Oct 23, 2015 — President Lindon B. Johnson signed Medicaid into law in 1965, providing government-subsidized health care to those who can’t afford it. How has it changed since then? Family physician Dr. Kyle Bradford Jones gives a quick history lesson in how Medicaid has provided care for poor individuals and families in the past and more recently, including an ongoing debate some states are having about expanding Medicaid.

Interview

Dr. Jones: Happy Birthday, Medicaid. The social health care program for the poor turns 50 years old this year. I'm Dr. Kyle Bradford Jones, family physician at the University of Utah School of Medicine, and we're going to be talking about the history of the evolution of Medicaid, coming up next on The Scope.

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Dr. Jones: Medicaid is a government health insurance program for those who don't have the resources to pay for health care. Now, obviously, this is something that has changed over time in terms of who may or may not qualify for them. The program is jointly paid for by the federal government and the state governments. It's different for every state in terms of how much the federal government contributes to it, but roughly, two-thirds of the cost is covered by the federal government. However, despite paying more of the cost for Medicaid, it is run by the states with a lot of flexibility on whom they cover, and what benefits they offer.

Now, there are some basic minimum requirements that they need to meet from the federal government, but they have a lot of flexibility. Medicaid is essentially what's called a means-tested program, which basically means you need to prove that you don't have enough money to buy health care elsewhere. You do this through proving your income and your assets.

This was signed into law in 1965 by President Lyndon B. Johnson. Now, advocates had been crying for this for decades. They saw a huge need that they've been pushing to fill ever since the Great Depression. A lot of the states were against this because Medicare was being enacted at the same time, and that was fully a federal program. And so they wanted more flexibility with Medicaid to fill the needs of their people. What that means is the Medicaid program is pretty different from state to state and each state does not have to participate. They can decide to cover these individuals on their own. Arizona was the last state to participate, joining in 1982, 17 years after it had been signed into law.

These programs are monitored by the centers for Medicare and Medicaid services by the federal government to ensure that they are meeting the basic minimum requirements. They also provide waivers to different states to try new and innovative programs, if they'd like to, to offer more benefits or to offer different coverage options.

Now, there are about 65 million people covered on Medicaid and most of those are children. This number varies a lot depending on the economic status of the country. In the recession that started in 2008, the number of people on Medicaid jumped up significantly as there were more people who were unemployed. Over 25% of Medicaid's total costs goes to cover long-term care for the elderly, such as when individuals need to reside in nursing homes. Changes in demographics of the population and employment can certainly stress the state budgets and how much they're able to participate. And that can lead to a decrease in benefits and more stringent enrollment criteria.

The Affordable Care Act kind of added to that stress. Medicaid expansion was part of the law that would be required for all 50 states to cover individuals at 138% of federal poverty level or lower. What that means is about $33,000 per year for a family of four.
In 2012, the Supreme Court said, "You cannot force states to do that." The used the phrase "putting a gun to the head of the states." "You can't force them to spend that money." And so they ruled that states can choose whether they expand Medicaid or not. So as of September 1, 2015, 30 states and the District of Colombia had decided to expand Medicaid to cover this population. Those many states that haven't done it have decided against it for multiple reasons, whether it be political, ideological, or concern over the cost long-term to the state and its budget.

This last one is a big concern. Although there have been many studies that have showed improved economic growth with coverage of individuals under Medicaid, and it essentially pays for itself, many adults who would be covered by it are then able to get the health care that they need so that they can then get a job so that they can then contribute to society in ways that they want to, and they don't end up staying on Medicaid long term. However, the multiple states that have decided not to expand have left millions of people without health care coverage. So after 50 years of Medicaid, the future for the program is a little uncertain for multiple reasons, but it will be interesting to see how it may or may not impact those most in need of health care assistance going forward.

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