington, DC: The Kaiser Family Foundation.

Riley, T. (1995). "Medicaid: The Role of the States." Journal of the American Medical Association 274(3):267270.

Rogers, D. E.; Blendon, R. J.; and Moloney, T. W. (1982). "Who Needs Medicaid?" New England Journal of Medicine 307(1):1318.

Rowland, D. (1995). "Medicaid at 30." Journal of the American Medical Association 274(3):271273.

Rowland, D.; Salganicoff, A.; and Keenan, P. S. (1999). "The Key to the Door: Medicaid's Role in Improving Health Care for Women and Children." Annual Review of Public Health 20:403426.

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Medicaid

MEDICAID

A joint federal-state program that provideshealth careinsurance to low-income persons.

Medicaid was enacted in 1965 as an amendment to the Social Security Act of 1935 (title XIX, 42 U.S.C.A. § 1396), entitling low-income persons to medical care. The program is a joint federal-state endeavor, with the federal government providing money to the states, which provide additional financing and administer medical programs for the poor that satisfy federal standards. Medicaid has become a major social welfare program. By 1995, 34 million people were covered by Medicaid, including 17 million children.

Before 1965, a patchwork of programs financed by state and local governments, along with charities and community hospitals, provided indigent persons with limited health care. Most of these programs provided emergency health care services. President lyndon b. johnson supported Medicaid as well as medicare legislation for retired persons in 1965. The enactment of Medicaid meant that persons who met federal financial eligibility requirements were entitled to health care.

Medicaid furnishes at least five general categories of treatment: inpatient hospital services, outpatient hospital services, laboratory and X-ray services, skilled nursing home services, and physicians' services. Generally, each of these services is available to treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with the capacity for normal activity, or present a significant handicap. In addition, all states provide eye and dental care and prescription drugs. Almost all states provide physical therapy, hospice care, and rehabilitative services.

Medicaid is a "vendor" plan because payment is made directly to the vendor (the person or entity that provides the services) rather than to the patient. Only approved nursing homes, physicians, and other providers of medical care are entitled to receive Medicaid payments for their services. Since the early 1970s, rising medical costs have placed financial pressures on the

Medicaid program. Consequently, health care providers are not fully reimbursed for the services they provide to Medicaid patients. Because of lower reimbursement payments, one-third of physicians limit the number of Medicaid patients they see, and one-quarter of them refuse to accept any Medicaid patients.

The federal government, through statutes and regulations, has enacted an increasing number of criteria for the states to follow in administering the Medicaid program. For example, from 1987 to 1992, the federal government imposed 30 mandates on states that related to eligibility, reimbursement, and services. The intent of these mandates was to reduce variations among the states and to create more consistency in the coverage to low-income persons.

Under federal law, states cannot reduce other welfare benefits that people receive when they become eligible for Medicaid. State plans cannot impose a citizenship or residency requirement other than requiring that an applicant be a resident of the state. No age requirement exists, and everyone receiving welfare may apply for Medicaid. People who are "medically needy" because they are unable to cover costs for their medical care are also eligible, even if their incomes or resources exceed the level that would qualify them for welfare. Beginning in 1988, Medicaid was extended to the "working poor"—low-income persons who have jobs with no health coverage.

When Medicaid began, persons who were eligible had the right to select their own doctors, hospitals, or other medical facilities. Because of skyrocketing medical expenditures, almost all states have received waivers from the federal government concerning the choice of physician. These states now direct most of their Medicaid clients to private, managed care programs. Managed care is a general term that refers to health plans that attempt to control the cost and quality of care by coordinating medical and other health-related services.

The federal government has also granted waivers to states that prefer to pay for home and community care for elderly beneficiaries who otherwise would end up in nursing homes. This type of care is less expensive than nursing home care and allows state funds to be stretched further.

The federal government reimburses states based mainly on their per capita income. States with high per capita incomes, such as New York and Illinois, receive 50 cents from the federal government for every dollar they spend on Medicaid. Poorer states receive more, with Mississippi receiving reimbursement of 79 percent. The average reimbursement level is 57 percent.

Medicaid fraud has plagued the program. The size and complexity of the system, with each state administering Medicaid differently, create opportunity for health care providers and state employees to engage in abuse. It is estimated that ten percent of Medicaid expenditures are paid on fraudulent claims by vendors. Relatively little fraud is attributable to individuals who provide false information to receive Medicaid benefits.

Another problem for Medicaid has been the growing number of middle-class, elderly persons who divest their assets, usually to their children, to meet the Medicaid financial guidelines and qualify for state-paid nursing home care. This practice results in cases where the truly needy cannot find a bed in a nursing home. In addition, the divestiture of assets imposes additional financial pressures on a program that already has difficulty meeting the demands of the truly needy. If an individual or couple gives away or sells a resource at less than fair market value, the social security administration must report such a transfer to the state Medicaid agency. A transfer of assets may result in a period of ineligibility for certain Medicaid covered nursing home services.

The U.S. Supreme Court, in Wisconsin Department of Health and Family Service v. Blumer, 534 U.S. 473, 122 S. Ct. 962, 151 L. Ed. 2d 935 (2002), upheld a Medicaid formula for determining Medicaid eligibility for a person needing nursing home care. More than 30 states developed Medicaid rules that used an "income-first" formula, while the remainder of the states used a "resource-first" formula to help determine eligibility for Medicaid assistance and the proper amount of income for the community spouse. The "income-first" rule generally calls upon the community spouse to count more of his or her assets toward his spouse's nursing home care. The "resource-first" rule allows the spouse to keep more assets, in the belief that income from these assets will help to support the community spouse.

The state of Wisconsin used the income-first formula. A married coupled challenged this formula, and the U.S. Supreme Court determined that either formula could be used by a state without violating the Medicare Catastrophic Coverage Act of 1988 (MCCA). The Court placed great emphasis on the fact that the health and human services department (HHS) had issued several statements in support of the income-first rule and noted that in late 2001 HHS had proposed a rule that would formalize this support.

The seriousness of these fraudulent transfers led Congress in 1996 to make a person criminally liable who "knowingly and willfully disposes of assets (including by any transfer in trust) in order for an individual to become eligible for medical assistance" (42 U.S.C.A. § 1320a–7b(a)). A person convicted of this offense may be fined $25,000 and imprisoned for five years.

The Balanced Budget Act of 1997 provided a new opportunity for states to further expand health insurance coverage for children under Medicaid. The legislation created a new State Children's Health Insurance Program under Title XXI of the social security act. Funding is available to states for this voluntary program. A state's allotment may be used to expand Medicaid, to develop a new program or to expand an existing program to provide health insurance to uninsured children, or to implement a combination of the two approaches. Up to ten percent of a state's allotment may be used for administrative costs, outreach, or other health care services for children. The new funds must be used to serve children below age 19 living in families with incomes at or below 200 percent of the federal poverty level.

The increase in state and federal expenditures on Medicaid ($240 billion in 2003) and in federal mandates to states on administration of the program have led to calls for reform. Reform efforts, which have been based on the payment to the states of block grants for medical assistance, have been unsuccessful. President george w. bush asked Congress to consider a block grant program for Medicaid in his 2003 legislative proposals. His proposal would give more authority to the states to set eligibility requirements. By 2003, 45 million people qualified for Medicaid assistance.

further readings

Bove, Alexander A., Jr. 1996. The Medicaid Planning Handbook: A Guide to Protecting Your Family's Assets from Catastrophic Nursing Home Costs. 2d ed. Boston: Little Brown.

Bremner, Faith. 2002 "Kempthorne Pleased with Bush Medicaid Reform Plan." Gannett News Service (February 24).

cross-references

Health Care Law; Health Insurance.

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Medicaid

Medicaid

Definition

Medicaid is a federal-state entitlement program for low-income citizens of the United States. The Medicaid program is part of Title XIX of the Social Security Act Amendment that became law in 1965. Medicaid offers federal matching funds to states for costs incurred in paying health care providers for serving covered individuals. State participation is voluntary, but since 1982, all 50 states have chosen to participate in Medicaid.


Description

Medicaid benefits

Medicaid benefits cover basic health care and long-term care services for eligible persons. About 58% of Medicaid spending covers hospital and other acute care services. The remaining 42% pays for nursing home and long-term care.

States that choose to participate in Medicaid must offer the following basic services:

  • hospital care, both inpatient and outpatient
  • nursing home care
  • physician services
  • laboratory and diagnostic x ray services
  • immunizations and other screening, diagnostic, and treatment services for children
  • family planning
  • health center and rural health clinic services
  • nurse midwife and nurse practitioner services
  • physician assistant services

Participating states may offer the following optional services and receive federal matching funds for them:

  • prescription medications
  • institutional care for the mentally retarded
  • home- or community-based care for the elderly, including case management
  • personal care for the disabled
  • dental and vision care for eligible adults

Because participating states are allowed to design their own benefits packages as long as they meet federal minimum requirements, Medicaid benefits vary considerably from state to state. About half of all Medicaid spending covers groups of people and services above the federal minimum.


Eligibility for Medicaid

Medicaid covers three major groups of low-income Americans:

  • All recipients. In 2001, Medicaid covered 44 million low-income persons in the United States.
  • Parents and children. In 2001, Medicaid covered 24 million low-income children, approximately one-fifth of all children in the United States. It provided coverage to an estimated 9.3 million low-income adults in families with children; most of these low-income adults were women.
  • The elderly. In 2001, Medicaid covered five million adults over the age of 65. Medicaid is the largest single purchaser of long-term and nursing home care in the United States.
  • The disabled. About 17% of Medicaid recipients are blind or disabled. Most of these persons are eligible for Medicaid because they receive assistance through the Supplemental Security Income (SSI) program.

All Medicaid recipients must have incomes and resources below specified eligibility levels. These levels vary from state to state depending on the local cost of living and other factors. For example, in 2001, the federal poverty level (FPL) was determined to be $14,630 for a family of three on the mainland of the United States, but $16,830 in Hawaii and $18,290 in Alaska.

In most cases, persons must be citizens of the United States to be eligible for Medicaid, although legal immigrants may qualify in some circumstances depending on their date of entry. Illegal aliens are not eligible for Medicaid, except for emergency care.

Persons must fit into an eligibility category to receive Medicaid, even if their income is low. Childless couples and single childless adults who are not disabled or elderly are not eligible for Medicaid.


Medicaid costs

Medicaid is by far the government's most expensive general welfare program. In 1966, Medicaid accounted for 1.4% of the federal budget, but by 2001, its share had risen to nearly 9%. Combined federal and state spending for Medicaid takes approximately 20 cents of every tax dollar. The federal government covers about 56% of costs associated with Medicaid. The states pay for the remaining 44%.

As of 2001, costs for Medicaid rose at an average annual rate of 7.9%. The federal government spent $107 billion on Medicaid in fiscal year (FY) 1999, a sum that is expected to rise to $159 billion in 2004. The states spent $81 billion to cover Medicaid costs in FY 1999. These costs are projected to increase to $120 billion by FY 2004.

Although more than half (54%) of all Medicaid beneficiaries are children, most of the money (more than 70%) goes for services for the elderly and disabled. The single largest portion of Medicaid money pays for long-term care for the elderly. Only 18% of Medicaid funds are spent on services for children.

There are several factors involved in the steep rise of Medicaid costs:

  • The rise in the number of eligible individuals. As the lifespan of most Americans continues to increase, the number of elderly individuals eligible for Medicaid also rises. The fastest-growing age group in the United States is people over 85.
  • The price of medical and long-term care. Advances in medical technology, including expensive diagnostic imaging tests, cause these costs to rise.
  • The increased use of services covered by Medicaid.
  • The expansion of state coverage from the minimum benefits package to include optional groups and optional services.

Normal results

The need to contain Medicaid costs is considered one of the most problematic policy issues facing legislators. In addition, the complexity of the Medicaid system, its vulnerability to billing fraud and other abuses, the confusing variety of the benefits packages available in different states, and the time-consuming paperwork are other problems that disturb both taxpayers and legislators.

Medicaid has increased the demand for health care services in the United States without greatly impacting or improving the quality of health care for low-income Americans. Medicaid is the largest health insurer in the United States. As such, it affects the employment of several hundred thousand health care workers, including health care providers, administrators, and support staff. Participation in Medicaid is optional for physicians and nursing homes . Many do not participate in the program because the reimbursement rates are low. As a result, many low-income people who are dependent on Medicaid must go to overcrowded facilities where they often receive substandard health care.


See also Medicare.


Resources

books

Albanese, Beverly H. and Heidi Macomber. Medicaid EZ: A Guide to Get Those Nursing Home Bills Paid. New York: iUniverse, 2000.

Conklin, Joan H. Medicare for the Clueless: The Complete Guide to This Federal Program. New York: Kensington Publishing, 2002.

Pratt, David A., and Sean K. Hornbeck. Social Security and Medicare Answer Book Gaithersburg, MD: Aspen, 2002.

Stevens, Robert, and Rosemary Stevens. Welfare Medicine in America: A Case Study of Medicaid. Somerset, NJ: Transaction Publishers, 2003.


periodicals

Benko, L. B. "Health Hazard. Medicaid Cuts Could Endanger Patients." Modern Healthcare 33 (2003): 2627.

Chaudry, R. V, W. P. Brandon, C. R. Thompson, R. S. Clayton, and N. B. Schoeps. "Caring for Patients under Medicaid Mandatory Managed Care: Perspectives of Primary Care Physicians." Qualitative Health Research 13 (2003): 3756.

Lambert, D., J. Gale, D. Bird, and D. Hartley. "Medicaid Managed Behavioral Health in Rural Areas." Journal of Rural Health 19 (2003): 2232.

Vastag, B. "Capitol Health Call: Proposal for State Medicaid Autonomy under Fire." Journal of the American Medical Association, 289 (2003): 10931094.


organizations

Health Care Financing Administration. United States Department of Health and Human Services. 200 Independence Avenue SW, Washington, D.C. 20201. <http://www.hcfa.gov>.

Kaiser Commission on Medicaid and the Uninsured. 1450 G Street NW, Suite 250, Washington, DC 20005. (202) 347-5270; Fax: (202) 347-5274. <http://www.kff.org>.

National Center for Policy Analysis. 655 15th Street NW, Suite 375, Washington, DC 20005. (202) 628-6671; Fax: (202) 628-6474. <http://www.ncpa.org>.

United States Department of Health and Human Services. 200 Independence Avenue SW, Washington, DC 20201. <http://www.hhs.gov>.

other

Centers for Medicare and Medicaid Services, US Department of Health and Human Services [cited March 14, 2003]. <http://cms.hhs.gov/>.

National Association of State Medicaid Directors [cited March 14, 2003]. <http://www.nasmd.org/>.

National Governor's Association [cited March 14, 2003]. <http://www.nga.org/>.

Social Security Administration [cited March 14, 2003]. <http://www.ssa.gov/>.


L. Fleming Fallon, Jr, MD, DrPH

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Medicaid

Medicaid

BIBLIOGRAPHY

The U.S. Medicaid program was enacted in 1965 as Title XIX of the Social Security Act. It is a federal-state program of health-care coverage for some low-income Americans, administered at the federal level by the Centers for Medicare and Medicaid Services. There are distinct Medicaid programs in every state, the District of Columbia, and the U.S. territories, but every program operates within guidelines set at the federal level. Medicaid is financed through federal and state general revenue funds using a formula (based on a states per capita income) whereby federal dollars are matched to state dollars at a rate of between 50 and 77 percent. In fiscal year 2004, Medicaid served approximately fifty-two million recipients at a cost of $288 billion.

Medicaid is a highly complex program, in part because there is considerable variation among states. Federal law requires states to cover some populations, referred to as categorically needy, and some services, referred to as mandatory. States may also cover medically needy and special populations and optional services and still receive federal matching funds. The major categorically needy groups are pregnant women and children under age six with family income at or below 133 percent of the federal poverty level (FPL); children ages six to nineteen with family income up to 100 percent of the FPL; and aged or disabled people who meet the income eligibility standards for the Supplemental Security Income program. Although there are many more recipients in the first two categories, the largest share of Medicaid dollars is spent on behalf of the third. Aged and disabled Medicaid recipients may also be eligible for Medicare, in which case Medicaid covers what Medicare does not.

Mandatory services for the categorically needy population comprise a comprehensive medical benefit, including inpatient and outpatient hospital, physician, prenatal, and postpartum care, as well as laboratory and x-ray, home-health, and nursing-facility services. Because Medicaid is a means-tested program vying with other state programs for general revenue funds, however, Medicaid reimbursement rates are typically substantially lower than those paid by Medicare and private insurers. Consequently, many Medicaid recipients have difficulty finding providers who will treat them for what the program will pay. Some states have addressed the access problem by requiring that Medicaid enroll recipients in managed-care organizations that contract to serve the program population in return for a yearly per capita payment. Managed care is also viewed as a cost-containment strategy.

Medicaid pays for almost half of all nursing-home care, compared with approximately 12 percent by Medicare and 8 percent by private insurers. Although Medicaid coverage is limited to low-income elders, program rules allow residents to qualify for nursing-home benefits by spending down their resources first and then turning to the program for assistance. Because Medicare covers only short-term and medically involved nursing-home stays and because private long-term care insurance is costly and time-limited, even middle-class elderly seek Medicaid benefits in a nursing home. In recent years, states have received federal waivers of some program requirements in order to provide comprehensive longterm care in recipients homes.

SEE ALSO Medicare; Medicine, Socialized; National Health Insurance; Poverty; Poverty, Indices of; Public Health; Welfare; Welfare State

BIBLIOGRAPHY

Centers for Medicare and Medicaid Services. Medicaid-At-a-Glance 2005: A Medicaid Information Source. http://www.cms.hhs.gov/MedicaidGenInfo/.

Grogan, Colleen, and Eric Patashnik. 2003. Between Welfare Medicine and Mainstream Entitlement: Medicaid at the Political Crossroads. Journal of Health Politics, Policy, and Law 28 (5): 821858.

Kaiser Commission on Medicaid and the Uninsured. May 2006. Medicaid Enrollment and Spending Trends. http://www.kff.org/medicaid/7523.cfm.

Sandra J. Tanenbaum

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Medicaid

Medicaid, national health insurance program in the United States for low-income persons and persons with disabilities. It was established in 1965 with passage of the Social Security Amendments and is now run by the Centers for Medicare and Medicaid Services. In 2010 the program was expanded as part of heath insurance legislation, to provide insurance for low-income people not eligible for subsidies under the new law, but the expansion was made voluntary for the states, and only about half the states elected to participate in the expansion (effective 2014). The federal role in Medicaid is limited to setting standards, issuing regulations and guidelines, and overseeing operation of the program by the states. More than 58 million people received Medicaid in 2013. Of the various services covered under Medicaid, about half of the funds are used to purchase in-patient hospital services and nursing home services; the remainder covers physician services, drugs, laboratory services, X rays, and other services. Political debate on the future of Medicaid has accompanied health-care reform and budget deficit reduction debates.

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Medicaid

MEDICAID


Medicaid is a large social welfare program operated jointly by the federal and state governments. A 1965 amendment to the Social Security Act of 1935 created the program, which allows low-income individuals access to medical care.

How does it work? The federal government provides money to the states. The states then add funding of their own to this amount and administer medical programs for the poor in compliance with federally established standards.

Before Medicaid developed, health care for the poor was very limited and came from a variety of sources, including hospitals, charities, and state and local governments.

What type of care can a Medicaid patient receive? A Medicaid recipient may obtain treatment from five different categories of care: inpatient hospital services, outpatient hospital services, laboratory and x-ray services, skilled nursing home services, and physician services.

Initially, Medicaid recipients were able to select their own doctors and hospitals, but because of a large increase in medical expenditures, states now direct Medicaid recipients to certain health plans that attempt to control costs and quality of care. As a result, only approved medical care providers, including physicians, nursing homes, and hospitals are entitled to receive Medicaid payments for their services.

In 1995, there were about 30 million Medicaid recipients.

See also: Medicare, Social Security Act

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Medicaid

Med·i·caid / ˈmediˌkād/ a federal system of health insurance for those requiring financial assistance.

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Medicaid

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