Medicaid Program: Benefits, Challenges, and Policy Reform

Introduction

Medicaid was formed in 1965 as a public insurance program to provide health coverage to families and individuals with low incomes. The populations the program covers include children, parents, pregnant women, older adults, and people living with disabilities (Stevens & Stevens, 2017). The Medicaid program was established jointly by the federal government and state governments. Each state within the United States operates its own Medicaid program in accordance with federal government guidelines. Stimpson and Wilson (2018) point out that in 2019, the Medicaid health coverage program helped 97 million families in the United States within that year. Of that total, the program is said to have helped 32 million children, 28 million adults, 6 million older adults, and 9 million people with disabilities who had low incomes. Spending on children constitutes the largest share compared to other groups.

Although the Medicaid program was established in the United States decades ago, it has not sufficiently penetrated all states, and there remains a need to identify ways of ensuring its broader reach. California has the highest number of Medicaid enrollments, followed by New York. When calculated as a percentage of the population, New Mexico is arguably the state with the highest share of Medicaid enrollees.

This essay evaluates the status of the Medicaid program, examining its advantages and disadvantages. It also identifies the opportunities the program provides to communities and the specific challenges it presents, and concludes with strategic recommendations to address those disadvantages and challenges.

Eligibility and Coverage

The Medicaid program was not designed to serve all people — rather, specific categories of individuals are eligible to benefit from it. One such group is pregnant and uninsured women. According to Stimpson and Wilson (2018), eligibility factors affecting pregnant women include household size, immigration status, and income. Women who wish to benefit from the program must visit their state's website on pregnancy-related Medicaid to determine their coverage limits based on their individual circumstances. Pregnant women who are covered by Medicaid also have their children covered.

Children and teenagers are also eligible, particularly those from low-income families. This group encompasses all boys and girls under 18 years old without insurance coverage, including teenagers living independently. Some states extend coverage to children up to age 21.

A third eligible group is adults aged 65 and older. Currie and Duque (2019) observe that despite economic improvements in the United States over time, many elderly Americans struggle to meet their basic living expenses. The authors indicate that 41% of the nation's elderly population have low incomes — below twice the federal poverty level. In 1994, the federal poverty level was $7,100 per year for a single adult and $9,000 for a couple, and 12% of the elderly population fell below that threshold (Rowland & Lyons, 1996). As a result, approximately 5.9 million elderly poor individuals were eligible to benefit from Medicaid, many of whom resided in nursing homes.

People living with disabilities represent another group served by Medicaid. Individuals may be born with disabilities or acquire them during their lives, and they are often marginalized and face barriers to education and employment, leaving many in poverty. For persons diagnosed with developmental and intellectual disabilities, Medicaid acts as a critical source of funding. It services their needs and supports their ability to live normal lives. Approximately 12% of adults in the United States have a disability (Hung, Ross, Boockvar, & Siu, 2011). The Medicaid program provides both short-term and long-term care services to meet the needs of persons with disabilities, including preventive care, nursing home care, medical treatment, and assistance in finding and maintaining employment.

As a social insurance program, Medicaid covers basic healthcare needs for people with low incomes. Depending on the state, the specific services covered may vary; however, mandatory Medicaid services in every state include "inpatient hospital services, outpatient hospital services, nursing facility services, home health services, family planning services, physician services, nurse midwife services, transportation to medical care, and tobacco cessation counselling for pregnant women," among other required services (Stimpson & Wilson, 2018, p. 311). The program also covers optical and dental services for eligible individuals up to limits set by individual states. Each state is required to run its own program, with the federal government providing approximately half of the funding.

Optional Medicaid benefits include prescription drugs, physical therapy, clinic services, occupational therapy, respiratory care services, eyeglasses, dentures, personal care, and practitioner services. The Medicaid senior program additionally covers services in enrollees' homes, including skilled nursing care, transportation, home-delivered meals, healthy eating support, and physical therapy.

Although the United States government is at the forefront of ensuring nationwide insurance coverage, many individuals are ineligible for Medicaid due to their immigration status. Such individuals receive only temporary federal protection. As of April 2020, Medicaid eligibility has expanded significantly, with 35 states having implemented the Medicaid expansion program to serve low-income adults. It is projected that by 2029, the program will serve an additional 14 million individuals. By 2021, 39 states had implemented the expansion, leaving 12 states that had not yet adopted it. Some states, such as Missouri and Oklahoma, had adopted the program but had not yet implemented the expansion.