Verified by 
During the chronic, never-ending debates about healthcare in the United States, our nation’s Medicaid system is often mentioned, but rarely with the full attention and recognition this program deserves. Medicaid was created in 1965 under a law signed by President Lyndon B. Johnson. In a move that might be surprising to many modern day Republicans, it was GOP President Nixon who dramatically expanded the program, assuring healthcare to children in poverty throughout our country. The Affordable Care Act expanded Medicaid eligibility to now cover a larger number of adults living in poverty, and provided a rich array of benefits and services to a much greater swath of our country’s citizens. During recent debates over repealing the ACA, it was in fact the expanded coverage of Medicaid, accepted by many states with Republican governors, that threw substantial monkey wrenches in the discussions. Ultimately, the 2017 GOP plan to change health care failed, partly because of the plan’s restrictions and limits on Medicaid spending which would have dramatically impacted millions of people across our country, as well as overwhelming countless state budgets which receive millions and billions in Federal dollars for Medicaid.
When Medicaid began in 1966, it covered only 2% of the US population. In 2015, Medicaid covered 21% of our country. Medicaid now covers the costs of half the births in our country, and the medical care for one out of four children in the United States. Why has this program grown so much? Why are states fighting so hard to preserve it? Simply put, because it is the health insurance program we all wish we had.
As a psychologist and healthcare administrator in New Mexico, I’ve learned a lot about Medicaid over the past two decades—half of the New Mexico population is covered by Medicaid, 75% of our state's children are born under Medicaid, and Medicaid itself makes up over 80% of my mental health agency’s budget. And I will tell you, I often wish that I, and my family were able to be on Medicaid, as opposed to the health insurance we currently purchase. Why? Because the benefits are far, far better:
- Medicaid is provided to recipients at no charge. For free. No premiums, and typically no co-pays. Some states have recently begun redesigning their Medicaid systems to require small copays and premiums, but these are, right now, the majority. In my experience, these strategies are typically just token symbolic efforts anyway. Most people on Medicaid can’t afford these costs, and often simply withdraw from services when they can’t pay them (or the money comes out of the provider’s pocket in the form of decreased reimbursement).
- Medicaid has no deductibles to be met. Need that knee replacement? End up in the hospital for emergency care? Don’t worry, under Medicaid you won’t walk away with a huge bill and face possible bankruptcy.
- Medicaid covers transportation costs, recognizing that it’s impossible to provide good health care to people who cannot get to the doctor’s office. When was the last time your health insurance company paid you back for transportation?
- A strong, vibrant system of advocates and laws exist to protect Medicaid recipients and ensure their rights are met. The Protection and Advocacy system exists to protect the rights of disabled persons, and many of their battles are with the Medicaid system, to ensure people get the health care they are guaranteed, by laws such as EPSDT and others. If, like most of us, you’ve ever been in the uncomfortable position of arguing with your health insurance company about their denial of coverage, you know that most health insurance consumers are typically on their own, fighting a large, bureaucratic monster.
- Medicaid patients can’t be charged when the insurance doesn’t pay for a service. How many times have you gotten a bill from a doctor, saying that your insurance company isn’t contracted with them, didn’t authorize the service, or only paid a portion of the bill? Under Medicaid law, patients can only be billed for services in incredibly rare circumstances.
- Medicaid is often administered through managed care companies. And while I have mixed feelings about managed care, these companies are typically required by contract and law to put a very high percentage of their funds straight into services. Their profits are restricted. And, many contracts require the companies to also reinvest in the community, funding services or “value-added benefits” out of their profits. Some Medicaid managed care organizations provide a free car seat to the families of the many Medicaid-covered babies born when Medicaid pays the bill, because the companies know it’s in the end, cheaper to provide a car seat, than cover the medical costs of a car accident when the baby is unrestrained.
- Medicaid has been the center of a great deal of innovative, forward-thinking healthcare development. Projects such as health homes, certified community behavioral health clinics, federally qualified health centers, and outcomes-based funding have all largely been developed within Medicaid-funded programs. The modern push for integration of behavioral and physical health mostly began in Medicaid. The push for electronic medical records and better sharing of patient data began in Medicaid and Medicare. Funding for prevention services, to prevent, rather than merely treat healthcare problems, largely comes from Medicaid.
- The patient-centered model of treatment was developed and initiated in Medicaid funded services for the developmentally-disabled. In that crucible was born the idea that it’s important for doctors, healthcare providers and managed care organizations to provide the services a patient wants and needs, as opposed to the services someone else thinks they should get.
- Medicaid covers a far, far broader array of important services. Most of our country’s long-term services, for the chronically ill, disabled or elderly, are actually paid for by Medicaid. In many sad cases, families have to wait until a family member is bankrupted by medical care, before they can get the member onto Medicaid which then foots the bill moving forward.
As a behavioral health provider, it’s those Medicaid services I know best:
- Medicaid covers critically important community-based services, that go far beyond the traditional outpatient psychotherapy or psychiatric medications covered under commercial health insurance. My Medicaid patients have access to services such as psychosocial rehabilitation programs, case management services to help them navigate the complex array of systems and services, and assertive community treatment, a program which provides intensive home-based support for those with chronic mental illness. I regularly see patients with severe mental illness who would benefit from those services, but cannot access them because the patient is “unlucky” enough to be able to afford health insurance. As a result, families often end up paying out of pocket for very expensive long-term services.
- Medicaid covers a much richer array of substance abuse services than do most health insurance companies. Services such as intensive outpatient treatment, residential treatment, detox, community reinforcement programs, mobile crisis services and others are commonly covered under Medicaid, but excluded from commercial coverage.
- “Parity” laws actually exclude Medicaid and Medicare. Parity laws require that if mental health benefits are offered, that an insurance company cannot have different rules for them compared to physical health. But, while CMS is exempted from the parity laws in the ACA, Medicaid has actually been forced by laws and lawsuits for many years to provide services without discrimination.
I can go on and on with the list of reasons why Medicaid is a much, much better system than the commercial insurance available to those of who can/must purchase it. Of course, the Medicaid system is no shining rose—it has its deep flaws:
- Medicaid is an incredibly bureaucratically-laden system, slow-to-change, clunky, and highly politicized.
- While the Medicaid state systems are required to ensure access, and often have a much deeper pool of contracted providers, some states have reduced provider reimbursement so much that few providers take Medicaid and it can be difficult in some areas to find a provider.
- Many Medicaid providers are underfunded and overwhelmed, providing the bare minimum of services with the short staff they are able to hire.
I often hear pundits suggest that “Medicare for all” is the answer to universal health coverage in our country. That always makes me wince. Medicare provides far fewer services, is much, much more difficult to bill (as a provider), and is much more likely to leave patients holding significant costs. There is a reason why so many Republican states pushed back against the effort to restrict and decimate Medicaid: simply put, it works extremely well, and provides the best level of care to our most vulnerable citizens. Believe it or not, if you have commercial health insurance, you're the unlucky one. Medicaid provides people in poverty healthcare that none of us could afford, if purchased from a commercial health insurance company. Now, I believe it’s important that we start to work to offer those same benefits to everyone else.
