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Medicaid Difference by State

Medicaid is managed by the states, and each one has varying criteria on how to qualify for the program, what services are covered, and how physicians and care providers are reimbursed through the program. Differences between states are often influenced by the political ideologies of the state and cultural beliefs of the general population. Differing criteria can also make it very difficult for people to understand how to navigate the system, leave people who need coverage uninsured because they don’t meet certain criteria, and deepen inequality in certain populations.

Political Influences

There are several political factors that can influence the cost and eligibility of health care programs, as detailed in a study conducted by Gideon Lukens^[1]. In the case of Medicaid specifically, this study found that some of the most important factors in determining eligibility included “party control, the ideology of state citizens, the prevalence of women in legislatures, the line-item veto, and physician interest group size.” This study also supports the hypothesis that while Democrats are relatively more in favor of generous eligibility policies over payment policies while the opposite is true for Republicans. Moreover, when the Supreme Court ruled to allow states to decide whether or not they planned to expand Medicaid in 2012, the states that chose to expand Medicaid, (which often meant extending existing eligibility), were much disproportionately northern states that where Democratic legislators held a significant number or at least a majority of seats. 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 that waive 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 has been adopted by other Republican-led states^[2]. However, private coverage is more expensive than Medicaid and the states would not have to contribute as much to the cost of private coverage ^[3]. Further, certain groups of individuals, such as migrants, may face more barriers to obtaining health care than others as a result of various factors that are less concrete than policy despite the fact that they can be extremely challenging to face. Such factors are not limited to status of the individual, transportation, a lack of knowledge about the healthcare system (perhaps including eligibility)^[4].

Eligibility/Coverage

Medicaid eligibility policies are very complicated. In general, Medicaid eligibility is linked to a person's eligibility for Aid to Families with Disabled 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 asses Medicaid differences as well. SSI coverage is largely consistent by state, and requirements on how to qualify or what benefits are provided are standard. AFDC has differing eligibility standards, however, and are influenced by: 1) The Low-Income Wage Rate: State welfare programs base the level of assistance they provide on some concept of what is minimally necessary. 2) 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. 3) Racism. Empirical studies have found that specific demographic characteristics of AFDC recipients also affect voters' perceptions of the appropriate AFDC payment level

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 ^[5]. The discrepancy in the reimbursements Medicaid offers may affect the type of care provided to patients. Care providers have no incentive to strive towards quality care, and though patients may have Medicare coverage, they have no way of accessing quality healthcare with it.