Nearly six decades in, Medicaid is still going strong

Medicaid turned 58 in July, but it may be more robust than it has ever been. The program, created as part of Lyndon B. Johnson’s Great Society vision, continues to promote health care access and equity, and at a greater scale than ever before.

Because Medicaid serves people with lower incomes and individuals with disabilities, the program regularly confronts stark barriers to good health and navigates the limits of a stretched safety net. Nonetheless, a new vanguard of Medicaid leaders at both the state and federal level offers a vision for improving and transforming health care.

Here are a few key trends:

Medicaid is covering more people.

Enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) hit an all-time high this year—roughly 94 million people in spring of 2023. Federal changes have driven some of this increase. After the Affordable Care Act passed, 41 states expanded their Medicaid programs to include adults with slightly higher incomes. Then, as a condition of enhanced federal funding, states maintained continuous Medicaid enrollment during the COVID-19 public health emergency. With the American Rescue Plan of 2021, 46 states have expanded, or plan to expand, postpartum coverage to a full year after delivery, instead of 60 days. Under a longstanding state option, 33 states provide 12 months of continuous eligibility to children. (That option will transition to a requirement for all states in 2024.) And some states like Oregon now have special federal permission to provide continuous coverage from birth to six years.

To fill remaining coverage gaps, a few states have begun to expand coverage with funding from their state budgets, without the typical federal match for Medicaid services. For example, California is expanding Medicaid eligibility to all income-eligible residents, regardless of immigration status. So is Oregon, and the state of Washington has a similar plan. Some states, like New Jersey, have expanded access for undocumented children.

Thanks to Medicaid, the uninsured rate reached a record low of 7.7 percent nationally in early 2023. As states unwind COVID-19 protections for Medicaid members, the uninsured rate will likely go back up, with some rocky transitions, but states will continue to work to connect individuals to other forms of insurance.

Medicaid is removing barriers to health equity.

Medicaid programs nationwide are seeking to advance health equity and reduce racial and ethnic disparities in health outcomes. To do this, states and territories are directly engaging Medicaid members, creating formal health equity roles and initiatives, and entering into new partnerships to confront systematic barriers to health. For example, Nathan Chomilo, medical director for Minnesota Medicaid, identified opportunities to improve programming and reduce racial health disparities by directly engaging U.S.-born Black Minnesotans covered by Medicaid. To promote more equitable health outcomes for this community, the state is expanding coverage for kids, investing in Medicaid navigators, and increasing awareness of doula benefits.

In other states, leaders are finding new ways to improve health equity, such as stemming the increase in mortality for Black mothers and babies and working to improve pre-release and transition services for individuals transitioning from jails and prisons.

Medicaid is promoting state and local innovation.

Nearly 60 years after Medicaid’s beginning, state and territorial Medicaid agencies are still creating new innovations—developing broad policy goals and direction and implementing new initiatives in partnership with managed care plans, health systems, and community-based organizations.

For example, Medicaid members often struggle with food and housing insecurity, and with finding reliable transportation. Over the years, Medicaid leaders have worked to address these barriers. Medicaid has provided rides to medical appointments as part of a non-emergency medical transportation benefit and covered home-delivered meals and home modifications as part its home and community-based services. Some Medicaid managed care plans have elected to offer their members food boxes and air conditioners, to partner with community-based organizations that use community health workers, and to invest in local supportive housing units.

Now, the Centers for Medicare & Medicaid Services (CMS) is allowing Medicaid programs to test nutrition and housing support services at scale. For example, North Carolina is providing transportation, housing, food, and interpersonal violence prevention services as part of its Healthy Opportunities Pilot. Arizona covers six months’ worth of transitional rent for individuals experiencing homelessness, giving them the stability needed to connect to care and maintain coverage. By allowing states to experiment with these supportive services, CMS will usher in new approaches to bridge the worlds of health and social care, and it will accelerate partnerships between health care organizations and community-based organizations providing social services.

Medicaid will continue to find opportunities for innovation.

In many ways, Medicaid represents the uniquely piecemeal approach to health care in the United States. Medicaid is tasked with serving a large and diverse population—including millions of children, pregnant people, older adults, and people with disabilities. Medicaid is often asked to fill in the gaps where other systems fall short, while at the same time containing costs and delivering efficient care.

In the years to come, Medicaid will continue to promote access, equity, and innovation. It will find ways to minimize coverage disruptions; improve and monitor access to care under shifting federal rules; use race, ethnicity, language, sexual orientation, and gender identity data to identify opportunities for quality improvement; and mobilize health care dollars to expand access to nutrition and housing supports.

There will be challenges. But Medicaid will remain a crucial lifeline for its members—and an important leader in the push for more equitable and comprehensive health care.