It has barely been mentioned on the presidential campaign trail, but few government programs are more entwined in the lives of Americans than Medicaid. The program, whose costs are shared by the federal government and states, provides largely free health insurance to 73 million people — roughly 1 in 5 Americans — many of whom are pregnant, disabled, elderly or chronically ill. Most have limited income.
Enrollment has soared in the decade since states were given the option of expanding Medicaid under the Affordable Care Act to cover adults without young children. It is the among the largest programs in the federal budget, costing more than $600 billion a year.
Presidential elections inevitably bring questions about the future of such a sweeping program, especially if the candidates are pitching costly policies of their own. Former President Donald J. Trump has promised to protect Medicare and Social Security, while also expressing support for a wide variety of tax cuts. Some health policy experts believe that Medicaid would be in the cross hairs as a result.
In his first term, Mr. Trump sought to repeal the Affordable Care Act, including its Medicaid expansion. He encouraged states to require some enrollees to work. And he proposed overhauling how Medicaid is paid for, in a way that would have substantially squeezed it.
Project 2025 — a compilation of proposals written by the conservative Heritage Foundation as a policy agenda for the next Republican administration — calls for work requirements, spending caps, and time limits or lifetime caps on Medicaid benefits. Mr. Trump has repeatedly distanced himself from the plan, but many of its authors, including the one who wrote its health care proposals, served in his first administration.
Danielle Alvarez, a senior adviser for the Trump campaign, said in a statement that only Mr. Trump and his campaign — “not any other organization” — can speak to plans for a second term. Asked whether Mr. Trump would pursue changes to Medicaid, the campaign provided a list of broad goals related to health care, such as, “Restore the health care safety net by eliminating waste and fraud and refocusing taxpayer dollars on those most in need.”
Vice President Kamala Harris would likely maintain the status quo with Medicaid. In particular, Ms. Harris has promoted a new option that states can adopt, allowing all women who have Medicaid during their pregnancies to keep it for a year after they give birth.
Asked about her plans for Medicaid, a campaign spokeswoman pointed to comments Ms. Harris made at a recent event in Las Vegas: “I firmly and deeply believe that access to health care is a right and should be a right, and not just a privilege of those who can afford it.”
Polls have consistently found Medicaid to have strong bipartisan support from voters, many of whom have personal experience with the program either for their own care or that of a family member. Still, many people may not know the full scope of its reach.
Here are the stories of five Americans and the role Medicaid plays in their lives.
Los Angeles
Lahela Bautista, 28, is among hundreds of thousands of women for whom Medicaid has covered prenatal care and childbirth this year.
Lahela Bautista enrolled in California’s Medicaid program within days of learning she was pregnant with her first child last December. She was covered by her parents’ health insurance until she reached the age limit of 26.
Ms. Bautista developed high blood pressure early in her pregnancy and was surprised to learn Medicaid in California recently started covering doulas — coaches of sorts, who offer emotional and physical support to women before, during and after childbirth. A number of states have started covering doula care under Medicaid because of evidence that it might help keep women and babies healthier during pregnancy and the postpartum period.
Ms. Bautista’s doula, Sabrina Jimenez, met with her four times before she gave birth and six times after.
“Because of her, I was not scared at all,” Ms. Bautista said recently as she cradled her son, born in early August.
“You can’t separate your mind and your spirit from your body.” — Sabrina Jimenez, Ms. Bautista’s doula
Her experience has not been without frustration; finding a primary care doctor has proved challenging, she said.
She is an undecided voter, aiming to make up her mind in the coming days. Medicaid is temporary for her until she gets back to work as a driver on Hollywood movie sets, she said; the cost of groceries is more pressing.
“It’s time to do my research,” she said of the candidates.
Eau Claire, Wis.
Emilia Bertrand, 4, has learned to talk in nearly complete sentences with Medicaid covering a type of therapy for autism.
The first time that Savannah Bertrand voted for president, she was 21 and her choice was Mr. Trump. A driving reason was health care: Because her husband was insured through his job, she could not qualify for a subsidized Obamacare plan despite their modest income, a gap in the Affordable Care Act that has since been fixed.
Eight years later, Ms. Bertrand has two young children with fragile x syndrome and autism, relies on Medicaid for the many therapies they receive, and considers preserving access to the program a top priority in choosing a candidate.
Her daughter, Emilia, qualified for Medicaid’s home and community-based services because of her disability; she started a type of therapy called applied behavioral analysis when she was 2. Before going to therapy five days a week, Ms. Bertrand said, Emilia was nonverbal and frequently banged her head against a wall and threw herself to the ground.
Two years later, she is talking in nearly complete sentences and is harming herself far less often. She is also receiving speech therapy four times a week through the public prekindergarten she attends — another service paid for by Medicaid.
“My kids have put the fire in me to fight for the things they deserve.” — Savannah Bertrand
Both Emilia Bertrand, 4, and her brother, Max, 11, have fragile X syndrome and autism.
Emilia’s parents knew by the time she turned 2 that she needed specialized treatment. She was hitting her head against the wall, biting herself and struggling to control her body movements, they said.
Emilia receives therapy at DreamShip Center in Eau Claire, Wis., which carefully tracks her progress. She has gone from being nonverbal to being able to communicate with those around her.
Therapists rotate Emilia in and out of learning and play. One of the biggest challenges for children with autism is making transitions.
Making transitions from one activity to the next as smooth as possible reduces stress on Emilia and her family.
“There was a time when I couldn’t fall asleep,” said Savannah Bertrand, adding that she used to fear for Emilia’s safety.
The home and community-based services program remains particularly vulnerable to budget cuts because each state can decide whether to offer it and how much to spend. If the federal government makes cuts to Medicaid, optional programs could be first on the chopping block.
“My kids have put the fire in me to fight for the things they deserve,” Ms. Bertrand said. She said she will vote for Ms. Harris.
Carnes, Miss.
Nathan Evans, 19, became eligible for a sister program to Medicaid when he was diagnosed with Type 1 diabetes at 10, but he will lose the coverage in November.
This is a season of change for Nathan Evans. He started college, moving into a dorm room at Pearl River Community College in Poplarville, about a half-hour drive from his home. And as of Nov. 1, he will no longer be eligible for the Children’s Health Insurance Program, or CHIP, a sister program to Medicaid, after almost a decade.
For Mr. Evans, health insurance is not optional: He was diagnosed with Type 1 diabetes when he was 10 and needs to take insulin every day. As a child, he qualified for CHIP because his parents’ income was low enough — his father is a freelance event photographer, and his mother is disabled and stopped working after teaching for 20 years.
In states that have expanded Medicaid to cover low-income adults who do not have young children, many people aging out of CHIP, as Mr. Evans did when he turned 19 this month, can transition to Medicaid. But Mississippi is one of the 10 states that have not expanded the program.
Nathan Evans’s parents have been helping him manage his Type 1 diabetes since he was diagnosed at age 10.
A sister program to Medicaid has covered Nathan’s insulin, the pump that dispenses it and a continuous glucose monitoring device. ”All Type 1’s should be eligible for Medicaid — from newborns to 30 or 35,” Nathan said.
Nathan’s family is Southern Baptist and lives less than a mile from their church, where he leads the choir every Sunday.
Nathan is a student at Pearl River Community College, where he keeps a device in his dorm room that projects his glucose readings. His parents are able to monitor his data on their phones.
Nathan’s parents are helping him find new private health coverage now that he has aged out of the Children’s Health Insurance Program.
Until now, CHIP has covered the cost of his insulin, the pump that dispenses it and the device he wears to track his glucose levels around the clock.
Mr. Evans said he will vote for Mr. Trump, partly because he has heard the former president say that Ms. Harris wants to give “free health care” to undocumented immigrants. The Trump campaign repeated that claim in response to questions for this article.
In a Democratic primary debate in 2019, Ms. Harris raised her hand when the moderator asked candidates “if your government plan would provide coverage for undocumented immigrants.” But she was not pressed about details, including whether it would be free. She has not made such a proposal during her current campaign.
Mr. Evans’s father, Martin Evans, is shopping for a private insurance plan for him through the Obamacare marketplace. They do not know yet how much it will cost, though Nathan Evans will qualify for government subsidies that lower the price. The family is grateful for the option but disappointed that Medicaid is not an option.
“Wait until I’m stable in life and have a great job, and then cut me off,” he said. “All Type 1’s should be eligible for Medicaid — from newborns to 30 or 35.”
Washington, N.C.
Anthony Brooks, 59, is among half a million low-income residents in North Carolina who have enrolled in Medicaid since the state expanded the program in January.
Anthony Brooks had been working his entire adult life but was uninsured when he had a medical emergency one weekend in 2022. Doctors diagnosed congenital heart failure during a hospital stay.
Two years later, Mr. Brooks takes six prescription drugs daily and has two heart specialists monitoring him. He is able to see the specialists because in January, North Carolina expanded Medicaid to cover all low-income adults, including him.
As a working-age adult, Mr. Brooks is in a Medicaid population that could be particularly vulnerable to cuts or restrictions. The federal government pays 90 percent of the cost for covering the expansion population, and any reduction of that share would require states to either make up for it or tighten eligibility rules.
Anthony Brooks takes numerous prescription drugs daily for his congenital heart failure.
He had to stop working as a home health aide after his heart diagnosis, he said, and began collecting disability. “Homelessness was one step away,” he said.
He lives in a largely Republican county in Washington, N.C.
When he initially applied for Medicaid in 2022, before North Carolina expanded the program, he was denied coverage. “When you get a denial from Medicaid,” he said, “that is a nail in the coffin.”
Mr. Brooks frequently spends time with his friend Beulah Williams, 90, who is a Republican, despite their political differences.
Mr. Brooks says he will vote for Ms. Harris. He worries about the possibility of losing his coverage before he becomes eligible for Medicare.
“I feel comfortable because I have insurance, but that could change,” he said. “It is not written in stone.”
Crownpoint, N.M.
Because of his low income, Billy Martin, 96, qualifies for Medicaid to cover his Medicare premiums, keeping his out-of-pocket costs minimal.
At 96, Billy Martin, a member of the Navajo Nation, is among the oldest Americans covered by Medicaid.
Mr. Martin also has Medicare, the government health insurance for people 65 and older. But his income is low enough to qualify for both programs; Medicaid covers his Medicare premiums, keeping his out-of-pocket costs minimal.
Billy Martin’s family said he started to show signs of dementia after his wife died in 2019. His children now take care of him on the Navajo Nation land where he has lived for most of his life.
Priscilla Martin, Mr. Martin’s daughter, used her cellphone flashlight one night because her home’s electricity had been shut off. She is covered by Medicaid and travels to Albuquerque for monthly chemotherapy for cervical cancer.
Mr. Martin often retreats into a hogan, or traditional Navajo dwelling, that he built. When he was younger, he worked for a railroad and as a tribal police officer.
“Voting as a Navajo in Albuquerque, we are thinking about Social Security, food, rent, gas,” said Zakariah Martin, Mr. Martin’s grandson, who helps care for him. “Here, we are thinking about land, electricity, water, livestock.”
One of Mr. Martin’s dementia symptoms is wandering, and sometimes he does not know how to get back home. His family then searches for him with their car.
“If we are capable, we will take care of him,” said Shirley Martin, another of Mr. Martin’s daughters. “He took care of us.”
The extra coverage is a relief to Mr. Martin’s daughters, Shirley Martin, 62, and Priscilla Martin, 53. He has dementia and moved in with Priscilla after his wife died in 2019.
For now, his medical care consists of periodic visits to an Indian Health Service clinic to check on his high blood pressure. Medicaid is also covering chemotherapy for Priscilla Martin, who has cervical cancer and qualified for the program after she quit her job to take care of her parents.
Shirley Martin said that she and her extended family had been contemplating voting for Mr. Trump until they watched the presidential debate last month and thought Ms. Harris seemed more committed to protecting Social Security. Another factor was YouTube videos that she watched about Project 2025, which she said made her nervous.
“I think my family is leaning toward Kamala Harris,” Shirley Martin said. Next week, she added, she will take her father to vote early.
Alain Delaquérière contributed research.