Navigating federal health policy and the conversations about it can sometimes feel challenging because of the many different programs being discussed. If you sometimes feel lost about who is covered and how it works, this guide is for you: a primer about Medicare, Medicaid, and other programs and legislation relevant to the health care debate.
MEDICARE
In a nutshell: Medicare is a federal health insurance program for people age 65 and older. It also covers some younger individuals who have a long-term disability. As a government program, Medicare usually costs less than private insurance, but it’s not free. Beneficiaries still pay premiums, deductibles, and co-insurance based on their work history, income, and chosen coverage. It is also funded through federal contributions and a mix of payroll and Social Security taxes. Medicare was established in 1965 during the Lyndon B. Johnson administration and expanded in 1972.
Medicare has four parts — A, B, C, and D. Parts A and B are sometimes referred to as “original Medicare” and provide coverage for hospitalization (Part A) and outpatient doctor visits (Part B). The average monthly premium for Parts A and B is around $185, though actual costs vary, much like private insurance plans.
Part C (Medicare Advantage) and Part D (Prescription Drug Plans) provide additional coverage, at an additional cost to the insured. These plans are offered by private insurers but regulated by the federal government. More than half of eligible Medicare recipients are enrolled in an Advantage plan.
In 2024, Medicare made up about 13% of the federal budget.
Historically, lawfully present immigrants could qualify for Medicare if they met the same eligibility criteria as US citizens — being 65 or older or disabled, and having a work history that included paying Medicare taxes. In 2025, Congress passed a law that will limit Medicare eligibility starting in January 2027 to US citizens and green card holders only, even if other lawful residents have been working and paying Medicare taxes. Medicare is not available to undocumented immigrants.
MEDICAID
In a nutshell: Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families who can’t afford private insurance. It also helps many seniors by covering nursing home and in-home care costs and by helping pay for out-of-pocket Medicare expenses that Medicare alone does not cover. Medicaid was created alongside Medicare in 1965 and has been updated over time.
To receive federal funding, states must meet certain basic requirements set by Congress, but they can design and manage their programs differently.
Children in foster care and people who receive Supplemental Security Income (SSI), automatically qualify for Medicaid. (SSI is a program for low income individuals who are over 65 or disabled; it provides a variable amount of support to cover necessities like food and housing. Individuals who already receive SSI also qualify for Medicaid.) Other recipients must be in a covered category (e.g., pregnant, disabled, or over 65) and also meet income limits. Undocumented immigrants are not eligible, and lawful immigrants must observe waiting periods and meet other requirements before qualifying for Medicaid.
Income tests for eligibility usually rely on some percentage of the federal poverty level (FPL).
Example: a pregnant woman with an income below 133% of the FPL qualifies for Medicaid. In 2024, the poverty line for a single person was $15,060, so pregnancy and an annual income less than around $20,000 could qualify for coverage.
Some data about Medicaid:
About 20% of Medicare beneficiaries also rely on Medicaid.
About 21% of Americans are covered by Medicaid, though rates vary by state — some states are below 15% and others are above 25%. Many of the recipients are children, individuals with disabilities, and nursing home residents. Even though they are only about one-quarter of the enrollees, the elderly and disabled account for about half of Medicaid spending because their needs are more complicated and expensive.
Medicaid pays for 61% of all long-term care in the US.
EMTALA: Emergency Medical Treatment and Active Labor Act
In a nutshell: EMTALA is a federal law passed in 1986 that requires any hospital with an emergency department that accepts Medicare to treat and stabilize any patient with an emergency medical condition, regardless of their ability to pay. Hospitals must screen and stabilize patients before transferring or discharging them.
Notably, EMTALA does not require emergency rooms to provide any and all care to patients. It requires that they screen patients to determine whether they have an “emergency medical condition” and provide care required to “stabilize” the patient before they are released or transferred elsewhere. The definition of “emergency medical condition” includes those that place an individual’s life in serious jeopardy or will result in serious impairment/dysfunction of bodily functions or organs.
Of course, being entitled to receive life-saving care is not the same as receiving it for free. EMTALA dictates that patients receive that care regardless of whether they have insurance or the means to pay. It does not mean that the care is free. The hospital will still bill the patient for any care. If a patient does not pay the bill, it will likely end up in the collections process.
Hospitals cannot delay treatment to check citizenship or immigration status. All patients are entitled to emergency lifesaving care under EMTALA. Patients who are denied emergency care can also sue the hospital under EMTALA to recover damages if they are further harmed by being turned away. However, the courts have made clear that EMTALA is not the same as medical malpractice law.
The Department of Health and Human Services (HHS) enforces EMTALA. It can investigate complaints, fine hospitals for violations, require corrective actions, or even exclude repeat violators from Medicare funding.
Because EMTALA applies to pregnancy-related emergencies, it has been at the center of legal disputes since the Supreme Court overturned the constitutional right to abortion in Dobbs v. Jackson Women’s Health Organization in 2022. After Dobbs, HHS clarified that because of EMTALA, hospitals must still provide emergency care for conditions such as ectopic pregnancies or severe preeclampsia, even in states with abortion bans. In 2025, the Trump administration rolled back some of that guidance, leaving it to state abortion law to determine the required care.
Courts have issued mixed rulings on how EMTALA interacts with laws like those in Idaho and Texas that significantly restrict abortion, even in some medical emergencies. In Texas v. Becerra, the Fifth Circuit Court of Appeals ruled that EMTALA did not require Texas hospitals to provide emergency abortions. In Idaho v. United States, a federal court blocked Idaho’s abortion ban in instances where it conflicted with EMTALA. Procedurally, however, that case, which was begun in 2022 under the Biden administration, required additional action from the United States Department of Justice. The Trump administration dismissed its challenge to the law and the case is no longer active.
HIPAA: Health Insurance Portability and Accountability Act
In a nutshell: HIPAA was passed in 1996 to protect patient privacy. It sets limits on the information that health care providers and insurance companies may share without patient authorization. It also requires that patients be kept informed about how their medical information is being used. The Office for Civil Rights division of the Department of Health and Human Services oversees HIPAA enforcement.
One of the primary requirements of HIPAA is that patients receive detailed notices about the use and sharing of their “protected health information” (PHI). PHI covers any information about an individual’s physical or mental health, medical treatment, or payment for medical treatment. That includes things like test results, diagnoses, prescriptions, and insurance information.
Under HIPAA, medical providers and insurers may share PHI without patient consent only for the narrow purpose of providing medical treatment. For example, a doctor may freely share patient information with a laboratory running a test on the patient. The doctor may also share treatment information with the patient’s insurance company for billing purposes. But neither the doctor, the lab, nor the insurance company may sell or give the patient’s PHI to a third party for reasons unrelated to treatment unless the patient authorizes this. For instance, a doctor may not give the name of a pregnant woman to a baby formula company, or information about someone’s diagnosis to a drugmaker, for marketing purposes.
Medical professionals are allowed under HIPAA to share “de-identified” health information for research or in making public health announcements, but this information cannot include anything that would allow someone to connect it with a particular patient. A hospital could say during a measles outbreak how many cases it had treated, for example, but could not say who the patients were.
HIPAA does not prohibit non-medical organizations from requesting information about someone’s health as a condition of participation in events. A conference may require a Covid test of those attending its meetings, and a sports league may ask that players in a tournament provide documentation that they’ve received a physical. The patient is then able to choose whether they wish to share this information, because it is their own data.
HIPAA establishes security standards for the protection of patient information — whether that information is housed physically, electronically, or both — and requires that patients be given access to their records upon request.
HIPAA also does a couple of things unrelated to privacy and medical records. It allows people to sign up for health care plans outside of the standard enrollment periods if they lose their coverage (e.g., because of unemployment) or go through a qualifying event such as marriage, adoption, or the birth of a child. And it puts limits on insurers’ and employers’ ability to discriminate against individuals with preexisting health conditions — protections later strengthened by the Affordable Care Act.