History of Medicaid in Timeline
Medicaid in the United States is a joint federal and state government program providing health insurance to low-income adults and children. While primarily administered by individual states, the federal government establishes basic requirements and contributes substantially to funding. States have significant flexibility in setting eligibility criteria and determining the scope of benefits offered within their Medicaid programs. Although participation is optional, every state has opted into Medicaid since 1982.
1927: Section 1927 is added
Section 1927 of the Social Security Act of 1935 is later added and becomes effective in 1991.
1927: Section 1927 is amended
The Omnibus Budget Reconciliation Act of 1993 amended Section 1927 of the Act and requires estate recovery for long-term care costs.
1935: Social Security Act of 1935
The Social Security Act of 1935 is amended to include section 1927.
1965: Medicaid Established
Medicaid was established in 1965 as part of President Lyndon B. Johnson's Great Society programs.
1965: Medicaid Estate Recovery
Since its inception in 1965, Medicaid allowed states to recover expenses from the estates of deceased recipients over 65 without surviving spouses, minor children, or disabled adult children.
1965: Medicaid Created
The Social Security Amendments of 1965 created Medicaid by adding Title XIX to the Social Security Act.
1973: Rehabilitation Act and Medicaid
The Rehabilitation Act of 1973, Section 504, mandates a "free appropriate public education" for children with disabilities, impacting Medicaid's role in school services.
1982: Arizona Joins Medicaid
Arizona became the last state to join Medicaid in 1982.
1982: All States Participate in Medicaid
By 1982, all U.S. states were participating in the Medicaid program.
1982: State Participation in Medicaid and Service Provision
By 1982, all states had voluntarily participated in Medicaid. Some states subcontract Medicaid to private insurers, while others pay providers directly. Services covered vary by state, with intermediate care for the mentally disabled, prescription drugs, and nursing facility care for under 21-year-olds being the most common, and institutional religious (non-medical) healthcare, respiratory care for the ventilator-dependent, and PACE (inclusive elderly care) being the least common.
1990: OBRA-90 Creates Programs
The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) created the Medicaid Drug Rebate Program and HIPP.
January 1, 1991: Medicaid Drug Rebate Program and HIPP Created
The Medicaid Drug Rebate Program and the Health Insurance Premium Payment Program (HIPP) became effective on January 1, 1991, under the Omnibus Budget Reconciliation Act of 1990.
1993: OBRA-93 Amends Medicaid Drug Rebate Program
The Omnibus Budget Reconciliation Act of 1993 (OBRA-93) amended the Medicaid Drug Rebate Program.
1993: Omnibus Budget Reconciliation Act and Medicaid Estate Recovery
The Omnibus Budget Reconciliation Act of 1993 broadened Medicaid estate recovery to include recipients aged 55 or older, while outlining exemptions for surviving spouses, dependent children, caretaker adult children, jointly owned property, and income-generating property.
August 22, 1996: Medicaid Eligibility for Legal Permanent Residents
On August 22, 1996, new regulations affected Medicaid eligibility for Legal Permanent Residents (LPRs), introducing a five-year waiting period for those entering after the date, with exceptions for children, pregnant women, and individuals with substantial work history or military connections.
1999: Public Charge Definition and Impact on Immigration
A 1999 policy letter clarified the "public charge" definition regarding immigration, outlining which public benefits were considered when determining inadmissibility or deportability. The letter indicated that receiving public benefits alone wouldn't necessarily lead to removal.
2000: Shift in Hospital Stay Payments for Children
From 2000 to 2012, there was a significant shift in how hospital stays for children were funded. The proportion paid by Medicaid rose by 33%, while the proportion covered by private insurance dropped by 21%.
2001: Dual Enrollment in Medicare and Medicaid
In 2001, approximately 6.5 million people were enrolled in both Medicare and Medicaid, also known as "dual eligibles" or "medi-medi's".
2002: Medicaid Enrollment and Demographics
In 2002, Medicaid enrollment reached 39.9 million Americans, with children comprising the largest group (18.4 million, or 46%).
2003: Increase in Medicaid-Billed Hospital Stays
Between 2003 and 2012, the proportion of hospital stays billed to Medicaid saw an increase.
2004: Medicaid Enrollment and Costs
In 2004, Medicaid enrollment totaled 43 million Americans (including 19.7 million children) at a cost of \$295 billion.
2004: Medicaid Enrollment and Costs
In 2004, Medicaid covered 43 million Americans, incurring a total cost of $295 billion.
2005: Deficit Reduction Act and Medicaid
The Deficit Reduction Act of 2005 mandated proof of citizenship or legal residency for Medicaid eligibility, with exceptions for emergency cases and specific groups.
November 25, 2008: New Federal Rule on Medicaid Premiums and Co-payments
On November 25, 2008, a new federal rule allowed states to charge premiums and higher co-payments for Medicaid, aiming to reduce state and federal spending. This shift placed greater financial burden on recipients, raising concerns about potential disincentives for seeking healthcare.
2008: Health Insurance Premium Payment Program (HIPP)
As of 2008, the Health Insurance Premium Payment Program (HIPP) allowed Medicaid to pay for private health insurance for some recipients. Despite limited adoption and low enrollment at the time, interest in HIPP remained high.
2008: Medicaid Coverage Expansion
By 2008, Medicaid expanded its coverage to approximately 49 million low-income individuals, encompassing children, pregnant women, the elderly, and disabled individuals.
2008: Recession's Impact on Medicaid Enrollment
During the 2008-2009 recession, income and medical insurance coverage loss resulted in a spike in Medicaid enrollment in 2009, straining state budgets, with nine states seeing a 15% or more increase in enrollment.
2008: Medicaid Coverage and Expenditures
In 2008, Medicaid provided coverage to around 49 million low-income individuals, with federal outlays estimated at $204 billion.
2008: Oregon Medicaid Experiment
In 2008, Oregon conducted a randomized lottery for Medicaid eligibility, providing a unique opportunity to study the effects of health insurance on individuals' health and eliminate selection bias.
2009: Medicaid Enrollment Increase
In 2009, Medicaid enrollment reached 62.9 million Americans 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 one month during the 2009-10 period.
2009: Recession's Impact on Medicaid Enrollment Continued
Medicaid enrollment surged significantly in 2009, a direct consequence of the 2008-2009 recession, which led to widespread job and health insurance loss. This put a substantial strain on state budgets as nine states experienced a 15% or greater increase in Medicaid enrollment.
2010: Affordable Care Act Expands Medicaid
The Affordable Care Act (ACA) significantly expanded Medicaid in 2010.
2010: ACA Expands Medicaid Eligibility
The Affordable Care Act (ACA), passed in 2010, significantly expanded Medicaid eligibility.
2011: Medicaid's Share of Hospital Costs
In 2011, Medicaid covered 7.6 million hospital stays, accounting for 15.6% of total inpatient costs.
January 2012: Medicaid/CHIP Funding for Employer Premiums
As of January 2012, Medicaid and/or CHIP funds could be used to help cover employer health care premiums in six states: Alabama, Alaska, Arizona, Colorado, Florida, and Georgia.
2012: Increase in Medicaid-Billed Hospital Stays
Between 2003 and 2012, the proportion of hospital stays billed to Medicaid increased.
2012: Shift in Hospital Stay Payments for Children Continued
By 2012, following a trend since 2000, the proportion of children's hospital stays funded by Medicaid had increased by 33%, accompanied by a 21% decrease in the proportion paid by private insurance.
2012: Supreme Court Decision on Medicaid Expansion
In 2012, the Supreme Court ruled that states could opt out of the ACA's Medicaid expansion.
2012: Political Influences on Medicaid Eligibility
In 2012, the Supreme Court's decision allowed states to decide whether to expand Medicaid. This led to disproportionate expansion in northern states with predominantly Democratic legislators, who generally favored more generous eligibility policies, compared to Republican-led states. Political factors, including party control and citizen ideology, played a significant role in shaping eligibility.
2012: Supreme Court Decision Impacts Medicaid Expansion
The 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius allowed states to opt out of the ACA's Medicaid expansion.
2013: Dual Enrollment in Medicare and Medicaid Increases
The number of people dually eligible for both Medicare and Medicaid increased to approximately 9 million in 2013.
2013: Medicaid Reimbursement Disparities
In 2013, there were substantial differences in Medicaid reimbursements to care providers between states. For instance, a study comparing New Jersey and Delaware found an average \$3,047 difference for 10 common orthopedic procedures, which potentially affected the quality of care received by patients.
2013: Medicaid Recipient Demographics
In 2013, the Kaiser Family Foundation reported the following racial breakdown for Medicaid recipients: 40% White, 21% Black, 25% Hispanic, and 14% other races.
2013: Affordable Care Act and Medicaid Payment Increase
In 2013, as part of the Affordable Care Act, Medicaid payments were temporarily increased to match Medicare payment levels to incentivize provider participation and improve access to care for Medicaid patients. This increase was federally funded and also implemented in 2014, but most states did not sustain it afterwards.
2013: Medicaid Eligibility Requirements
As of 2013, Medicaid eligibility was category-based, including low-income children, pregnant women, parents of eligible children, and low-income disabled or elderly individuals. Specific category definitions varied by state.
2013: Medicaid Expansion and Uninsured Rate Changes
Between 2013 and 2015, the uninsured rate in Arkansas dropped significantly from 42% to 14%, and in Kentucky from 40% to 9%, following Medicaid expansion. This contrasts with Texas, a non-expansion state, where the uninsured rate only decreased from 39% to 32% during the same period.
2014: Report on Medicaid Costs
A 2014 Kaiser Family Foundation report estimated the national average per capita annual cost of Medicaid services.
2014: Growth of Medicaid Managed Care
As of 2014, 26 states contracted with managed care organizations (MCOs) for long-term care.
2014: Medicaid and SCHIP Coverage for Children
By 2014, Medicaid and the State Children's Health Insurance Program (SCHIP) insured a significant portion of children, leading to increased utilization of preventive and primary care services compared to uninsured children, although still lower than privately insured patients. The uninsured rate for children reduced to 6%.
2014: ACA Medicaid Expansion Implementation
In 2014, the ACA's Medicaid expansion aimed to cover individuals earning up to 138% of the Federal poverty level.
2014: Affordable Care Act and Medicaid Payment Increase Continued
The federally-funded increase in Medicaid payments, bringing them to 100% of equivalent Medicare payments to encourage provider participation, continued into 2014 as part of the Affordable Care Act. However, this provision was not widely maintained by states in subsequent years.
October 2015: Medicaid Expansion Costs and Coverage
In October 2015, the Centers for Medicare and Medicaid Services (CMS) estimated that the cost of Medicaid expansion was \$6,366 per person, exceeding previous estimates. Around 9 to 10 million people gained coverage, primarily low-income adults, while the Kaiser Family Foundation estimated that 3.1 million remained uninsured in states that rejected the expansion.
2015: Medicaid Expansion and Uninsured Rate Changes Continued
Following the trend from 2013, by 2015 the uninsured rates continued to drop in Medicaid expansion states Arkansas and Kentucky, reaching 14% and 9%, respectively. This is a significant decrease compared to the 32% uninsured rate in Texas, which did not expand Medicaid.
2015: Variation in Medicaid Asset Tests
In 2015, asset tests for Medicaid varied by state. Some states had no asset tests for specific pathways, such as for working people with disabilities or aged/blind/disabled individuals.
2016: Uninsured Rates in Expansion vs. Non-Expansion States
In the first quarter of 2016, states that expanded Medicaid had lower uninsured rates compared to non-expansion states.
2016: Long-Term Effects of Medicaid
A 2016 study found that Medicaid eligibility during childhood had long-term positive effects on recipients' health, reducing mortality and disability. It also showed increases in employment and reduced reliance on disability programs and public health insurance, leading to government savings and returns on investment.
2016: Medicaid Expansion Impact Study
A 2016 study compared the impact of Medicaid expansion in Kentucky and Arkansas (expansion states) with Texas (non-expansion state). Residents of Kentucky and Arkansas experienced improved access to healthcare services and reduced emergency room costs and medical bill payment difficulties, while Texas residents saw no similar improvements. Both Kentucky and Arkansas later considered modifying their programs.
2016: Medicaid Expansion Impact on Exchange Policy Premiums
In 2016, a DHHS study found that states that expanded Medicaid had lower premiums on exchange policies due to having fewer low-income enrollees, who generally have poorer health than higher-income individuals.
2017: Medicaid's Impact on Health and Financial Security
A 2017 review of existing research confirmed that Medicaid improved recipients' health and financial well-being, linking it to higher employment and student status. Another 2017 study found Medicaid expansion decreased unpaid medical bills, prevented delinquencies, and boosted credit scores, improving households' financial health and access to better credit terms.
2017: Medicaid Enrollment and Political Participation
A 2017 study linked increased Medicaid enrollment to greater political participation, as measured by voter registration and turnout.
2017: Medicaid Costs and Funding
In 2017, the annual cost of Medicaid exceeded \$600 billion, with the federal government contributing \$375 billion and states adding \$230 billion.
2017: Medicaid Costs Exceed $600 Billion
The total annual cost of Medicaid surpassed $600 billion in 2017.
2018: Medicaid's Impact on Infant and Child Mortality
A 2018 study revealed that Medicaid's introduction significantly reduced infant and child mortality in the 1960s and 1970s, with a particularly pronounced decline for nonwhite children. Another 2018 study showed declines in infant mortality in states with ACA Medicaid expansions. A further study from 2018 attributed a 6% decline in mortality to Medicaid expansion in select states during the early 2000s.
2018: Medicaid Expansion and Uninsured Rates Data
Data from 2018 showed that states that had expanded Medicaid under the ACA had significantly lower uninsured rates than those that didn't. Specifically, adults between 100% and 399% of the poverty level in expansion states had an uninsured rate of 12.7%, compared to 21.2% in non-expansion states.
July 2019: Medicaid Expansion and Mortality Rates
In July 2019, the National Bureau of Economic Research (NBER) published a study indicating that states with Medicaid expansion experienced statistically significant reductions in mortality rates.
September 2019: Medicaid Expansion and Uninsured Rates
In September 2019, the Census Bureau reported considerably lower uninsured rates in states that expanded Medicaid under the ACA. For example, adults between 100% and 399% of the poverty level had a 12.7% uninsured rate in expansion states compared to 21.2% in non-expansion states in 2018. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid.
2019: Medicaid Funds Half of U.S. Births
In 2019, Medicaid paid for half of all births in the United States.
2019: Medicaid Expansion under PPACA
In 2019, following the Patient Protection and Affordable Care Act (PPACA), Medicaid expansion streamlined eligibility using a Modified Adjusted Gross Income test, eliminating state variations and asset tests.
2019: Positive Impacts of Medicaid Expansion
A 2019 Kaiser Family Foundation review summarized positive impacts of Medicaid expansion, such as improved coverage, access to care, and financial security.
2019: Medicaid's Role in Births
By 2019, Medicaid funded half of all births in the United States.
2019: Medicaid Expansion's Impact on Hospitals and Patient Health
A 2019 study showed that Medicaid expansion significantly improved hospital revenue and profitability, particularly for government hospitals. While it increased hospital and emergency room usage and shifted care towards private and higher-quality hospitals, no significant patient health improvements were detected.
2019: Positive Fiscal Effects of Medicaid Expansion in Michigan
A 2019 study revealed that the expansion of Medicaid in Michigan led to overall positive financial outcomes for the state.
2019: Impact of Medicaid Restrictions on COFA Migrants
A 2019 study showed that when Hawaii restricted Medicaid access for Compact of Free Association migrants, Medicaid-funded hospitalizations and emergency room visits decreased significantly, while uninsured ER visits rose, especially for infants. Another study confirmed that Medicaid expansion lowered mortality rates.
2020: Medicaid Expansion Affordability Concerns and Potential Costs of Rejection
In 2020, several states raised concerns about the affordability of the 10% contribution required for Medicaid expansion. Studies suggested that rejecting the expansion could lead to higher costs due to increased spending on uncompensated emergency care. Additionally, it was estimated that up to 6.4 million people might earn too much for Medicaid but not qualify for exchange subsidies.
2020: Medicaid Spending on Long-Term Care
Medicaid spent $215 billion on long-term services and supports in 2020.
2020: Medicaid Expansion's Impact on Hospitals
In 2020, research revealed that Medicaid expansion increased revenue and operating margins for rural hospitals, had no impact on small urban hospitals, and decreased revenue for large urban hospitals.
2020: Medicaid Expansion and Breast Cancer Incidence
In 2020, a study found that Medicaid expansion under the ACA was associated with a lower occurrence of advanced-stage breast cancer. Another 2020 study found no evidence of adverse effects on the quality of care for Medicare recipients.
2020: ACA Medicaid Expansion Cost Sharing
By 2020, states were to pay for 10% of the costs for the newly covered population under the ACA's Medicaid expansion.
2021: Long-Term Benefits of Early Childhood Medicaid Access
A 2021 study highlighted that early childhood Medicaid access had long-term benefits, reducing mortality and disability, boosting employment, and decreasing reliance on disability programs, ultimately saving the government money and improving quality of life.
2021: Medicaid Expansion and Dentist Location
A 2021 study indicated that expanded adult Medicaid dental coverage attracted more dentists to previously underserved, low-income areas.
2021: Medicaid Expansion and Mortality Reduction
In 2021, a study linked the expansion of Medicaid under the Affordable Care Act to a substantial decrease in mortality rates, primarily from disease-related deaths.
2021: Medicaid Expansion and Medical Debt Reduction
In 2021, a study showed that Medicaid expansion in Louisiana led to decreases in medical debt.
2022: Medicaid and Crime Reduction
A 2022 study found that Medicaid eligibility in childhood decreased the likelihood of criminal behavior in early adulthood. Previous studies had also linked Medicaid expansion to reduced crime rates, suggesting that increased economic security and access to substance abuse/behavioral disorder treatment played a role.
2022: Medicaid Service Provision
According to the Centers for Medicare & Medicaid Services (CMS), the Medicaid program provided health care services to more than 92 million people in 2022.
2022: Medicaid Covers Millions
As of 2022, Medicaid provided free health insurance to 85 million low-income and disabled people.
March 2023: State Medicaid Expansion Status
As of March 2023, 40 states and the District of Columbia had accepted the ACA's Medicaid expansion.