Use vs Misuse: Medicaid

Some statistics:

An estimated 37 million U.S. children (49%) were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) as of October 2024, according to an AAP analysis of data from the Centers for Medicare & Medicaid Services (CMS). The portion of children ages 0-18 covered by Medicaid/CHIP ranged from 18% in Utah to 71% in New Mexico. https://www.medicaid.gov/

In January 2025, 71.4 million individuals were enrolled in Medicaid, and 7.3 million individuals were enrolled in CHIP. Each month, all states and the District of Columbia are required to provide data to the CMS, which is reported in the Medicaid & CHIP Enrollment Report. Data from U.S. territories are not available in this reporting system. https://data.medicaid.gov/medicaid-chip-eligibility-enrollment-snapshot-data

I will be honest here. I am not writing this from an insurance, budget, or numerical perspective, as those are not my areas of expertise. However, I do educate myself on related topics from time to time. I intend to highlight some scenarios from the clinical side as to why and how Medicaid can be best utilized, safeguarded, and preserved for vital areas.  

Let’s dive into three examples that we encounter on a very routine basis in any primary care practice. As always, my target audience is the general public, encompassing both healthcare and non-healthcare, and the discussion will be transparent on both sides.

Where Medicaid is truly needed:

Let us say a patient with high severity of autism spectrum disorder comes into the clinic. He also has other neurological problems. He has a minor procedure that needs to be done. This procedure would have been easily performed in an outpatient setting. But due to his health condition, he experiences involuntary movements of his arms and legs, he does not understand what is going on, and would not be able to cooperate for the procedure, making it impossible to perform. Therefore, the Nurse Practitioner (NP) recommends that the mother take the child to the hospital Emergency Room (ER) to undergo the procedure. The mother begins to cry. Seeing the mom crying, the NP asks the mom, “Is there anything we can do to help you take your son to the ER? Mom states that “He recently lost his Medicaid.”

"He was under Medicaid coverage, and that’s how he was seeing the doctors and receiving therapies. Now that my other children have started working, our household income has exceeded the threshold to qualify for Medicaid. His dad is trying to enroll him for insurance through his job, but he cannot do that immediately. Currently, he has no insurance, and I cannot afford the costs of the ER. I also don’t have his seizure medications anymore; we ran out, and now he has seizures every day, and it has been tough to manage him."

This is rough! Obviously, not every situation will be this extreme. However, this is a valid reason for the parent to go to the ER.

Where Medicaid is not needed:

A toddler, aged 2-3 years, presents to the clinic with parents reporting less than 24 hours of fever. The NP performs a detailed exam. In the absence of any source of fever on exam, she concludes that it is a viral fever and would not last more than 3 days. If it exceeds 3 days, she tells them to follow up. She also provides recommendations on how to take care of the child at home.

The parents expressed that they understood everything. They conclude, saying, “No problem, if the fever does not go away by tomorrow, we will take him to the ER.”

The NP tries again to explain to the parents the importance of avoiding the ER, and instead coming in for a follow-up if the problem persists. The parents state, “We have Medicaid, we will take him to the ER, no problem.”

This is a misuse! Despite the NP telling the parents not to go to the ER, the parents insist. From a healthcare standpoint, it is unnecessary to go to the ER if the issue is manageable at home.

How Non-Medicaid people respond:

A parent brings their child to her primary care provider for asthma management. The child gets an asthma flare-up during sports. The parent educated themselves enough to understand that the maintenance inhaler will keep the child’s symptoms under control.

NP asks the parents, “What made you think of discussing maintenance inhalers today?”

Parent: "We studied that if she uses maintenance inhalers every day, then we can avoid the chances of having asthma attacks. This will save us from having to go to the ER. Our insurance will not cover everything if we have to take her to the ER."

This is not easy either; they will be paying high deductibles and high insurance costs while still having to worry about every little healthcare service.

These are three scenarios that came to my mind. I have tons of examples that I can provide in each category. These examples are situational and not all Medicaid and non-Medicaid users fit into these scenarios.

Medicaid cuts affect not only people who need emergency care but also the vast majority of children, including those who require routine check-ups and immunizations. Mental health services for these children will also be neglected without Medicaid coverage. Millions of people truly rely on Medicaid coverage to receive healthcare. People who have complex health problems, people who are under long-term treatments; Medicaid plays a crucial role.

We must protect Medicaid and safeguard our children. Medicaid not only serves as a vital service but also keeps healthcare facilities running. It is the primary source of funding for these facilities.

On the other hand, while we have the privilege of Medicaid coverage, it has also been misused by many. Every single dollar spent on Medicaid services comes from the federal government and other sources. I am not here to blame any people, category, or entity, but when I see Medicaid being misused, it bothers me.

If the revenue intended for those who genuinely need Medicaid were used as intended, things would likely be different. If I am to rant on people misusing Medicaid, many people demand medications when it is not needed. People do not make efforts to take care of their health, and overuse medications and treatment facilities. How can we regulate this? Is there any way to monitor this? Who is responsible for addressing the misuse of this resource?

With this, I will leave my readers to interpret the current situation of Medicaid, what needs to be done, and what needs to be protected. Who needs it? And who doesn’t?

I will also invite healthcare leaders and Policymakers to brainstorm differently. Perhaps it is not the Medicaid cuts that are necessary, but rather a Medicaid Review Program or some limitation or capping that is needed.

I will greatly appreciate your thoughts and constructive feedback.