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Special Communication |

Medicare and Medicaid at 50 Years Perspectives of Beneficiaries, Health Care Professionals and Institutions, and Policy Makers

Drew Altman, PhD1; William H. Frist, MD1,2
[+] Author Affiliations
1Kaiser Family Foundation, Menlo Park, California
2Dr Frist is the former US Senate majority leader.
JAMA. 2015;314(4):384-395. doi:10.1001/jama.2015.7811.
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Importance  Medicare and Medicaid are the nation’s 2 largest public health insurance programs, serving the elderly, those with disabilities, and mostly lower-income populations. The 2 programs are the focus of often deep partisan disagreement. Medicare and Medicaid payment policies influence the health care system and Medicare and Medicaid spending influences federal and state budgets. Debate about Medicare and Medicaid policy sometimes influences elections.

Objective  To review the roles of Medicare and Medicaid in the health system and the challenges the 2 programs face from the perspectives of the general public and beneficiaries, health care professionals and health care institutions, and policy makers.

Evidence  Analysis of publicly available data and private surveys of the public and beneficiaries.

Findings  Together, Medicare and Medicaid serve 111 million beneficiaries and account for $1 trillion in total spending, generating 43% of hospital revenue and representing 39% of national health spending. The median income for Medicare beneficiaries is $23 500 and the median income for Medicaid beneficiaries is $15 000. Future issues confronting both programs include whether they will remain open-ended entitlements, the degree to which the programs may be privatized, the scope of their cost-sharing structures for beneficiaries, and the roles the programs will play in payment and delivery reform.

Conclusions and Relevance  As the number of beneficiaries and the amount of spending for both Medicare and Medicaid increase, these programs will remain a focus of national attention and policy debate. Beneficiaries, health care professionals, health care organizations, and policy makers often have different interests in Medicare and Medicaid, complicating efforts to make changes to these large programs.

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Figure 1.
Key Milestones in Medicare and Medicaid
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Figure 2.
Public Support for Various Deficit-Reducing Changes to Medicare

Data are from a Kaiser Family Foundation/Harvard School of Public Health/Robert Wood Johnson Foundation poll conducted January 3-9, 2013.21 The survey interviewed 1347 adults in English and Spanish via land-line and cellular telephone, including 1026 adults aged 18 to 64 years and 315 aged 65 years or older. The response rate calculated based on the American Association of Public Opinion Research’s Response Rate 3 formula was 18% for the land-line telephone sample and 16% for the cellular telephone sample.

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Figure 3.
Individuals Covered by Medicaid

HIV indicates human immunodeficiency virus. The federal poverty level (FPL) was $19 530 for a family of 3 in 2013. Data are from a Kaiser Commission on Medicaid and the Uninsured (KCMU)/Urban Institute analysis of the 2013 Annual Social and Economic Supplement to the Current Population Survey, the 2012 Maternal and Child Health Update (birth data),36 the Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (Medicare data),37 a KCMU analysis of 2012 National Health Interview Survey data (functional limitations data), the 2009 Centers for Disease Control and Prevention Medical Monitoring Project (nonelderly with HIV data), and 2012 Online Survey, Certification and Reporting data (nursing home resident data).

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Figure 4.
Medicaid Enrollees and Expenditures, 2011

Data are from Kaiser Commission on Medicaid and the Uninsured/Urban Institute estimates based on data from the fiscal year 2011 Medicaid Statistical Information System (MSIS) and Centers for Medicare & Medicaid Services (CMS) Form 64 (Medicaid Financial Management Reports). Fiscal year 2010 data from MSIS were used for Florida, Kansas, Maine, Maryland, Montana, New Mexico, New Jersey, Oklahoma, Texas, and Utah but adjusted to 2011 CMS Form 64.

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Figure 5.
Self-reported Access to Care—Medicaid, Private Insurance, and Uninsured, 2013

Data are from a Kaiser Commission on Medicaid and the Uninsured analysis of 2014 National Health Interview Survey data. The “usual source of care” measure reflects respondent self-report of having a general source of care. Well-child checkups, specialist visits for both children and adults, and general physician visits for adults reflect self-reported experiences in the past 12 months. Respondents who said their usual source of care was the emergency department were not counted as havind a usual source of care.

aDifference from employer-sponsored insurance is statistically significant (P<.05).

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Figure 6.
Medicaid Spending and Enrollment

Data are from Medicaid Enrollment: June 2013 Data Snapshot.67 Spending data are from a Kaiser Commission on Medicaid and the Uninsured (KCMU) analysis of Centers for Medicare & Medicaid Services Form 64 data for historic Medicaid growth rates. Fiscal year 2014 and 2015 data are based on a KCMU survey of Medicaid officials in 50 states and the District of Columbia conducted in October 2014.51 Enrollment percentage changes from June to June of each year. Spending growth percentages are for states’ fiscal years.

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Figure 7.
Growth in Average Annual Medicaid Spending on Medical Services vs Growth in Other Indicators, 2007-2013

Medicaid estimates are from an Urban Institute analysis of data from the Medicaid Statistical Information System, Centers for Medicare & Medicaid Services (CMS) Form 64 (Medicaid Financial Management Reports), and Kaiser Commission on Medicaid and the Uninsured and Health Management Associates data. National health expenditure and private health insurance data are from the CMS Office of the Actuary, National Health Statistics Group. Medical care consumer price index data are from the Bureau of Labor Statistics Consumer Price Index Detail Report Tables. Gross domestic product data are from the Bureau of Economic Analysis.

aAcute care includes payments to managed care plans.

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