medicaid medicaid in the united states, medicaid is a government program that provides health insurance for adults and children with limited income and resources. the program is partially funded and primarily managed by state governments, which also have wide latitude in determining eligibility and benefits, but the federal government sets baseline standards for state medicaid programs and provides a significant portion of their funding. not to be confused with medicare (united states). centers for medicare and medicaid services (medicaid administrator) logomedicaid was established in 1965 and was significantly expanded by the affordable care act (aca), which was passed in 2010. in most states, anyone with income up to 138% of the federal poverty line qualifies for medicaid coverage under the provisions of the aca. a 2012 supreme court decision established that states may continue to use pre-aca medicaid eligibility standards and receive previously established levels of federal medicaid funding; in states that make that choice, income limits may be significantly lower, and able-bodied adults may not be eligible for medicaid at all. 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 85 million low-income and disabled people as of 2022; in 2019, the program paid for half of all u.s. births. as of 2017, the total annual cost of medicaid was just over $600 billion, of which the federal government contributed $375 billion and states an additional $230 billion. states are not required to participate in the program, although all have since 1982. in general, medicaid recipients must be u.s. citizens or qualified non-citizens, and may include low-income adults, their children, and people with certain disabilities. as of 2022 45% of those receiving medicaid or chip were children. medicaid covers healthcare costs for people with low incomes, while medicare is a universal program providing health coverage for the elderly. medicaid offers elder care benefits not normally covered by medicare, including nursing home care and personal care services. there are also dual health plans for people who have both medicaid and medicare. along with medicare, tricare, and champva, medicaid is one of the four government-sponsored medical insurance programs in the united states. the u.s. centers for medicare & medicaid services in baltimore, maryland provides federal oversight. research shows that existence of the medicaid program improves health outcomes, health insurance coverage, access to health care, and recipients' financial security and provides economic benefits to states and health providers. 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, which in turn provide comprehensive care and accept the risk of managing total costs. nationwide, roughly 80% of medicaid enrollees are enrolled in managed care plans. core eligibility groups of low-income families 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 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. a 2014 kaiser family foundation report estimates the national average per capita annual cost of medicaid services for children to be $2,577, adults to be $3,278, persons with disabilities to be $16,859, aged persons (65+) to be $13,063, and all medicaid enrollees to be $5,736. history health care in the united states government health programs federal employees health benefits program (fehbp) indian health service (ihs) medicaid / state health insurance assistance program (ship) medicare prescription assistance (spap) military health system (mhs) / tricare children's health insurance program (chip) program of all-inclusive care for the elderly (pace) veterans health administration (vha) private health coverage consumer-driven healthcare flexible spending account (fsa) health reimbursement account (hra) health savings account (hsa) high-deductible health plan (hdhp) medical savings account (msa) private fee-for-service (pffs) health insurance in the united states managed care (ccp) exclusive provider organization (epo) health maintenance organization (hmo) preferred provider organization (ppo) medical underwriting health care reform law emergency medical treatment and active labor act (1986) health insurance portability and accountability act (1996) medicare prescription drug, improvement, and modernization act (2003) patient safety and quality improvement act (2005) health information technology for economic and clinical health act (2009) patient protection and affordable care act (2010) state level reform municipal health coverage healthcare in california healthy san francisco healthy way la my health la fair share health care act (maryland) healthy howard (howard co., maryland) 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 provided matching funds to states to enable them to provide medical assistance to residents who met certain eligibility requirements. the objective was to help states assist residents whose income and resources were insufficient to pay the costs of traditional commercial health insurance plans. by 1982, all states were participating. the last state to do so was arizona. 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 and became effective on january 1, 1991. this program was formed due to the costs that medicaid programs were paying for discount price outpatient drugs. the omnibus budget reconciliation act of 1993 (obra-93) amended section 1927 of the act, bringing changes to the medicaid drug rebate program. it requires states to implement a medicaid estate recovery program to recover from the estate of deceased beneficiaries the long-term-care-related costs paid by medicaid, and gives states the option of recovering all non-long-term-care costs, including full medical costs. 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 students with special education needs. federal law mandates that children with disabilities receive a "free appropriate public education" under section 504 of the rehabilitation act of 1973. decisions by the united states supreme court and subsequent changes in federal law require states to reimburse part or all of the cost of some services provided by schools for medicaid-eligible disabled children. expansion under the affordable care act medicaid expansion by state, as of march 27, 2023 adopted the medicaid expansion medicaid expansion under discussion not adopting medicaid expansion states that expanded medicaid under aca had a lower uninsured rate in 2018 at various income levels. the affordable care act (aca), passed in 2010, substantially expanded the medicaid program. before the law was passed, some states did not allow able-bodied adults to participate in medicaid, and many set income eligibility far below the federal poverty level. under the provisions of the law, any state that participated in medicaid would need to expand coverage to include anyone earning up to 138% of the federal poverty level beginning in 2014. the costs of the newly covered population would initially be covered in full by the federal government, although states would need to pay for 10% of those costs by 2020. however, in 2012, the supreme court held in national federation of independent business v. sebelius that withdrawing all medicaid funding from states that refused to expand eligibility was unconstitutionally coercive. states could choose to maintain pre-existing levels of medicaid funding and eligibility, and some did; over half the national uninsured population lives in those states. as of march 2023, 40 states have accepted the affordable care act medicaid extension, as has the district of columbia, which has its own medicaid program; 10 states have not. among adults aged 18 to 64, states that expanded medicaid had an uninsured rate of 7.3% in the first quarter of 2016, while non-expansion states had a 14.1% uninsured rate. the centers for medicare and medicaid services (cms) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. an estimated 9 to 10 million people had gained medicaid coverage, mostly low-income adults. the kaiser family foundation estimated in october 2015 that 3.1 million additional people were not covered in states that rejected the medicaid expansion. in some states that chose not to expand medicaid, income eligibility thresholds are significantly below 133% of the poverty line. some of these states do not make medicaid available to non-pregnant adults without disabilities or dependent children, no matter their income. because subsidies on commercial insurance plans are not available to such individuals, most have few options for obtaining any medical insurance. for example, in kansas, where only non-disabled adults with children and with an income below 32% of the poverty line were eligible for medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both medicaid and federal subsidies to buy insurance. studies of the impact of medicaid expansion rejections calculated that up to 6.4 million people would have too much income for medicaid but not qualify for exchange subsidies. several states argued that they could not afford the 10% contribution in 2020. some studies suggested that rejecting the expansion would cost more due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by medicaid coverage, a 2016 study found that residents of kentucky and arkansas, which both expanded medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. residents of texas, which did not accept the medicaid expansion, did not see a similar improvement during the same period. kentucky opted for increased managed care, while arkansas subsidized private insurance. later, arkansas and kentucky governors proposed reducing or modifying their programs. from 2013 to 2015, the uninsured rate dropped from 42% to 14% in arkansas and from 40% to 9% in kentucky, compared with 39% to 32% in texas. a 2016 dhhs study found that states that expanded medicaid had lower premiums on exchange policies because they had fewer low-income enrollees, whose health, on average, is worse than that of people with higher income. the census bureau reported in september 2019 that states that expanded medicaid under aca had considerably lower uninsured rates than states that did not. for example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. of the 14 states with uninsured rates of 10% or greater, 11 had not expanded medicaid. a july 2019 study by the national bureau of economic research (nber) indicated that states enacting medicaid expansion exhibited statistically significant reductions in mortality rates. the aca was structured with the assumption that medicaid would cover anyone making less than 133% of the federal poverty level throughout the united states; as a result, premium tax credits are only available to individuals buying private health insurance through exchanges if they make more than that amount. this has given rise to the so-called medicaid coverage gap in states that have not expanded medicaid: there are people whose income is too high to qualify for medicaid in those states, but too low to receive assistance in paying for private health insurance, which is therefore unaffordable to them. 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