100 things to know about Medicaid

Medicaid is in the midst of an unprecedented unwinding of continuous coverage requirements. The program is also expanding in some states and adding postpartum coverage. 

Here are 100 things to know about the history of Medicaid and the current challenges facing the program: 

History

1. The Medicaid and Medicare programs were signed into law by President Lyndon B. Johnson in 1965. 

2. For most of Medicaid's history, only low-income children, parents of eligible children, and adults with disabilities were eligible for the program. 

3. In 1965, 26 states opted to adopt the program. 

4. Arizona was the last state to implement the program, adopting Medicaid in 1982. It was also the first to use statewide managed care for its Medicaid program, or outsourcing services to private insurers.  

5. CHIP, the Children's Health Insurance Program, was established in 1997. The program extends coverage to children from families with incomes up to 200 percent of the federal poverty level. 

6. Signed in 2010, the Affordable Care Act expanded Medicaid eligibility to all adults with incomes up to 138 percent of the federal poverty line. This expanded eligibility took effect in 2014. 

7. In 2012, the Supreme Court ruled that states could choose to implement the ACA's Medicaid expansion. As of August 2023, 40 states and the District of Columbia have adopted expansion.

Expansion

8. In March, North Carolina Gov. Roy Cooper signed a bill expanding the state's Medicaid program, though its funding is still in limbo. 

9. In November 2022, voters in South Dakota approved expansion of the state's Medicaid program. 

10. Expansion is largely paid for by the federal government, with 90 percent of the costs covered. 

11. 10 states — Florida, Texas, Mississippi, Alabama, Georgia, South Carolina, Tennessee, Kansas, Wisconsin and Wyoming — have not expanded Medicaid. 

12. These states are not likely to expand the program any time soon, according to reporting from The Washington Post. 

13. In states that have not expanded Medicaid, around 1.9 million people fall into a "coverage gap." These individuals have too much income to qualify for Medicaid in their state, but do not make enough to qualify for subsidized coverage on the ACA exchange.

14. Two in 5 individuals in the coverage gap live in Texas, according to KFF, where childless adults are not eligible for the program, and parents with incomes at 16 percent of the federal poverty line or less are eligible. 

15. Almost all residents who fall into the "coverage gap" live in the South, at 97 percent, according to KFF.

Fast facts 

16. In April, 94.1 million people were enrolled in Medicaid, according to the latest data from CMS, accounting for 21.1 percent of the U.S. population. 

17. Of these enrollees, 87.1 million were enrolled in Medicaid, and 7.1 million were enrolled in CHIP. 

18. Children under 18 account for 45 percent of Medicaid enrollees, according to CMS. 

19. In 2021, Medicaid paid for 2 in 5 births in the U.S. 

20. In eight states, more than 25 percent of residents are enrolled in Medicaid or CHIP.

21. New Mexico has the highest percentage of its residents enrolled in Medicaid, at 34.4 percent. 

22. North Dakota has the lowest percentage of its residents enrolled in Medicaid, at 9.8 percent. 

23. California has the largest state Medicaid program, with 14.2 million enrollees, according to CMS. 

24. Medicaid pays for $1 of every $6 spent in the U.S. healthcare system. 

25. Total Medicaid spending was $728 billion in federal fiscal year 2021. The federal government paid for 69 percent of this figure, and states paid for 31 percent. 

26. States receive federal matching funds from the federal government for Medicaid. The minimum payment match is 50 percent, with some states with lower per-capita income receiving higher federal payments. 

27. States can receive Section 1115 waivers from the federal government to test and implement Medicaid programs outside of federal requirements. 

28. The majority of people — 76 percent —  hold positive views of the Medicaid program, according to a 2023 survey from KFF. 

29. Medicaid pays for the majority of long-term care and support services in the U.S., at 54 percent. 

30. Individuals eligible for the program based on age or disability account for 21 percent of the program's enrollees, and 55 percent of program spending. 

31. Each state administers its own Medicaid program within federal requirements and can set different eligibility requirements for the program. 

32. In 2019, Medicaid spent an average of $7,106 per enrollee. 

33. Spending per enrollee was highest in the District of Columbia, at $10,573 per enrollee, and lowest in Nevada, at $4,873 per enrollee. 

34. Fifty-two percent of Medicaid payments go to Medicaid managed-care organizations. 

MCOs 

35. Forty-one states use some form of managed care to deliver Medicaid services. 

36. Around 3 in 4 Medicaid enrollees receive benefits through managed care organizations. 

37. This number has steadily increased over the past 20 years. In 2011, 47 percent of Medicaid enrollees were in managed care plans, and in 1995, just 15 percent of enrollees were in managed care plans. 

38. According to a 2021 survey from KFF, 28 states tie payments to MCOs to some form of quality measures. 

39. Five nonprofit companies control 50 percent of the Medicaid managed care market. 

40. Centene has the highest Medicaid membership of the largest payers. In the second quarter of 2023, the company had 16.1 million Medicaid members. 

41. Elevance Health had the second-highest number of Medicaid members, at 11.8 million in the second quarter of 2023. 

42. Molina Healthcare has the largest share of Medicaid members as a share of its total membership, with Medicaid contracts making up 92 percent of the payer's business, according to KFF. 

43. Medicaid managed-care organizations denied around 1 in 8 prior authorization requests in 2019, according to a 2023 audit from HHS' Office of Inspector General. 

44. Molina Healthcare had the highest overall denial rate of the seven largest MCOs, at 17.7 percent, according to the OIG's audit. 

45. AmeriHealth Caritas had the lowest overall denial rate, at 6.1 percent. 

Redeterminations 

46. During the COVID-19 public health emergency, states were required to keep people continuously enrolled in Medicaid, regardless of income. 

47. During the pandemic, Medicaid enrollment rose by 20 million people, as of November 2022. 

48. In the first quarter of 2023, the nation reached a record low uninsured rate of 7.7 percent, according to data from the CDC. 

49. Continuous coverage requirements ended in April, with states beginning the process of redetermining the eligibility of all of their Medicaid enrollees. 

50. Most states expect the redetermination process to take 12 to 14 months, according to KFF. One state, Arkansas, is planning to complete the process in six months. 

51. As of August, every state except for Oregon has started removing members from its Medicaid rolls, according to KFF. 

52. An estimated 15 to 18 million people are expected to lose Medicaid coverage during this unwinding process, according to estimates from CMS and the Robert Wood Johnson Foundation. 

53. Around 3.8 million people are expected to become uninsured through the unwinding of continuous coverage requirements, with others finding coverage through the ACA exchange, employers or reenrolling in Medicaid. 

54. According to estimates from the Robert Wood Johnson Foundation, uninsured rates in Kentucky will rise by 32 percent after the Medicaid unwinding process, the highest of any state. 

55. In West Virginia and Missouri, uninsured rates will increase by over 30 percentage points, according to the foundation. 

56. The Robert Wood Johnson Foundation estimated that Utah will see nearly a third of current Medicaid recipients disenrolled, the highest share of any state. 

57. Nebraska will have the smallest share of members disenrolled, at 10.7 percent, according to the foundation's estimates .

58. As of Aug. 18, 4.8 million people had been disenrolled from Medicaid in 44 states and the District of Columbia, according to KFF. 

59. In the states that reported disenrollment data by age, around 1 in 3 people removed from Medicaid coverage were children, according to KFF. 

60. The majority of people disenrolled from the program have been removed due to procedural reasons, such as not returning required paperwork, or not having updated contact information with the state's Medicaid agency, rather than being determined ineligible for the program. 

61. As of Aug. 18, 75 percent of disenrollments were due to procedural reasons, according to state data analyzed by KFF. 

62. New Mexico had the highest rate of procedural disenrollments as of Aug. 18, at 97 percent. 

63. Another four states — Nevada, Georgia, Utah and Washington — and the District of Columbia had procedural termination rates above 90 percent. 

64. These rates of procedural terminations are higher than expected, many health policy experts say. 

65. In June, HHS Secretary Xavier Becerra said he was "deeply concerned" about the rate of procedural losses of coverage. 

66. CMS said it would implement additional flexibilities in June for states to try to slow the number of procedural terminations, including allowing states to delay disenrollments by one month. 

67. In August, CMS warned 36 states they were falling short of regulatory requirements for Medicaid call center wait times, application processing times and rates of procedural terminations. 

68. The agency said it required around half a dozen states to pause procedural terminations to fix compliance issues. 

69. Major payers invested in expanding ACA options ahead of the unwinding process and partnered with states, community organizations, national retailers and pharmacies to help people retain coverage. 

70. Walgreens and CVS pharmacies are playing an important role in Medicaid redeterminations through payer-agnostic outreach and education initiatives aimed at customers and employees in all 50 states.

71. A large number of Medicaid enrollees say their health plan has not reached out about how to renew coverage amid redeterminations. A poll from the Harris Group found that 35 percent of enrollees said their health plan has not reached out about renewing coverage, and 55 percent of enrollees 65 and older said the same

72. Every major payer reported losses in Medicaid membership in the first months of continuous coverage unwinding. 

73. Centene, which has the largest share of Medicaid members, lost 263,000 enrollees in the first months of redeterminations. 

74. Centene executives told investors these numbers were in line with their expectations. 

75. Around 54,000 people enrolled in individual coverage on the ACA exchange in the first month of Medicaid redeterminations, according to CMS data. 

Dual-eligible populations

76. Special needs plans, including those for individuals eligible for both Medicare and Medicaid, are the fastest growing form of Medicare Advantage. 

77. There are 12.5 million people jointly enrolled in Medicare and Medicaid, on the basis of age, income or disability status, accounting for 20 percent of the Medicare population. 

78. Of these individuals, around 5.5 million are enrolled in Medicare Advantage special needs plans. 

79. Dual-eligible beneficiaries are a heterogeneous group in terms of age and physical and mental health status, according to KFF. Of dual-eligible enrollees, 87 percent have an annual income of less than $20,000, and 40 percent have an annual income of less than $10,000. 

80. Dual-eligible individuals are younger than the general Medicare population — 40 percent are under 65 and eligible for Medicare because they have received 24 months of Social Security disability payments. 

81. Different states have different standards for Medicaid and Medicare dual eligibility. The District of Columbia has the highest proportion of dual-enrolled individuals, making up 38 percent of the Medicare population. 

82. Utah has the smallest proportion of dual-eligible enrollees, accounting for 10 percent of the Medicare population. 

Work requirements 

83. Some lawmakers have pitched implementing work requirements in the Medicaid program. 

84. A proposal to require Medicaid beneficiaries to work, volunteer or be part of a work program for 80 hours per month to be eligible for benefits was struck from an April bill to raise the debt ceiling into next year.

85. In July, Georgia launched a program to partially expand Medicaid with work requirements, expanding eligibility to people with incomes under $14,580 annually, if they complete 80 hours of work, job training, education or community service per month. 

86. Georgia's program enrolled 285 people in its first month. 

87. Arkansas is seeking to add work requirements to its Medicaid program. The state previously implemented work requirements in 2018. 

88. A federal judge struck down the program in 2019, along with a similar requirement in Kentucky. 

89. According to KFF, 61 percent of adults enrolled in Medicaid in 2021 worked either full or part-time. 

90. Another 13 percent of adults enrolled in Medicaid did not work because of caregiving responsibilities, and 11 percent did not work due to illness or disability. 

Postpartum expansion 

91. States are required to provide Medicaid coverage for pregnant individuals up to 60 days postpartum. 

92. The American Rescue Plan gave states the option to extend this Medicaid coverage for up to 12 months postpartum. 

93. As of August, 36 states have implemented postpartum expansion, according to KFF. Another 10 states are planning to expand the program, and two have proposed limited postpartum expansions. 

News to note 

94. Nine state Medicaid programs currently cover Wegovy, Novo Nordisk's high-priced weight loss drug. 

95. CMS approved a proposal from California to eliminate asset tests for Medicaid eligibility, the first state to do so.  

96. In April, CMS proposed two new rules that would establish national standards of care provided through fee-for-service Medicaid/CHIP and managed care plans, along with a requirement to publicly disclose provider payment rates online. 

97. Decreasing Medicare and Medicaid payments are having more physicians considering reducing those patient bases, according to Medscape's "Physician Compensation Report." Sixty-five percent of physicians surveyed said they would continue treating current Medicare or Medicaid patients and take on new ones, the lowest percentage Medscape has seen in its annual compensation reports.

98. In January, California said it will award more payers contracts to manage its Medicaid program, reversing course on contract awards that could have forced two million Medi-Cal members to switch insurance. 

99. California is in the midst of overhauling Medi-Cal, its Medicaid program with more than 14 million members, to improve care equity and delivery.

100.  Noncitizens who use Medicaid and Children's Health Insurance Program benefits will not face immigration consequences, the Department of Homeland Security said in September 2022.