Medicaid

Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care."[1] Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017.[2][3][4] It is a means-tested program that is jointly funded by the state and federal governments and managed by the states,[5] with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or qualified non-citizens, and may include low-income adults, their children, and people with certain disabilities.[6] Poverty alone does not necessarily qualify someone for Medicaid.

The Patient Protection and Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and qualified non-citizens with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the Supreme Court of the United States ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards.[7]

Research suggests that Medicaid improves recipients' financial security. However, the evidence is mixed regarding whether Medicaid actually improves health outcomes, although "the best existing evidence says [having health insurance] improves health".[2]

Medicaid and Medicare are the two government sponsored medical insurance programs in the United States and are administered by the U.S. Centers for Medicare & Medicaid Services, Baltimore, Maryland.[8]

Centers for Medicare and Medicaid Services logo
Centers for Medicare and Medicaid Services (Medicaid administrator) logo

Features

Beginning in the 1980s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient's healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. As of 2014, 26 states have contracts with managed care organizations (MCOs) to deliver long-term care for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs that provide comprehensive care and accept the risk of managing total costs.[9] Nationwide, roughly 80% of enrollees are enrolled in managed care plans.[10] Core eligibility groups of poor children and parents are most likely to be enrolled in managed care, while the aged and disabled eligibility groups more often remain in traditional "fee for service" Medicaid.

Because the service level costs vary depending on the care and needs of the enrolled, a cost per person average is only a rough measure of actual cost of care. The annual cost of care will vary state to state depending on state approved Medicaid benefits, as well as the state specific care costs. 2008 average cost per senior was reported as $14,780 (in addition to Medicare), and a state by state listing was provided. In a 2010 national report for all age groups, the per enrolled average cost was calculated to $5,563 and a listing by state and by coverage age is provided.[11]

Eligibility and benefits

As of 2013, Medicaid is a program intended for those with low income, but a low income is not the only requirement to enroll in the program. Eligibility is categorical—that is, to enroll one must be a member of a category defined by statute; some of these categories include low-income children below a certain wage, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, low-income disabled people who receive Supplemental Security Income (SSI) and/or Social Security Disability (SSD), and low-income seniors 65 and older. The details of how each category is defined vary from state to state.

Some states operate a program known as the Health Insurance Premium Payment Program (HIPP). This program allows a Medicaid recipient to have private health insurance paid for by Medicaid. As of 2008 relatively few states had premium assistance programs and enrollment was relatively low. Interest in this approach remained high, however.[12]

Included in the Social Security program under Medicaid are dental services. These dental services are optional for adults above the age of 21; however, this service is a requirement for those eligible for Medicaid and below the age of 21.[13] Minimum services include pain relief, restoration of teeth, and maintenance for dental health. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a mandatory Medicaid program for children that aims to focus on prevention, early diagnosis and treatment of medical conditions.[13] Oral screenings are not required for EPSDT recipients, and they do not suffice as a direct dental referral. If a condition requiring treatment is discovered during an oral screening, the state is responsible for taking care of this service, regardless of whether or not it is covered on that particular Medicaid plan.[14]

History

The Social Security Amendments of 1965 created Medicaid by adding Title XIX to the Social Security Act, 42 U.S.C. §§ 1396 et seq. Under the program, the federal government provides matching funds to states to enable them to provide medical assistance to residents who meet certain eligibility requirements. The objective is to help states provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. Medicaid serves as the nation's primary source of health insurance coverage for low-income populations.

States are not required to participate. Those that do must comply with federal Medicaid laws under which each participating state administers its own Medicaid program, establishes eligibility standards, determines the scope and types of services it will cover, and sets the rate of payment. Benefits vary from state to state, and because someone qualifies for Medicaid in one state, it does not mean they will qualify in another.[15] The federal Centers for Medicare and Medicaid Services (CMS) monitors the state-run programs and establishes requirements for service delivery, quality, funding, and eligibility standards.

The Medicaid Drug Rebate Program and the Health Insurance Premium Payment Program (HIPP) were created by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90). This act helped to add Section 1927 to the Social Security Act of 1935 which became effective on January 1, 1991. This program was formed due to the costs that Medicaid programs were paying for outpatient drugs at their discounted prices.[16]

The Omnibus Budget Reconciliation Act of 1993 (OBRA-93) amended Section 1927 of the Act as it brought changes to the Medicaid Drug Rebate Program,[16] as well as requiring states to implement a Medicaid estate recovery program to sue the estate of decedents for medical care costs paid by Medicaid.[17]

Medicaid also offers a Fee for Service (Direct Service) Program to schools throughout the United States for the reimbursement of costs associated with the services delivered to special education students.[18] Federal law mandates that every disabled child in America receive a "free appropriate public education." Decisions by the United States Supreme Court and subsequent changes in federal law make it clear that Medicaid must pay for services provided for all Medicaid-eligible disabled children.

Medicaid expansion under the Affordable Care Act

ACA Medicaid expansion by state
2018 Medicaid expansion by state.
  Expanding Medicaid
  Not expanding Medicaid

The Patient Protection and Affordable Care Act, passed in 2010, would have revised and expanded Medicaid eligibility starting in 2014. Under the law as written, states that wished to participate in the Medicaid program would be required to allow people with income up to 133% of the poverty line to qualify for coverage, including adults without dependent children. The federal government would pay 100% of the cost of Medicaid eligibility expansion in 2014, 2015, and 2016; 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and all subsequent years.[19]

However, the Supreme Court ruled in NFIB v. Sebelius that this provision of the ACA was coercive, and that the federal government must allow states to continue at pre-ACA levels of funding and eligibility if they chose. Several states have opted to reject the expanded Medicaid coverage provided for by the act; over half of the nation's uninsured live in those states. They include Texas, Florida, Kansas, Georgia, Louisiana, Alabama, and Mississippi.[20] As of May 24, 2013 a number of states had not made final decisions, and lists of states which have opted out or were considering opting out varied,[21][22] but Alaska,[22] Idaho,[23] South Dakota,[23] Nebraska,[21] Wisconsin,[23] Maine,[23] North Carolina,[23] South Carolina,[23] and Oklahoma[23] seemed to have decided to reject expanded coverage.[23]

MedicaidForIdahoVan
A canvassing campaign, Medicaid for Idaho, to put Medicaid expansion on the ballot in early 2018; the Methodist Cathedral of the Rockies hosted the volunteers

Several factors are associated with states' decisions to accept or reject Medicaid expansion in accordance with the Patient Protection and Affordable Care Act. Partisan composition of state governments is the most significant factor, with states led primarily by Democrats tending to expand Medicaid and states led primarily by Republicans tending to reject expansion.[24] Other important factors include the generosity of the Medicaid program in a given state prior to 2010, spending on elections by health care providers, and the attitudes people in a given state tend to have about the role of government and the perceived beneficiaries of expansion.[25][26]

The federal government will pay 100 percent of defined costs for certain newly eligible adult Medicaid beneficiaries in "Medicaid Expansion" states.[27][28] The NFIB v. Sebelius ruling, effective January 1, 2014, allows Non-Expansion states to retain the program as it was before January 2014.

As of January 2014, 20 states confirmed opting out, including Alabama, Alaska, Florida, Georgia, Idaho, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Virginia & Wisconsin. States opting in after 2014 are Indiana & Pennsylvania.[29] On July 17, 2015, Governor Bill Walker sent a letter to the Alaskan state legislature, providing the required 45-day notice of his intention to accept the expansion of Medicaid in Alaska.[30]. As of January 2019, confirmed opting out states have shrunk to 13 states: Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, & Wisconsin.

Under 2017 American Health Care Act (AHCA) legislation under the House and Senate, both versions of proposed Republican bills have proposed cuts to Medicaid funding on differing timelines. Under both bills, the Congressional Budget Office has rated these as Medicaid coverage reductions, with the Senate bill reducing the costs of Medicaid by 26 percent by the year 2026, in comparison to projections of ACA subsidies. Additionally, CBO estimates have predicted the number of uninsured rising under AHCA from 28 million persons to 49 million (under the Senate bill) or to 51 (under the House Bill).[31]

State implementations

States may bundle together the administration of Medicaid with other programs such as the Children's Health Insurance Program (CHIP), so the same organization that handles Medicaid in a state may also manage the additional programs. Separate programs may also exist in some localities that are funded by the states or their political subdivisions to provide health coverage for indigents and minors.

State participation in Medicaid is voluntary; however, all states have participated since 1982 when Arizona formed its Arizona Health Care Cost Containment System (AHCCCS) program. In some states Medicaid is subcontracted to private health insurance companies, while other states pay providers (i.e., doctors, clinics and hospitals) directly. There are many services that can fall under Medicaid and some states support more services than other states. The most provided services are intermediate care for mentally handicapped, prescription drugs and nursing facility care for under 21-year-olds. The least provided services include institutional religious (non-medical) health care, respiratory care for ventilator dependent and PACE (inclusive elderly care).[32]

Most states administer Medicaid through their own programs. A few of those programs are listed below:

As of January 2012, Medicaid and/or CHIP funds could be obtained to help pay employer health care premiums in Alabama, Alaska, Arizona, Colorado, Florida, and Georgia.[33]

Medicaid differences by state

Medicaid is managed by the states, and each one has varying criteria on how to qualify for the program, what services are covered, and how physicians and care providers are reimbursed through the program. Differences between states are often influenced by the political ideologies of the state and cultural beliefs of the general population. Differing criteria can also make it very difficult for people to understand how to navigate the system, leave people who need coverage uninsured because they don’t meet certain criteria, and deepen inequality in certain populations.

There are several political factors that can influence the cost and eligibility of health care programs, as detailed in a study conducted by Gideon Lukens.[34] In the case of Medicaid specifically, this study found that some of the most important factors in determining eligibility included “party control, the ideology of state citizens, the prevalence of women in legislatures, the line-item veto, and physician interest group size.” This study also supports the hypothesis that while Democrats are relatively more in favor of generous eligibility policies over payment policies while the opposite is true for Republicans. Moreover, when the Supreme Court ruled to allow states to decide whether or not they planned to expand Medicaid in 2012, the states that chose to expand Medicaid, (which often meant extending existing eligibility), were much disproportionately northern states that where Democratic legislators held a significant number or at least a majority of seats. Certain states in which there is a Republican-controlled legislature may be forced to expand Medicaid in ways extending beyond increasing existing eligibility in the form of waivers that waive certain Medicaid requirements so long as they follow certain objectives. In its implementation, this has meant using Medicaid funds to pay for low-income citizens’ health insurance; this private-option was originally carried out in Arkansas but has been adopted by other Republican-led states.[35] However, private coverage is more expensive than Medicaid and the states would not have to contribute as much to the cost of private coverage.[36]

Further, certain groups of individuals, such as migrants, may face more barriers to obtaining health care than others as a result of various factors that are less concrete than policy despite the fact that they can be extremely challenging to face. Such factors are not limited to status of the individual, transportation, a lack of knowledge about the healthcare system (perhaps including eligibility).[37]

Medicaid eligibility policies are very complicated. In general, Medicaid eligibility is linked to a person's eligibility for Aid to Families with Disabled Children (AFDC), which provides aid to children whose families have low or no income, and to the Supplemental Security Income (SSI) program for the aged, blind, and disabled. States are required under federal law to provide all AFDC and SSI recipients with Medicaid coverage. Because eligibility for AFDC and SSI essentially guarantees Medicaid coverage, examining eligibility/coverage differences per state in AFDC and SSI is an accurate way to assess Medicaid differences as well. SSI coverage is largely consistent by state, and requirements on how to qualify or what benefits are provided are standard. AFDC has differing eligibility standards, however, and are influenced by:

  1. The Low-Income Wage Rate: State welfare programs base the level of assistance they provide on some concept of what is minimally necessary.
  2. Perceived Incentive for Welfare Migration. Not only do social norms within the state affect its determination of AFDC payment levels, but regional norms will affect a state's perception of need as well.
  3. Racism. Empirical studies have found that specific demographic characteristics of AFDC recipients also affect voters' perceptions of the appropriate AFDC payment level

Beyond the variance in eligibility and coverage between states, there is a large variance in the reimbursements Medicaid offers to care providers; the clearest examples of this are common orthopedic procedures. For instance, in 2013, the average difference in reimbursement for 10 common orthopedic procedures in the states of New Jersey and Delaware was $3,047.[38] The discrepancy in the reimbursements Medicaid offers may affect the type of care provided to patients. Care providers have no incentive to strive towards quality care, and though patients may have Medicare coverage, they have no way of accessing quality healthcare with it.

Enrollment

According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001.[39][5] In 2002, Medicaid enrollees numbered 39.9 million Americans, the largest group being children[40] (18.4 million or 46 percent). From 2000 to 2012, the proportion of hospital stays for children paid by Medicaid increased by 33 percent, and the proportion paid by private insurance decreased by 21 percent.[41] Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. In 2009, 62.9 million Americans were enrolled in Medicaid for at least one month, with an average enrollment of 50.1 million.[42] In California, about 23% of the population was enrolled in Medi-Cal for at least 1 month in 2009–10.[43]

Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The federal government pays on average 57 percent of Medicaid expenses.

Loss of income and medical insurance coverage during the 2008–2009 recession resulted in a substantial increase in Medicaid enrollment in 2009. Nine U.S. states showed an increase in enrollment of 15% or more, resulting in heavy pressure on state budgets.[44]

The Kaiser Family Foundation reported that for 2013, Medicaid recipients were 40% white, 21% black, 25% hispanic, and 14% other races.[45]

Comparisons with Medicare

Unlike Medicaid, Medicare is a social insurance program funded at the federal level[46] and focuses primarily on the older population. As stated in the CMS website,[5] Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and (through the End Stage Renal Disease Program) people of all ages with end-stage renal disease. The Medicare Program provides a Medicare part A which covers hospital bills, Medicare Part B which covers medical insurance coverage, and Medicare Part D which covers prescription drugs.

Medicaid is a program that is not solely funded at the federal level. States provide up to half of the funding for the Medicaid program. In some states, counties also contribute funds. Unlike the Medicare program, Medicaid is a means-tested, needs-based social welfare or social protection program rather than a social insurance program. Eligibility is determined largely by income. The main criterion for Medicaid eligibility is limited income and financial resources, a criterion which plays no role in determining Medicare coverage. Medicaid covers a wider range of health care services than Medicare.

Some people are eligible for both Medicaid and Medicare and are known as Medicare dual eligible or medi-medi's.[47][48] In 2001, about 6.5 million Americans were enrolled in both Medicare and Medicaid. In 2013, approximately 9 million people qualified for Medicare and Medicaid.[49]

Eligibility

Medicaid is a joint federal-state program that provides health coverage or nursing home coverage to certain categories of low-asset people, including children, pregnant women, parents of eligible children, people with disabilities and elderly needing nursing home care. Medicaid was created to help low-asset people who fall into one of these eligibility categories "pay for some or all of their medical bills."[50]

There are two general types of Medicaid coverage. "Community Medicaid" helps people who have little or no medical insurance. Medicaid nursing home coverage pays all of the costs of nursing homes for those who are eligible except that the recipient pays most of his/her income toward the nursing home costs, usually keeping only $66.00 a month for expenses other than the nursing home.

While Congress and the Centers for Medicare and Medicaid Services (CMS) set out the general rules under which Medicaid operates, each state runs its own program. Under certain circumstances, an applicant may be denied coverage. As a result, the eligibility rules differ significantly from state to state, although all states must follow the same basic framework.

Poverty

Having limited assets is one of the primary requirements for Medicaid eligibility, but poverty alone does not qualify people to receive Medicaid benefits unless they also fall into one of the defined eligibility categories.[51] According to the CMS website, "Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups."[51] In 2010, the Patient Protection and Affordable Care Act expanded Medicaid eligibility starting in 2014; people with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[52][53] However, the United States Supreme Court ruled that the federal government must make participation in the expanded Medicaid program voluntary, and several state governments have declared that they will not participate.

More recently, many states have authorized financial requirements that will make it more difficult for working-poor adults to access coverage. In Wisconsin, nearly a quarter of Medicaid patients were dropped after the state government imposed premiums of 3% of household income.[54] A survey in Minnesota found that more than half of those covered by Medicaid were unable to obtain prescription medications because of co-payments.[54]

Categories

There are a number of Medicaid eligibility categories; within each category there are requirements other than income that must be met. These other requirements include, but are not limited to, assets, age, pregnancy, disability,[55] blindness, income and resources, and one's status as a U.S. citizen or a lawfully admitted immigrant.[7]

The Deficit Reduction Act of 2005 requires anyone seeking Medicaid to produce documents to prove that he is a United States citizen or resident alien. An exception is made for Emergency Medicaid where payments are allowed for the pregnant and disabled regardless of immigration status.[56][57] Special rules exist for those living in a nursing home and disabled children living at home. A child may be covered under Medicaid if he or she is a U.S. citizen or a permanent resident.

A child may be eligible for Medicaid regardless of the eligibility status of his parents. Thus, a child may be covered by Medicaid based on his individual status even if his parents are not eligible. Similarly, if a child lives with someone other than a parent, he may still be eligible based on its individual status.[58]

Immigration status

Legal permanent residents (LPRs) with a substantial work history (defined as 40 quarters of Social Security covered earnings) or military connection are eligible for the full range of major federal means-tested benefit programs, including Medicaid (Medi-Cal).[59] LPRs entering after August 22, 1996, are barred from Medicaid for five years, after which their coverage becomes a state option, and states have the option to cover LPRs who are children or who are pregnant during the first five years. Noncitizen SSI recipients are eligible for (and required to be covered under) Medicaid. Refugees and asylees are eligible for Medicaid for seven years after arrival; after this term, they may be eligible at state option.

Nonimmigrants and unauthorized aliens are not eligible for most federal benefits, regardless of whether they are means tested, with notable exceptions for emergency services (e.g., Medicaid for emergency medical care), but states have the option to cover nonimmigrant and unauthorized aliens who are pregnant or who are children, and can meet the definition of "lawfully residing" in the United States. Special rules apply to several limited noncitizen categories: certain "cross-border" American Indians, Hmong/Highland Laotians, parolees and conditional entrants, and cases of abuse.

Aliens outside the United States who seek to obtain visas at US consulates overseas, or admission at US ports of entry, are generally denied entry if they are deemed "likely at any time to become a public charge."[60] Aliens within the United States who seek to adjust their status to that of lawful permanent resident (LPR), or who entered the United States without inspection, are also generally subject to exclusion and deportation on public charge grounds. Similarly, LPRs and other aliens who have been admitted to the United States are removable if they become a public charge within five years after the date of their entry due to causes that preexisted their entry.

A 1999 policy letter from immigration officials defined "public charge" and identified which benefits are considered in public charge determinations, and the policy letter underlies current regulations and other guidance on the public charge grounds of inadmissibility and deportability. Collectively, the various sources addressing the meaning of public charge have historically suggested that an alien's receipt of public benefits, per se, is unlikely to result in the alien being deemed to be removable on public charge grounds.

Coverage and use

One-third of children and over half (59%) of low-income children are insured through Medicaid or SCHIP. The insurance provides them with access to preventive and primary services which are used at a much higher rate than for the uninsured, but still below the utilization of privately insured patients. As of 2014, rate of uninsured children was reduced to 6% (5 million children remain uninsured).[61]

Dental

Children enrolled in Medicaid are individually entitled under the law to comprehensive preventive and restorative dental services, but dental care utilization for this population is low. The reasons for low use are many, but a lack of dental providers who participate in Medicaid is a key factor.[62][63] Few dentists participate in Medicaid – less than half of all active private dentists in some areas.[64] Low reimbursement rates, complex forms and burdensome administrative requirements are commonly cited by dentists as reasons for not participating in Medicaid.[65][66] In Washington state, a program known as Access to Baby and Child Dentistry (ABCD) has helped increase access to dental services by providing dentists higher reimbursements for oral health education and preventive and restorative services for children.[67][68] After the passing of the Affordable Care Act, many dental practices began using Dental Service Organizations to provide business management and support, allowing practices to minimize costs and pass the saving on to patients currently without adequate dental care.[69][70]

HIV

Medicaid provided the largest portion of federal money spent on health care for people living with HIV/AIDS until the implementation of Medicare Part D when the prescription drug costs for those eligible for both Medicare and Medicaid shifted to Medicare. Unless low income people who are HIV positive meet some other eligibility category, they are not eligible for Medicaid assistance unless they can qualify under the "disabled" category to receive Medicaid assistance — as, for example, if they progress to AIDS (T-cell count drops below 200).[71] The Medicaid eligibility policy contrasts with the Journal of the American Medical Association (JAMA) guidelines which recommend therapy for all patients with T-cell counts of 350 or less, or in certain patients commencing at an even higher T-cell count. Due to the high costs associated with HIV medications, many patients are not able to begin antiretroviral treatment without Medicaid help. More than half of people living with AIDS in the US are estimated to receive Medicaid payments. Two other programs that provide financial assistance to people living with HIV/AIDS are the Social Security Disability Insurance (SSDI) and the Supplemental Security Income.

Supplemental Security Income beneficiaries

Once someone is approved as a beneficiary in the Supplemental Security Income program, they may automatically be eligible for Medicaid coverage (depending on the laws of the state they reside in).[72]

Assets

Both the federal government and state governments have made changes to the eligibility requirements and restrictions over the years. The Deficit Reduction Act of 2005 (DRA) significantly changed the rules governing the treatment of asset transfers and homes of nursing home residents.[73] The implementation of these changes proceeded state-by-state over the next few years and has now been substantially completed.

Five year "look-back"

The DRA created a five-year "look-back period." That means that any transfers without fair market value (gifts of any kind) made by the Medicaid applicant during the preceding five years are penalizable.

The penalty is determined by dividing the average monthly cost of nursing home care in the area or State into the amount of assets gifted. Therefore, if a person gifted $60,000 and the average monthly cost of a nursing home was $6,000, one would divide $6000 into $60,000 and come up with 10. 10 represents the number of months the applicant would not be eligible for medicaid.

All transfers made during the five-year look-back period are totaled, and the applicant is penalized based on that amount after having already dropped below the Medicaid asset limit. This means that after dropping below the asset level ($2,000 limit in most states), the Medicaid applicant will be ineligible for a period of time. The penalty period does not begin until the person is eligible for medicaid but for the gift.[74]

Elders who gift or transfer assets can be caught in the situation of having no money but still not being eligible for Medicaid.

Utilization

During 2003–2012, the share of hospital stays billed to Medicaid increased by 2.5 percent, or 0.8 million stays.[75]

Medicaid super utilizers (defined as Medicaid patients with four or more admissions in one year) account for more hospital stays (5.9 vs.1.3 stays), longer length of stay (6.1 vs. 4.5 days), and higher hospital costs per stay ($11,766 vs. $9,032).[76] Medicaid super-utilizers were more likely than other Medicaid patients to be male and to be aged 45–64 years.[76] Common conditions among super-utilizers include mood disorders and psychiatric disorders, as well as diabetes; cancer treatment; sickle cell anemia; septicemia; congestive heart failure; chronic obstructive pulmonary disease; and complications of devices, implants and grafts.[76]

Budget

U.S. healthcare GDP
Medicaid spending as part of total U.S. healthcare spending (public and private). Percent of gross domestic product (GDP). Congressional Budget Office chart.[77]

Unlike Medicare, which is solely a federal program, Medicaid is a joint federal-state program. Each state operates its own Medicaid system, but this system must conform to federal guidelines in order for the state to receive matching funds and grants.[78] The matching rate provided to states is determined using a federal matching formula (called Federal Medical Assistance Percentages), which generates payment rates that vary from state to state, depending on each state's respective per capita income.[79] The wealthiest states only receive a federal match of 50% while poorer states receive a larger match.[80]

Medicaid funding has become a major budgetary issue for many states over the last few years, with states, on average, spending 16.8% of state general funds on the program. If the federal match expenditure is also counted, the program, on average, takes up 22% of each state's budget.[81][82] Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion.[83] In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. Federal Medicaid outlays were estimated to be $204 billion in 2008.[84] In 2011, there were 7.6 million hospital stays billed to Medicaid, representing 15.6 percent (approximately $60.2 billion) of total aggregate inpatient hospital costs in the United States.[85] At $8,000, the mean cost per stay billed to Medicaid was $2,000 less than the average cost for all stays.[86]

Medicaid does not pay benefits to individuals directly; Medicaid sends benefit payments to health care providers. In some states Medicaid beneficiaries are required to pay a small fee (co-payment) for medical services.[7] Medicaid is limited by federal law to the coverage of "medically necessary services".[87]

Since Medicaid program was established in 1965, "states have been permitted to recover from the estates of deceased Medicaid recipients who were over age 65 when they received benefits and who had no surviving spouse, minor child, or adult disabled child."[88] In 1993, Congress enacted the Omnibus Budget Reconciliation Act of 1993, which required states to attempt to recoup "the expense of long-term care and related costs for deceased Medicaid recipients 55 or older."[88] The Act also allowed states to recover other Medicaid expenses for deceased Medicaid recipients 55 or older, at each state's choice.[88] However, states are prohibited from estate recovery when "there is a surviving spouse, a child under the age of 21 or a child of any age who is blind or disabled" and "the law also carved out other exceptions for adult children who have served as caretakers in the homes of the deceased, property owned jointly by siblings, and income-producing property, such as farms."[88] Each state now maintains a Medicaid Estate Recovery Program, although the sum of money collected significantly varies from state to state, "depending on how the state structures its program and how vigorously it pursues collections."[88]

Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The federal government pays on average 57 percent of Medicaid expenses.

On November 25, 2008, a new federal rule was passed that allows states to charge premiums and higher co-payments to Medicaid participants.[89] This rule will enable states to take in greater revenues, limiting financial losses associated with the program. Estimates figure that states will save $1.1 billion while the federal government will save nearly $1.4 billion. However, this means that the burden of financial responsibility will be placed on 13 million Medicaid recipients who will face a $1.3 billion increase in co-payments over 5 years.[90] The major concern is that this rule will create a disincentive for low-income people to seek healthcare. It is possible that this will force only the sickest participants to pay the increased premiums and it is unclear what long-term effect this will have on the program.

Effects

After Medicaid was enacted, some states repealed their filial responsibility laws, but most states still require children to pay for the care of their impoverished parents.

A 2017 survey of the academic research on Medicaid found it improved recipients' health and financial security.[2] A 2017 paper found that Medicaid expansion under the Affordable Care Act "reduced unpaid medical bills sent to collection by $3.4 billion in its first two years, prevented new delinquencies, and improved credit scores. Using data on credit offers and pricing, we document that improvements in households' financial health led to better terms for available credit valued at $520 million per year. We calculate that the financial benefits of Medicaid double when considering these indirect benefits in addition to the direct reduction in out-of-pocket expenditures."[91] A 2019 study found that Medicaid expansion reduced the poverty rate.[92]

A 2016 paper found that Medicaid has substantial positive long-term effects on the health of recipients: "Early childhood Medicaid eligibility reduces mortality and disability and, for whites, increases extensive margin labor supply, and reduces receipt of disability transfer programs and public health insurance up to 50 years later. Total income does not change because earnings replace disability benefits."[93] The government recoups its investment in Medicaid through savings on benefit payments later in life and greater payment of taxes because recipients of Medicaid are healthier: "The government earns a discounted annual return of between 2 and 7 percent on the original cost of childhood coverage for these cohorts, most of which comes from lower cash transfer payments."[93]

A 2018 study in the Journal of Political Economy found that upon its introduction, Medicaid reduced infant and child mortality in the 1960s and 1970s.[94] The decline in the mortality rate for nonwhite children was particularly steep.[94] A 2018 study in the American Journal of Public Health found that the infant mortality rate declined in states that had Medicaid expansions (as part of the Affordable Care Act) whereas the rate rose in states that declined Medicaid expansion.[95]

A 2017 study found that Medicaid enrollment increases political participation (measured in terms of voter registration and turnout).[96]

A 2017 study found that Medicaid expansion, by increasing treatment for substance abuse, "led to a sizeable reduction in the rates of robbery, aggravated assault and larceny theft."[97]

A 2018 study found that Medicaid expansions in New York, Arizona, and Maine in the early 2000s caused a 6 percent decline in the mortality rate:[98]

HIV-related mortality (affected by the recent introduction of antiretrovirals) accounted for 20 percent of the effect. Mortality changes were closely linked to county-level coverage gains, with one life saved annually for every 239 to 316 adults gaining insurance. The results imply a cost per life saved ranging from $327,000 to $867,000 which compares favorably with most estimates of the value of a statistical life.

A 2019 paper by Stanford University and Wharton economists found that Medicaid expansion "produced a substantial increase in hospital revenue and profitability, with larger gains for government hospitals. On the benefits side, we do not detect significant improvements in patient health, although the expansion led to substantially greater hospital and emergency room use, and a reallocation of care from public to private and better-quality hospitals."[99]

Oregon Medicaid health experiment and controversy

In 2008 Oregon decided to hold a randomized lottery for the provision of Medicaid insurance in which 10,000 lower-income people eligible for Medicaid were chosen by a randomized system. The lottery enabled studies to accurately measure the impact of health insurance on an individual's health and eliminate potential selection bias in the population enrolling in Medicaid.

A sequence of two high-profile studies by a team from the Massachusetts Institute of Technology and the Harvard School of Public Health [100] found that "Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years", but did "increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain."

The study found that in the first year:[101]

  1. Hospital use increased by 30% for those with insurance, with the length of hospital stays increasing by 30% and the number of procedures increasing by 45% for the population with insurance;
  2. Medicaid recipients proved more likely to seek preventive care. Women were 60% more likely to have mammograms, and recipients overall were 20% more likely to have their cholesterol checked;
  3. In terms of self-reported health outcomes, having insurance was associated with an increased probability of reporting one's health as "good," "very good," or "excellent"—overall, about 25% higher than the average;
  4. Those with insurance were about 10% less likely to report a diagnosis of depression.
  5. Patients with catastrophic health spending (with costs that were greater than 30% of income) dropped.
  6. Medicaid patients had cut in half the probability of requiring loans or forgoing other bills to pay for medical costs.[102]

The studies spurred a debate about between proponents of expanding Medicaid coverage[103] , and fiscal conservatives challenging the value of this expansive government program.[104]

See also

References

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Further reading

External links

2017 Maine Question 2

Maine Question 2, formally titled "An Act To Enhance Access to Affordable Health Care", is a citizen-initiated ballot measure that has qualified for the November 7, 2017 statewide ballot. It seeks to expand Medicaid eligibility under the terms of the Affordable Care Act, something which has been vetoed six times by Maine Gov. Paul LePage.

Unofficial results have the referendum passing with 59% of the vote. Gov. LePage had said that he would not implement the expansion unless it was funded by the legislature in a way that meets his criteria, although a state court had ordered his administration to carry it out. His successor as governor, Janet Mills, signed an order to implement the expansion as one of her first acts as governor.

American Health Care Act of 2017

The American Health Care Act of 2017 often shortened to the AHCA, or nicknamed Trumpcare, was a bill in the 115th United States Congress. The bill, which was passed by the United States House of Representatives but not by the United States Senate, would have partially repealed the Patient Protection and Affordable Care Act (ACA).

Republican Party leaders had campaigned on the repeal of the ACA since its passage in 2010, and the 2016 elections gave Republicans unified control of Congress and the presidency for the first time since the ACA came into effect. Upon the start of the 115th Congress, Congressional Republicans sought to pass a partial repeal of the ACA using the reconciliation process, which allows legislation to bypass the Senate filibuster and pass with a simple majority in the Senate. With the support of President Donald Trump, House Republicans introduced the AHCA in early 2017, and the bill passed the House in a close vote on May 4, 2017. All House Democrats, along with several members of the centrist Tuesday Group and some other House Republicans, voted against the AHCA. The bill would have repealed the individual mandate and the employer mandate, dramatically cut Medicaid spending and eligibility, eliminated tax credits for healthcare costs, abolished some taxes on high earners, and altered rules concerning pre-existing conditions and essential health benefits.

Senate Republicans initially sought to pass the Better Care Reconciliation Act of 2017 (BCRA), a healthcare bill containing provisions largely similar to those of the AHCA. The BCRA was never voted on in its original form due to opposition from several Republican senators. Senate Majority Leader Mitch McConnell instead sought to pass the Health Care Freedom Act (HCFA), which was colloquially referred to as a "skinny repeal" since it would only repeal the individual mandate and the employer mandate. On July 27, the Senate rejected the HCFA in a 51-to-49 vote, with Republican senators Susan Collins, Lisa Murkowski, and John McCain joining with all Senate Democrats in voting against it. In September 2017, some Republican senators pushed a renewed effort to repeal the ACA, but their bill never received a vote in the Senate. The 115th Congress ultimately did not pass an ACA repeal bill, though it did pass the Tax Cuts and Jobs Act of 2017, which repealed the individual mandate.

The nonpartisan Congressional Budget Office projected that the AHCA would have increased the number of uninsured people by 23 million over 10 years, but would have decreased the federal budget deficit by $119 billion over the same period. Polling consistently showed that the AHCA was deeply unpopular with the American populace during and after its evaluations in Congress. Business Insider stated that the AHCA was "the least popular major bill in decades", and major medical organizations, including the American Medical Association and the American Academy of Pediatrics, strongly condemned the bill and excoriated its supporters in Congress. AHCA's unpopularity may have contributed to Republican losses in the 2018 elections.

Centers for Medicare and Medicaid Services

The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov.

Children's Health Insurance Program

The Children's Health Insurance Program (CHIP) – formerly known as the State Children's Health Insurance Program (SCHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

The program came in response to the failure of comprehensive health care reform proposed in 1993 by President Bill Clinton. The legislation to create it was sponsored by Senator Ted Kennedy in a partnership with Senator Orrin Hatch, with support coming from First Lady Hillary Clinton during the Clinton administration.

At its creation in 1997, SCHIP was the largest expansion of taxpayer-funded health insurance coverage for children in the U.S. since Lyndon Johnson established Medicaid in 1965. The statutory authority for CHIP is under title XXI of the Social Security Act.

States are given flexibility in designing their CHIP eligibility requirements and policies within broad federal guidelines. Some states have received authority through waivers of statutory provisions to use CHIP funds to cover the parents of children receiving benefits from both CHIP and Medicaid, pregnant women, and other adults. CHIP covered 7.6 million children during federal fiscal year 2010, and every state has an approved plan. Despite CHIP, the number of uninsured children continued to rise, particularly among families that cannot qualify for CHIP. An October 2007 study by the Vimo Research Group found that 68.7 percent of newly uninsured children were in families whose incomes were 200 percent of the federal poverty level or higher as more employers dropped dependents or dropped coverage altogether due to annual premiums nearly doubling between 2000 and 2006. Vimo cites the Kaiser Commission on Medicaid and the Uninsured when it says 48 percent of the newly uninsured were not eligible for any kind of public coverage, and that only those in the lowest income bracket might offset the loss of employer-sponsored coverage with increases in Medicaid and SCHIP. In FY 2008, the program faced funding shortfalls in several states.Two attempts to expand funding for the program were vetoed by President George W. Bush, who argued that such efforts were steps toward federalization of health care, and would "steer the program away from its core purpose of providing insurance for poor children and toward covering children from middle-class families." On February 4, 2009, President Barack Obama signed the Children's Health Insurance Reauthorization Act of 2009, expanding the healthcare program to an additional 4 million children and pregnant women, including “lawfully residing” immigrants without a waiting period.A 2018 survey of the existing research noted that the availability of "CHIP coverage for children has led to improvements in access to health care and to improvements in health over both the short-run and the long-run."As of February 2018, the CHIP program has been authorized to continue through the year 2027.

Greg Reed

Greg Reed (born June 5, 1965) is a Republican member of the Alabama Senate, representing the 5th District since 2010. He defeated Democrat Brett Wadsworth in the 2010 midterm elections to replace Charles Bishop in the 5th District.

Reed was named Chairman of the Alabama Senate Health Committee for the 2011 quadrennium. During his tenure, he sponsored and passed Medicaid reform legislation that created Regional Care Organizations (RCOs). RCOs are self-sustaining managed care organization that receive a capitated amount from Alabama Medicaid each year to provide services to Medicaid recipients within the RCO's geographical area. Alabama Medicaid expects the RCOs to generate significant cost savings once fully implemented.Reed made national news in February 2012 when he was questioned for his possible conflict of interest in being the vice-president of an ultrasound company while pushing a bill in the Alabama Senate that would require women seeking abortions to first have a trans vaginal ultrasound performed.Reed co-sponsored the legislation because of his strong pro-life beliefs. He stated that a conflict of interest did not exist because of his company's policy to not do business with abortion clinics. Reed continued to deny conducting business with abortion clinics even after written price quotes surfaced from an abortion provider by his company.In November 2014, Senator Greg Reed was re-elected without opposition. His peers elected him to the position of Majority Leader right after his re-election to the Alabama State Senate.The Alabama Association of Resource, Conservation and Development (AARCD) Councils named Senator Reed the 2015 Senate Leader of the Year at their annual meeting in April 2015.During the 2015 legislative session, Majority Leader Greg Reed continued his Medicaid reform efforts by passing legislation to create Integrated Care Networks (ICNs). The legislation allows ICNs to contracting with Medicaid to provide long-term care under a capitated system. Alabama Medicaid estimates it will save taxpayers $1.5 billion over the first ten years.

Harris v. McRae

Harris v. McRae, 448 U.S. 297 (1980), was a case in which the Supreme Court of the United States held that States that participated in Medicaid were not required to fund medically necessary abortions for which federal reimbursement was unavailable as a result of the Hyde Amendment, which restricted the use of federal funds for abortion. The Court also held that the funding restrictions of the Hyde Amendment did not violate either the Fifth Amendment or the Establishment Clause of the First Amendment.

Health care

Health care or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals (providers or practitioners) in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, midwifery, nursing, medicine, optometry, audiology, pharmacy, psychology, occupational therapy, physical therapy and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

Access to health care may vary across countries, communities, and individuals, largely influenced by social and economic conditions as well as health policies. Health care systems are organizations established to meet the health needs of targeted populations. According to the World Health Organization (WHO), a well-functioning health care system requires a financing mechanism, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, and well maintained health facilities to deliver quality medicines and technologies.An efficient health care system can contribute to a significant part of a country's economy, development and industrialization. Health care is conventionally regarded as an important determinant in promoting the general physical and mental health and well-being of people around the world. An example of this was the worldwide eradication of smallpox in 1980, declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions.

Health insurance in the United States

Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits".

In a more technical sense, the term "health insurance "is used to describe any form of insurance providing protection against the costs of medical services. This usage includes private insurance and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.

In addition to medical expense insurance, "health insurance" may also refer to insurance covering disability or long-term nursing or custodial care needs. Different health insurance provides different levels of financial protection and the scope of coverage can vary widely, with more than 40% of insured individuals reporting that their plans do not adequately meet their needs as of 2007.The share of Americans without health insurance has been cut in half since 2013. Many of the reforms instituted by the Affordable Care Act of 2010 were designed to extend health care coverage to those without it; however, high cost growth continues unabated. National health expenditures are projected to grow 4.7% per person per year from 2016 to 2025. Public healthcare spending was 29% of federal mandated spending in 1990 and 35% of it in 2000. It is also projected to be roughly half in 2025.

ICD-10 Procedure Coding System

The ICD-10 Procedure Coding System (ICD-10-PCS) is an international system of medical classification used for procedural coding. The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM. ICD-9-CM contains a procedure classification; ICD-10-CM does not. ICD-10-PCS is the result. ICD-10-PCS was initially released in 1998. It has been updated annually since that time.

Joint Commission

The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 21,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements.The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois.

Long-term care

This article is about an integrated health care system, often for elders or those with disabilities, which often relies on a single type of health and social care service called a nursing facility, modernized to assisted living facilities. For specific information on providers of such services, see for example Direct Support Professional, Disability Public Policy (See, also wiki's disability portal), Aging Public Policy, and Field of Gerontology.

Long-term care (LTC) is a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves for long periods. Long term care is focused on individualized and coordinated services that promote independence, maximize patients' quality of life, and meet patients' needs over a period of time.It is common for long-term care to provide custodial and non-skilled care, such as assisting with normal daily tasks like dressing, feeding, using the bathroom. Increasingly, long-term care involves providing a level of medical care that requires the expertise of skilled practitioners to address the multiple chronic conditions associated with older populations. Long-term care can be provided at home, in the community, in assisted living facilities or in nursing homes. Long-term care may be needed by people of any age, although it is a more common need for senior citizens.

Long-term care insurance

Long-term care insurance (LTC or LTCI) is an insurance product, sold in the United States, United Kingdom and Canada that helps pay for the costs associated with long-term care. Long-term care insurance covers care generally not covered by health insurance, Medicare, or Medicaid.

Individuals who require long-term care are generally not sick in the traditional sense but are unable to perform two of the six activities of daily living (ADLs) such as dressing, bathing, eating, toileting, continence, transferring (getting in and out of a bed or chair), and walking.

Age is not a determining factor in needing long-term care. About 70 percent of individuals over 65 will require at least some type of long-term care services during their lifetime. About 40% of those receiving long-term care today are between 18 and 64. Once a change of health occurs, long-term care insurance may not be available. Early onset (before 65) Alzheimer's and Parkinson's disease occur rarely.

Long-term care is an issue because people are living longer. As people age, many times they need help with everyday activities of daily living or require supervision due to severe cognitive impairment. That impacts women even more since they often live longer than men and, by default, become caregivers to others.

Medicaid Fraud Dogg

Medicaid Fraud Dogg is the tenth studio album by American band Parliament, led by George Clinton. It was released on May 22, 2018, under the record label Clinton founded in 2003, C Kunspyruhzy Records. Guest musicians on the album include Fred Wesley and Pee Wee Ellis, one-time James Brown collaborators. It features guest appearances from Scarface and Mudbone. Medicaid Fraud Dogg was released in Japan by P-Vine records on September 12th, 2018.

Medicare (United States)

Medicare is a national health insurance program in the United States, begun in 1966 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It provides health insurance for Americans aged 65 and older, younger people with some disability status as determined by the Social Security Administration, as well as people with end stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). Medicare is funded by a combination of a payroll tax, beneficiary premiums and surtaxes from beneficiaries, and general U.S. Treasury revenue.

In 2017, Medicare provided health insurance for over 58 million individuals—more than 49 million people aged 65 and older and about 9 million younger people. On average, Medicare covers about half of healthcare expenses of those enrolled. According to annual Medicare Trustees reports and research by the government's MedPAC group, the enrollees then almost always cover their remaining costs either with additional insurance, or by joining a Medicare health plan. Almost no one uses United States Medicare only. No matter which of those two options the beneficiaries choose or if they choose to do nothing extra (around 1% according to annual Medicare Trustees reports), beneficiaries also have out of pocket (OOP) costs. OOP costs can include deductibles and co-pays; the costs of uncovered services—such as for long-term custodial, dental, hearing, and vision care; the cost of annual physical exams for those not on health plans; and the costs related to basic Medicare's lifetime and per-incident limits.

Medicare is divided into four Parts. Medicare Part A covers hospital (inpatient, formally admitted only), skilled nursing (only after being formally admitted to a hospital for three days and not for custodial care), and hospice services. Part B covers outpatient services including some providers' services while inpatient at a hospital, outpatient hospital charges, most provider office visits even if the office is "in a hospital," and most professionally administered prescription drugs. Part D covers mostly self-administered prescription drugs. Part C is an alternative called Managed Medicare by the Trustees that allows patients to choose health plans with at least the same service coverage as Parts A and B (and most often more), often the benefits of Part D, and always an annual OOP spend limit which A and B lack. The beneficiary must enroll in Parts A and B first before signing up for Part C.

National Federation of Independent Business v. Sebelius

National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012), was a landmark United States Supreme Court decision in which the Court upheld Congress' power to enact most provisions of the Patient Protection and Affordable Care Act (ACA), commonly called Obamacare, and the Health Care and Education Reconciliation Act (HCERA), including a requirement for most Americans to have health insurance by 2014. The Acts represented a major set of changes to the American health care system that had been the subject of highly contentious debate, largely divided on political party lines.

The Supreme Court, in an opinion written by Chief Justice John Roberts, upheld by a vote of 5 to 4 the individual mandate to buy health insurance as a constitutional exercise of Congress's taxing power. A majority of the justices, including Chief Justice Roberts, agreed that the individual mandate was not a proper use of Congress's Commerce Clause or Necessary and Proper Clause powers, though they did not join in a single opinion. A majority of the justices also agreed that another challenged provision of the Act, a significant expansion of Medicaid, was not a valid exercise of Congress's spending power as it would coerce states to either accept the expansion or risk losing existing Medicaid funding.

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA), often shortened to the Affordable Care Act (ACA) or nicknamed Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered during 2016. The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to major changes to individual insurance markets. Both involved new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office reports said that overall these provisions reduced the budget deficit, that repealing the ACA would increase the deficit, and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After the law went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.The act largely retains the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled around a three-legged scheme. Insurers in these markets are made to accept all applicants and charge the same rates regardless of pre-existing conditions or sex. To combat resultant adverse selection, the act mandates that individuals buy insurance and insurers cover a list of "essential health benefits". However, a repeal of the individual tax mandate, passed as part of the Tax Cuts and Jobs Act of 2017, became effective on January 1, 2019. To help households between 100–400% of the Federal Poverty Line afford these compulsory policies, the law provides insurance premium subsidies. Other individual market changes include health marketplaces and risk adjustment programs.

Since being signed into law in 2010, the PPACA has faced strong political opposition, calls for repeal (from Republicans) and numerous legal challenges; its enactment is considered to be a catalyst for the Tea Party movement. In National Federation of Independent Business v. Sebelius, the Supreme Court ruled that states could choose not to participate in the ACA's Medicaid expansion, although it upheld the law as a whole. The federal health exchange, HealthCare.gov, faced major technical problems at the beginning of its rollout in 2013. In 2017, a unified Republican government attempted but failed to pass several different partial repeals of the ACA. The law spent several years opposed by a slim plurality of Americans polled, although its provisions were generally more popular than the law as a whole, and the law gained majority support by 2017.

Social Security Amendments of 1965

The Social Security Amendments of 1965, Pub.L. 89–97, 79 Stat. 286, enacted July 30, 1965, was legislation in the United States whose most important provisions resulted in creation of two programs: Medicare and Medicaid. The legislation initially provided federal health insurance for the elderly (over 65) and for poor families.

Supplemental Security Income

Supplemental Security Income (SSI) is a United States government means-tested welfare program that provides cash assistance and health care coverage (i.e., Medicaid) to people with low-income and limited assets who are either aged 65 or older, blind, or disabled (children included). Although administered by the Social Security Administration, SSI is funded from the U.S. Treasury general funds, not the Social Security trust fund. SSI was created in 1974 to replace federal-state adult assistance programs that served the same purpose, but was administered by the State agencies and received criticism for lacking consistent eligibility criteria throughout the United States. The restructuring of these programs was intended to standardize the eligibility requirements and level of benefits. The new federal program was incorporated into Title XVI (Title 16) of the Social Security Act. Today the program provides benefits to approximately eight million Americans.

Supplemental needs trust

Supplemental needs trust is a US-specific term for a type of special needs trust (an internationally recognized term). Supplemental needs trusts are compliant with provisions of US state and federal law and are designed to provide benefits to, and protect the assets of, individuals with physical, psychiatric, or intellectual disabilities, and still allow such persons to be qualified for and receive governmental health care benefits, especially long-term nursing care benefits, under the Medicaid welfare program.Supplemental Needs Trusts are often used to receive an inheritance or personal injury litigation proceeds on behalf of an individual with a disability, in order to allow the person to qualify for Medicaid benefits despite their receipt of the settlement.

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