Medicaid covers very different people through different pathways, and a small group drives most of the spending. That imbalance shapes every value-based strategy.
Medicaid covers several distinct populations, each reaching the program through a different eligibility pathway, and each costing very different amounts. Understanding that split is the first step to understanding where value-based care can move the needle.
The main pathways
- Children are the largest group by headcount, covered through Medicaid and CHIP.
- Pregnant people qualify through pregnancy-related pathways.
- Adults include both parents and, in states that expanded, low-income adults up to 138 percent of the federal poverty level.
- People age 65 and older and people with disabilities qualify through age or disability pathways, and many also have Medicare.
Where the money goes
Enrollment and spending point in opposite directions. Children and adults dominate the headcount but cost relatively little per person. The aged and people with disabilities are the reverse: in FY 2022 they were about 20 percent of enrollees but about 51 percent of program spending.
| Group | Share of enrollees | Share of spending |
|---|---|---|
| Children and adults | ~80% | ~49% |
| Aged and people with disabilities | ~20% | ~51% |
Worth remembering: roughly a fifth of enrollees drive just over half the spending. That is the same “high-cost, high-need” concentration from the population-health module of the intro course, and it is where Medicaid value-based models focus their care management.
Dual eligibles
People enrolled in both Medicaid and Medicare, the dual eligibles, deserve special mention. They are disproportionately older, sicker, and poorer, and they sit at the seam between two programs that do not naturally coordinate. Medicare covers their acute care; Medicaid often covers their long-term services and supports. Getting the two programs to work together for this group is one of the hardest and highest-value problems in all of public coverage.
Key takeaways
- Medicaid covers children, pregnant people, adults, and the aged and disabled, each through a different pathway.
- Children and adults are most of the enrollment; the aged and disabled are most of the spending.
- Dual eligibles are a small, expensive, poorly coordinated group and a prime target for value-based design.
Sources
Check your understanding
People eligible on the basis of age (65+) or disability are what share of enrollment and spending?
In FY 2022 the aged and disabled were roughly a fifth of enrollees but just over half of program spending. That concentration is where value-based effort concentrates too.