Medicaid insured 85 million low-income and disabled Americans as of 2022. In 2019 it paid for half of all US births. For many families it is the difference between seeing a doctor and going without.
The program is about to change. The 2025 One Big Beautiful Bill Act requires most able-bodied adult enrollees to work or volunteer 80 hours a month to keep coverage. The rule takes effect in 2027.
A program built on state choice
The Social Security Amendments of 1965 created Medicaid, as part of President Lyndon B. Johnson’s Great Society. Washington sets baseline standards and pays a large share of the bill. States run the program and have wide latitude over who qualifies and what is covered. Participation is optional, though every state has been in since 1982.
The Affordable Care Act, passed in 2010, widened the program. In most states, anyone in a household earning up to 138% of the federal poverty line qualifies. A 2012 Supreme Court ruling let states keep their earlier eligibility rules and still receive the federal funding they had before, and some Republican-controlled states chose not to expand.
Who it covers, and what it costs
Children made up 37% of enrollees but only 15% of spending, about $3,000 per child. Seniors and disabled people were 21% of enrollees and 52% of spending, more than $18,000 each.
Long-term care explains much of that gap. Of the 7.7 million Americans who used long-term services and supports in 2020, about 5.6 million were covered by Medicaid.
Total federal and state spending hit $870 billion in 2023, and the average cost per enrollee was $7,600 in 2021. Recipients generally must be US citizens or qualified non-citizens. Research shows the program improves health outcomes, insurance coverage, access to care and financial security for recipients, and brings economic benefits to states and providers.
Since the 1980s, many states have won federal waivers for managed care. Enrollees join a private health plan, and the state pays the plan a fixed monthly premium. Roughly 80% of enrollees are now in managed care.
Politics
Democrats tend to back Medicaid. Republicans are divided over cuts to its spending, and the work requirement is the latest dividing line.
