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. 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 disabled, 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). most states administer medicaid through their own programs. a few of those programs are listed below: arizona: ahcccs california: medi-cal connecticut: husky d maine: mainecare massachusetts: masshealth new jersey: nj familycare oregon: oregon health plan oklahoma: soonercare tennessee: tenncare washington: washington apple health wisconsin: badgercare 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. differences by state states must comply with federal law, 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 reimbursement physicians and care providers. differences between states are often influenced by the political ideologies of the state and cultural beliefs of the general population. the federal centers for medicare and medicaid services (cms) closely monitors each state's program and establishes requirements for service delivery, quality, funding, and eligibility standards. medicaid estate recovery regulations also vary by state. (federal law gives options as to whether non-long-term-care-related expenses, such as normal health-insurance-type medical expenses are to be recovered, as well as on whether the recovery is limited to probate estates or extends beyond.) political influences several political factors influence the cost and eligibility of tax-funded health care. according to a study conducted by gideon lukens, factors significantly affecting eligibility included "party control, the ideology of state citizens, the prevalence of women in legislatures, the line-item veto, and physician interest group size". lukens' study supported the generalized hypothesis that democrats favor generous eligibility policies while republicans do not. when the supreme court allowed states to decide whether to expand medicaid or not in 2012, northern states, in which democrat legislators predominated, disproportionately did so, often also extending existing eligibility. 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 for 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 was adopted by other republican-led states. however, private coverage is more expensive than medicaid and the states would not have to contribute as much to the cost of private coverage. certain groups of people, such as migrants, face more barriers to health care than others due to factors besides policy, such as status, transportation and knowledge of the healthcare system (including eligibility). eligibility and coverage medicaid eligibility policies are very complicated. in general, a person's medicaid eligibility is linked to their eligibility for aid to families with dependent 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. however afdc has differing eligibility standards that depend on: the low-income wage rate: state welfare programs base the level of assistance they provide on some concept of what is minimally necessary. 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. reimbursement for care providers 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. the discrepancy in the reimbursements medicaid offers may affect the type of care provided to patients. in general, medicaid plans pay providers significantly less than commercial insurers or medicare would pay for the same care, paying around 67% as much as medicare would for primary care and 78% as much for other services. this disparity has been linked to lower provider rates of participation in medicaid programs vs medicare or commercial insurance, and thus decreased access to care for medicaid patients. one component of the affordable care act was a federally-funded increase in 2013 and 2014 in medicaid payments to bring them up to 100% of equivalent medicare payments, in an effort to increase provider participation. most states did not subsequently continue this provision. enrollment in 2002, medicaid enrollees numbered 39.9 million americans, with the largest group being children (18.4 million or 46%). from 2000 to 2012, the proportion of hospital stays for children paid by medicaid increased by 33% and the proportion paid by private insurance decreased by 21%. 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. in california, about 23% of the population was enrolled in medi-cal for at least 1 month in 2009–10. 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. according to cms, the medicaid program provided health care services to more than 92 million people in 2022. 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, putting a heavy strain on state budgets. the kaiser family foundation reported that for 2013, medicaid recipients were 40% white, 21% black, 25% hispanic, and 14% other races. comparisons with medicare unlike medicaid, medicare is a social insurance program funded at the federal level and focuses primarily on the older population. 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 covering hospital bills, medicare part b covering medical insurance coverage, and medicare part d covering purchase of prescription drugs. medicaid is a program that is not solely funded at the federal level. states provide up to half of the funding for medicaid. in some states, counties also contribute funds. unlike medicare, 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. in 2001, about 6.5 million people were enrolled in both medicare and medicaid. in 2013, approximately 9 million people qualified for medicare and medicaid. benefits there are two general types of medicaid coverage. "community medicaid" helps people who have little or no medical insurance. medicaid nursing home coverage helps pay for the cost of living in a nursing home for those who are eligible; the recipient also 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. 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. included in the social security program under medicaid are dental services. registration for dental services is optional for people older than 21 years but required for people eligible for medicaid and younger than 21. 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 focuses on prevention, early diagnosis and treatment of medical conditions. 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 paying for this service, regardless of whether or not it is covered on that particular medicaid plan. 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. few dentists participate in medicaid – less than half of all active private dentists in some areas. cited reasons for not participating are low reimbursement rates, complex forms and burdensome administrative requirements. in washington state, a program called 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. 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. eligibility 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. 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 are: 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. ppaca income test standardization as of 2019, when medicaid has been expanded under the ppaca, eligibility is determined by an income test using modified adjusted gross income, with no state-specific variations and a prohibition on asset or resource tests. non-ppaca eligibility while medicaid expansion available to adults under the ppaca mandates a standard income-based test without asset or resource tests, other eligibility criteria such as assets may apply when eligible outside of the ppaca expansion, including coverage for eligible seniors or disabled. these other requirements include, but are not limited to, assets, age, pregnancy, disability, blindness, income, and resources, and one's status as a u.s. citizen or a lawfully admitted immigrant. as of 2015, asset tests varied; for example, eight states did not have an asset test for a buy-in available to working people with disabilities, and one state had no asset test for the aged/blind/disabled pathway up to 100% of the federal