Fertilization occurs when the sperm successfully enters the ovum's membrane. The chromosomes of the sperm are passed into the egg to form a unique genome. The egg becomes a zygote
and the germinal stage of embryonic development begins. The germinal
stage refers to the time from fertilization, through the development of
the early embryo, up until implantation. The germinal stage is over at
about 10 days of gestation.
The zygote contains a full complement of genetic material
with all the biological characteristics of a single human being, and
develops into the embryo. Embryonic development has four stages: the morula stage, the blastula stage, the gastrula stage, and the neurula stage. Prior to implantation, the embryo remains in a protein shell, the zona pellucida, and undergoes a series of rapid mitotic cell divisions called cleavage.
A week after fertilization the embryo still has not grown in size, but
hatches from the zona pellucida and adheres to the lining of the
mother's uterus. This induces a decidual reaction,
wherein the uterine cells proliferate and surround the embryo thus
causing it to become embedded within the uterine tissue. The embryo,
meanwhile, proliferates and develops both into embryonic and
extra-embryonic tissue, the latter forming the fetal membranes and the placenta. In humans, the embryo is referred to as a fetus
in the later stages of prenatal development. The transition from
embryo to fetus is arbitrarily defined as occurring 8 weeks after
fertilization. In comparison to the embryo, the fetus has more
recognizable external features and a set of progressively developing
internal organs. A nearly identical process occurs in other species.
Human embryonic development refers to the development and formation of the human embryo. It is characterised by the process of cell division and cellular differentiation of the embryo that occurs during the early stages of development. In biological terms, human development entails growth from a one-celled zygote to an adult human being. Fertilization occurs when the sperm cell successfully enters and fuses with an egg cell (ovum). The genetic material of the sperm and egg then combine to form a single cell called a zygote and the germinal stage of prenatal development
commences. The embryonic stage covers the first eight weeks of
development; at the beginning of the ninth week the embryo is termed a fetus.
The germinal stage refers to the time from fertilization through the development of the early embryo until implantation is completed in the uterus. The germinal stage takes around 10 days. During this stage, the zygote begins to divide, in a process called cleavage. A blastocyst is then formed and implanted in the uterus. Embryonic development continues with the next stage of gastrulation, when the three germ layers of the embryo form in a process called histogenesis, and the processes of neurulation and organogenesis follow.
In comparison to the embryo, the fetus has more recognizable
external features and a more complete set of developing organs. The
entire process of embryonic development involves coordinated spatial and
temporal changes in gene expression, cell growth and cellular differentiation. A nearly identical process occurs in other species, especially among chordates.
A fetus is a stage in the human development considered to begin nine weeks after fertilization.
In biological terms, however, prenatal development is a continuum, with
many defining feature distinguishing an embryo from a fetus. A fetus is
also characterized by the presence of all the major body organs, though
they will not yet be fully developed and functional and some not yet
situated in their final location.
The fetus and embryo develop within the uterus, an organ that sits within the pelvis of the mother. The process the mother experiences whilst carrying the fetus or embryo is referred to as pregnancy. The placenta connects the developing fetus to the uterine
wall to allow nutrient uptake, thermo-regulation, waste elimination,
and gas exchange via the mother's blood supply; to fight against
internal infection; and to produce hormones which support pregnancy. The
placenta provides oxygen and nutrients to growing fetuses and removes
waste products from the fetus' blood. The placenta attaches to the wall
of the uterus, and the fetus' umbilical cord develops from the placenta. These organs connect the mother and the fetus. Placentas are a defining characteristic of placental mammals, but are also found in marsupials and some non-mammals with varying levels of development. The homology of such structures in various viviparous organisms is debatable, and in invertebrates such as Arthropoda, is analogous at best.
Childhood is the age span ranging from birth to adolescence. In developmental psychology, childhood is divided up into the developmental stages of toddlerhood (learning to walk), early childhood
(play age), middle childhood (school age), and adolescence (puberty
through post-puberty). Various childhood factors could affect a person's
attitude formation.
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testicles in a boy. In response to the signals, the gonads produce hormones that stimulate libido and the growth, function, and transformation of the brain, bones, muscle, blood, skin, hair, breasts, and sex organs. Physical growth—height
and weight—accelerates in the first half of puberty and is completed
when an adult body has been developed. Until the maturation of their
reproductive capabilities, the pre-pubertal physical differences between
boys and girls are the external sex organs.
On average, girls begin puberty around ages 10–11 and end puberty
around 15–17; boys begin around ages 11–12 and end around 16–17. The major landmark of puberty for females is menarche, the onset of menstruation, which occurs on average between ages 12 and 13; for males, it is the first ejaculation, which occurs on average at age 13.
In the 21st century, the average age at which children, especially
girls, reach puberty is lower compared to the 19th century, when it was
15 for girls and 16 for boys.
This can be due to any number of factors, including improved nutrition
resulting in rapid body growth, increased weight and fat deposition, or exposure to endocrine disruptors such as xenoestrogens, which can at times be due to food consumption or other environmental factors.Puberty which starts earlier than usual is known as precocious puberty, and puberty which starts later than usual is known as delayed puberty.
Notable among the morphologic changes in size, shape, composition, and functioning of the pubertal body, is the development of secondary sex characteristics, the "filling in" of the child's body; from girl to woman, from boy to man.
Adulthood
Biologically,
an adult is a human or other organism that has reached sexual maturity.
In human context, the term adult has additional meanings associated
with social and legal concepts. In contrast to a legal minor,
a legal adult is a person who has attained the age of majority and is
therefore regarded as independent, self-sufficient, and responsible. The
typical age of legal majority is 18 years in most contexts, although
the definition of majority may vary by legal rights and country.
Human adulthood encompasses psychological adult development.
Definitions of adulthood are often inconsistent and contradictory; an
adolescent may be biologically an adult and display adult behavior but
still be treated as a child if they are under the legal age of majority.
Conversely, a legal adult may possess none of the maturity and
responsibility that is supposed to define them; the mental and physical
development and maturity of an individual has been proven to be greatly
influenced by their life circumstances.
During childhood, the bones undergo a complex process of elongation that occurs in a specific area called epiphyseal growth plates (EGP). This process is regulated by various hormones
and factors, including the growth hormone, vitamin D, and others. These
hormones promote the production of insulin-like growth factor-1
(IGF-1), which plays a key role in the formation of new bone cells.
Adequate nutrient intake
is essential for the production of these hormones, which are critical
for proper bone growth. However, a lack of proper nutrition can hinder
this process and result in stunted growth.
Linear growth takes place in the epiphyseal growth plates (EGP) of long bones. In the growth plate, chondrocytes
proliferate, hypertrophy and secrete cartilage extracellular matrix.
New cartilage is subsequently remodeled into bone tissue, causing bones
to grow longer. Linear growth is a complex process regulated by the growth hormone (GH) - insulin-like growth factor-1 (IGF-1) axis, the thyroxine/triiodothyronine axis, androgens, estrogens, vitamin D, glucocorticoids and possibly leptin.
GH is secreted by the anterior pituitary gland in response to
hypothalamic, pituitary and circulating factors. It affects growth by
binding to receptors in the EGP, and inducing production and release of IGF-1 by the liver. IGF-1 has six binding proteins (IGFBPs), exhibiting different effects on body tissues, where IGFBP-3 is most abundant in human circulation.
IGF-1 initiates growth through differentiation and maturation of
osteoblasts, and regulates release of GH from the pituitary through
feedback mechanisms.
The GH/IGF-1 axis is responsive to dietary intake and infections. The
endocrine system seems to allow for rapid growth only when the organism
is able to consume sufficient amounts of nutrients and signaling from
key nutrients such as amino acids and zinc to induce production of IGF-1
is present.
At the same time inflammation and increased production of
pro-inflammatory cytokines may cause GH resistance and a decrease in
circulating IGF-1 and IGFBP-3 which in turn reduces endochondrial
ossification and growth. However, the EGP appears to conserve much growth capacity to allow for catch-up growth.
Concerns have been raised about associations between catch-up growth
and increased risk of non-communicable diseases in adulthood.
In a large study based on 5 birth cohorts in Brazil, Guatemala, India,
the Philippines and South Africa, faster linear growth at 0–2 years was
associated with improvements in adult stature and school performance,
but also an increased likelihood of overweight (mainly related to lean
mass) and a slightly elevated blood pressure in young adulthood.
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.
Medicaid 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 also covers long-term services and supports, including
both nursing home care and home- and community-based services, for those
with low incomes and minimal assets; the exact qualifications vary by
state. Medicaid spent $215 billion on such care in 2020, over half of
the total $402 billion spent on such services.
Of the 7.7 million Americans who used long-term services and supports
in 2020, about 5.6 million were covered by Medicaid, including 1.6
million of the 1.9 million in institutional settings.
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
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 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.
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 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:
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-basedsocial 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 Poverty Level.
More recently, many states have authorized financial requirements
that will make it more difficult for working-poor adults to access
coverage. In Wisconsin, nearly a quarter of Medicaid patients were dropped after the state government imposed premiums of 3% of household income. A survey in Minnesota found that more than half of those covered by Medicaid were unable to obtain prescription medications because of co-payments.
The Deficit Reduction Act of 2005
(DRA) requires anyone seeking Medicaid to produce documents to prove
that he is a United States citizen or resident alien. An exception is
made for Emergency Medicaid where payments are allowed for the pregnant
and disabled regardless of immigration status. Special rules exist for those living in a nursing home and disabled children living at home.
Supplemental Security Income beneficiaries
Once someone is approved as a beneficiary in the Supplemental Security Income program, they may automatically be eligible for Medicaid coverage (depending on the laws of the state they reside in).
Five year "look-back"
The
DRA has created a five-year "look-back period". This means that any
transfers without fair market value (gifts of any kind) made by the
Medicaid applicant during the preceding five years are penalizable.
The penalty is determined by dividing the average monthly cost of
nursing home care in the area or State into the amount of assets
gifted. Therefore, if a person gifted $60,000 and the average monthly
cost of a nursing home was $6,000, one would divide $6000 into $60,000
and come up with 10. 10 represents the number of months the applicant
would not be eligible for Medicaid.
All transfers made during the five-year look-back period are
totaled, and the applicant is penalized based on that amount after
having already dropped below the Medicaid asset limit. This means that
after dropping below the asset level ($2,000 limit in most states), the
Medicaid applicant will be ineligible for a period of time. The penalty
period does not begin until the person is eligible for Medicaid.
Elders who gift or transfer assets can be caught in the situation of having no money but still not being eligible for Medicaid.
Legal permanent residents (LPRs) with a substantial work history
(defined as 40 quarters of Social Security covered earnings) or military
connection are eligible for the full range of major federal
means-tested benefit programs, including Medicaid (Medi-Cal).
LPRs entering after August 22, 1996, are barred from Medicaid for five
years, after which their coverage becomes a state option, and states
have the option to cover LPRs who are children or who are pregnant
during the first five years. Noncitizen SSI recipients are eligible for
(and required to be covered under) Medicaid. Refugees and asylees are
eligible for Medicaid for seven years after arrival; after this term,
they may be eligible at state option.
Nonimmigrants and unauthorized aliens are not eligible for most
federal benefits, regardless of whether they are means tested, with
notable exceptions for emergency services (e.g., Medicaid for emergency
medical care), but states have the option to cover nonimmigrant and
unauthorized aliens who are pregnant or who are children, and can meet
the definition of "lawfully residing" in the United States. Special
rules apply to several limited noncitizen categories: certain
"cross-border" American Indians, Hmong/Highland Laotians, parolees and conditional entrants, and cases of abuse.
Aliens outside the United States who seek to obtain visas
at U.S. consulates overseas or admission at U.S. ports of entry are
generally denied entry if they are deemed "likely at any time to become a
public charge".
Aliens within the United States who seek to adjust their status to that
of lawful permanent resident (LPR), or who entered the United States
without inspection, are also generally subject to exclusion and deportation
on public charge grounds. Similarly, LPRs and other aliens who have
been admitted to the United States are removable if they become a public
charge within five years after the date of their entry due to causes
that preexisted their entry.
A 1999 policy letter from immigration officials defined "public
charge" and identified which benefits are considered in public charge
determinations, and the policy letter underlies current regulations and
other guidance on the public charge grounds of inadmissibility and
deportability. Collectively, the various sources addressing the meaning
of public charge have historically suggested that an alien's receipt of
public benefits, per se, is unlikely to result in the alien being deemed
to be removable on public charge grounds.
Children and SCHIP
A
child may be eligible for Medicaid regardless of the eligibility status
of his parents. Thus, a child may be covered by Medicaid based on his
individual status even if his parents are not eligible. Similarly, if a
child lives with someone other than a parent, he may still be eligible
based on its individual status.
One-third of children and over half (59%) of low-income children are insured through Medicaid or SCHIP.
The insurance provides them with access to preventive and primary
services which are used at a much higher rate than for the uninsured,
but still below the utilization of privately insured patients. As of
2014, rate of uninsured children was reduced to 6% (5 million children
remain uninsured).
HIV
Medicaid provided the largest portion of federal money spent on health care for people living with HIV/AIDS
until the implementation of Medicare Part D, when the cost of
prescription drugs for those eligible for both Medicare and Medicaid was
shifted to Medicare. Unless low income people who are HIV positive meet
some other eligibility category, they are not eligible for Medicaid
assistance unless they can qualify under the "disabled" category to
receive Medicaid assistance — for example, if they progress to AIDS (T-cell count drops below 200). The Medicaid eligibility policy differs from Journal of the American Medical Association
(JAMA) guidelines, which recommend therapy for all patients with T-cell
counts of 350 or less and even certain patients with a higher T-cell
count. Due to the high costs associated with HIV medications, many
patients are not able to begin antiretroviral
treatment without Medicaid help. It is estimated that more than half of
people living with AIDS in the United States receive Medicaid payments.
Two other programs that provide financial assistance to people living
with HIV/AIDS are the Social Security Disability Insurance (SSDI) and
the Supplemental Security Income programs.
Utilization
During 2003–2012, the share of hospital stays billed to Medicaid increased by 2.5%, or 0.8 million stays. As of 2019, Medicaid paid for half of all births in the United States.
Medicaid super utilizers (defined as Medicaid patients with four
or more admissions in one year) account for more hospital stays (5.9
vs.1.3 stays), longer lengths of stay (6.1 vs. 4.5 days), and higher
hospital costs per stay ($11,766 vs. $9,032). Medicaid super-utilizers were more likely than other Medicaid patients to be male and to be aged 45–64 years. Common conditions among super-utilizers include mood disorders and psychiatric disorders, as well as diabetes, cancer treatment, sickle cell anemia, sepsis, congestive heart failure, chronic obstructive pulmonary disease, and complications of devices, implants, and grafts.
Unlike Medicare, which is solely a federal program, Medicaid is a
joint federal-state program. Each state administers its own Medicaid
system that must conform to federal guidelines for the state to receive
Federal matching funds. Financing of Medicaid in the American Samoa, Puerto Rico, Guam, and the U.S. Virgin Islands is instead implemented through a block grant. The Federal government matches state funding according to the Federal Medical Assistance Percentages. The wealthiest states only receive a federal match of 50% while poorer states receive a larger match.
Medicaid funding has become a major budgetary issue for many
states over the last few years, with states, on average, spending 16.8%
of state general funds on the program. If the federal match expenditure
is also counted, the program, on average, takes up 22% of each state's
budget.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. Federal Medicaid outlays were estimated to be $204 billion in 2008.
In 2011, there were 7.6 million hospital stays billed to Medicaid,
representing 15.6% (approximately $60.2 billion) of total aggregate
inpatient hospital costs in the United States. At $8,000, the mean cost per stay billed to Medicaid was $2,000 less than the average cost for all stays.
Medicaid does not pay benefits to individuals directly; Medicaid
sends benefit payments to health care providers. In some states Medicaid
beneficiaries are required to pay a small fee (co-payment) for medical
services. Medicaid is limited by federal law to the coverage of "medically necessary services".
Since the Medicaid program was established in 1965, "states have
been permitted to recover from the estates of deceased Medicaid
recipients who were over age 65 when they received benefits and who had
no surviving spouse, minor child, or adult disabled child". In 1993, Congress enacted the Omnibus Budget Reconciliation Act of 1993,
which required states to attempt to recoup "the expense of long-term
care and related costs for deceased Medicaid recipients 55 or older." The Act allowed states to recover other Medicaid expenses for deceased Medicaid recipients 55 or older, at each state's choice.
However, states were prohibited from estate recovery when "there is a
surviving spouse, a child under the age of 21 or a child of any age who
is blind or disabled". The Act also carved out other exceptions for
adult children who have served as caretakers in the homes of the
deceased, property owned jointly by siblings, and income-producing
property, such as farms". Each state now maintains a Medicaid Estate Recovery Program,
although the sum of money collected significantly varies from state to
state, "depending on how the state structures its program and how
vigorously it pursues collections."
On November 25, 2008, a new federal rule was passed that allows
states to charge premiums and higher co-payments to Medicaid
participants.
This rule enabled states to take in greater revenues, limiting
financial losses associated with the program. Estimates figure that
states will save $1.1 billion while the federal government will save
nearly $1.4 billion. However, this meant that the burden of financial
responsibility would be placed on 13 million Medicaid recipients who
faced a $1.3 billion increase in co-payments over 5 years.
The major concern is that this rule will create a disincentive for
low-income people to seek healthcare. It is possible that this will
force only the sickest participants to pay the increased premiums and it
is unclear what long-term effect this will have on the program.
A 2019 study found that Medicaid expansion in Michigan had net positive fiscal effects for the state.
Effects
Coverage gains
A
2019 review by Kaiser Family Foundation of 324 studies on Medicaid
expansion concluded that "expansion is linked to gains in coverage;
improvements in access, financial security, and some measures of health
status/outcomes; and economic benefits for states and providers."
Mortality and disability reduction
A
2021 study found that Medicaid expansion as part of the Affordable Care
Act led to a substantial reduction in mortality, primarily driven by
reductions in disease-related deaths. A 2018 study in the Journal of Political Economy found that upon its introduction, Medicaid reduced infant and child mortality in the 1960s and 1970s. The decline in the mortality rate for nonwhite children was particularly steep. A 2018 study in the American Journal of Public Health
found that the infant mortality rate declined in states that had
Medicaid expansions (as part of the Affordable Care Act) whereas the
rate rose in states that declined Medicaid expansion. A 2020 JAMA
study found that Medicaid expansion under the ACA was associated with
reduced incidence of advanced-stage breast cancer, indicating that
Medicaid accessibility led to early detection of breast cancer and
higher survival rates.
A 2020 study found no evidence that Medicaid expansion adversely
affected the quality of health care given to Medicare recipients. A 2018 study found that Medicaid expansions in New York,
Arizona, and Maine in the early 2000s caused a 6% decline in the
mortality rate: "HIV-related mortality (affected by the recent
introduction of antiretrovirals) accounted for 20% of the effect.
Mortality changes were closely linked to county-level coverage gains,
with one life saved annually for every 239 to 316 adults gaining
insurance. The results imply a cost per life saved ranging from $327,000
to $867,000 which compares favorably with most estimates of the value
of a statistical life."
A 2016 paper found that Medicaid has substantial positive
long-term effects on the health of recipients: "Early childhood Medicaid
eligibility reduces mortality and disability and, for whites, increases
extensive margin labor supply, and reduces receipt of disability
transfer programs and public health insurance up to 50 years later.
Total income does not change because earnings replace disability
benefits."
The government recoups its investment in Medicaid through savings on
benefit payments later in life and greater payment of taxes because
recipients of Medicaid are healthier: "The government earns a discounted
annual return of between 2% and 7% on the original cost of childhood
coverage for these cohorts, most of which comes from lower cash transfer
payments". A 2019 National Bureau of Economic Research paper found that when Hawaii stopped allowing Compact of Free Association (COFA)
migrants to be covered by the state's Medicaid program that
Medicaid-funded hospitalizations declined by 69% and emergency room
visits declined by 42% for this population, but that uninsured ER visits
increased and that Medicaid-funded ER visits by infants substantially
increased. Another NBER paper found that Medicaid expansion reduced mortality.
A 2021 American Economic Review study found that early
childhood access to Medicaid "reduces mortality and disability,
increases employment, and reduces receipt of disability transfer
programs up to 50 years later. Medicaid has saved the government more
than its original cost and saved more than 10 million quality adjusted
life years."
Rural hospitals boosted revenue
A
2020 study found that Medicaid expansion boosted the revenue and
operating margins of rural hospitals, had no impact on small urban
hospitals, and led to declines in revenue for large urban hospitals.
A 2021 study found that expansions of adult Medicaid dental coverage
increasingly led dentists to locate to poor, previously underserved
areas. A 2019 paper by Stanford University and Wharton School of Business
economists found that Medicaid expansion "produced a substantial
increase in hospital revenue and profitability, with larger gains for
government hospitals. On the benefits side, we do not detect significant
improvements in patient health, although the expansion led to
substantially greater hospital and emergency room use, and a
reallocation of care from public to private and better-quality
hospitals."
Financial and health security increase
A 2017 survey of the academic research on Medicaid found it improved recipients' health and financial security. Studies have linked Medicaid expansion with increases in employment levels and student status among enrollees.
A 2017 paper found that Medicaid expansion under the Affordable Care
Act "reduced unpaid medical bills sent to collection by $3.4 billion in
its first two years, prevented new delinquencies, and improved credit scores.
Using data on credit offers and pricing, we document that improvements
in households' financial health led to better terms for available credit
valued at $520 million per year. We calculate that the financial
benefits of Medicaid double when considering these indirect benefits in
addition to the direct reduction in out-of-pocket expenditures." Studies have found that Medicaid expansion reduced rates of poverty and severe food insecurity in certain states.Studies on the implementation of work requirements for Medicaid in
Arkansas found that it led to an increase in uninsured individuals,
medical debt, and delays in seeking care and taking medications, without
any significant impact on employment. A 2021 study in the American Journal of Public Health found that Medicaid expansion in Louisiana led to reductions in medical debt.
Political participation increase
A
2017 study found that Medicaid enrollment increases political
participation (measured in terms of voter registration and turnout).
Crime reduction
Studies
have found that Medicaid expansion reduced crime. The proposed
mechanisms for the reduction were that Medicaid increased the economic
security of individuals and provided greater access to treatment for substance abuse or behavioral disorders. A 2022 study found that Medicaid eligibility during childhood reduced the likelihood of criminality during early adulthood.
In 2008, Oregon decided to hold a randomized lottery for the
provision of Medicaid insurance in which 10,000 lower-income people
eligible for Medicaid were chosen by a randomized system. The lottery
enabled studies to accurately measure the impact of health insurance on
an individual's health and eliminate potential selection bias in the
population enrolling in Medicaid.
A sequence of two high-profile studies by a team from the Massachusetts Institute of Technology and the Harvard School of Public Health
found that "Medicaid coverage generated no significant improvements in
measured physical health outcomes in the first 2 years", but did
"increase use of health care services, raise rates of diabetes detection
and management, lower rates of depression, and reduce financial strain."
The study found that in the first year:
Hospital use increased by 30% for those with insurance, with the
length of hospital stays increasing by 30% and the number of procedures
increasing by 45% for the population with insurance;
Medicaid recipients proved more likely to seek preventive care. Women were 60% more likely to have mammograms and recipients overall were 20% more likely to have their cholesterol checked;
In terms of self-reported health outcomes, having insurance was
associated with an increased probability of reporting one's health as
"good", "very good", or "excellent"—overall, about 25% higher than the
average;
Those with insurance were about 10% less likely to report a diagnosis of depression.
Patients with catastrophic health spending (with costs that were greater than 30% of income) dropped.
Medicaid patients had cut in half the probability of requiring loans or forgoing other bills to pay for medical costs.
The studies spurred a debate between proponents of expanding Medicaid
coverage and fiscal conservatives challenging the value of this
expansive government program.
