The number of Medicaid recipients in Nevada is at an all-time high thanks to the state’s decision to expand the program in 2014 under the Affordable Care Act.

But the future of that program, here in Nevada and across the country, hangs in the balance as President Donald Trump has vowed to repeal and replace the ACA, otherwise known as Obamacare. The truth is, no one has any idea what is going to happen with the ACA — whether it’ll be repealed, whether it’ll be replaced and, if so, with what.

That means at least for now state officials are continuing to operate and plan for the future under the current paradigm.

“We don’t know what the ACA repeal-reform-replace looks like,” said Dena Schmidt, deputy director at the Department of Health and Human Services, told the Assembly Committee on Health and Human Services today. “We know what we know right now, so we’re going with the information we have.”

Here’s a look at some of the details about Medicaid in Nevada that Schmidt and other state officials shared with the committee on Wednesday:

The state of Medicaid in Nevada post-ACA

The state’s budget for Medicaid in fiscal year 2016 was $3.4 billion. That included $1 billion for more than 200,000 newly-eligible childless adults, $850 million for more than 300,000 moms and children and nearly $750 million for roughly 70,000 aged, blind and disabled individuals.

The number of covered individuals in the state has doubled since Medicaid expansion was implemented in 2014, from 323,000 to 638,000. Gov. Brian Sandoval committed to expand Medicaid under the ACA in December 2012, and Medicaid expansion went into effect in Nevada in January 2014.

The uninsured rate in the state dropped from 22 percent in 2012 to 12 percent in 2015, though it still exceeds the 9 percent national average.

The state struggled with long wait times for Medicaid approval right after implementation, with average wait times at about 52 days. That’s down to about eight days now on average, said Naomi Lewis, deputy administrator of the Division of Welfare and Supportive Services.

The inclusion of childless adults under Medicaid expansion was responsible for the biggest jump in insured individuals.  The federal government covered 100 percent of Medicaid payments for those newly-eligible individuals in the 2014-16 fiscal years, dropping to 97.5 percent in fiscal year 2017 and 94.5 percent in fiscal year 2018. Federal funding for those individuals will continue to decline slightly each year until it reaches 90 percent in 2020, where it will remain.

But Marta Jensen, acting administrator for the Division of Health Care Financing and Policy, said that education generally about the ACA has led to an increase among all the groups they serve including their largest, moms and children.

“To me, that’s a good thing,” Jensen said. “More people are availing themselves of the health care coverage and getting their health care needs met.”

The significant problem for Nevada, she noted, is that while the number of covered individuals has doubled, the number of providers have not. The state started conducting listening sessions in January 2016 to figure out how to improve Medicaid in Nevada and hired a consultant to make a series of recommendations, which should be released by the end of the month.

“How do you feel about managed care? What about the services? It was pretty much a everyone come forward,” Jensen said of the listening sessions. “What we found from that is we got a lot of really good comments and a lot of concerns.”

In Nevada, Medicaid benefits are offered through two different systems, on a so-called fee-for-service basis or through managed care plans. The managed care plans are operated through traditional health insurers, currently Amerigroup and Health Plan of Nevada, and serve the 72 percent of Medicaid recipients who live in the state’s two urban counties, Clark and Washoe. The rural Medicaid recipients, the other 28 percent, are served by the fee-for-service framework, in which Medicaid providers charge specific state-set prices for individual services.

One of the steps to address this, Jensen said, is expanding the number of managed care plans from two to four, which will happen this summer. Other ameliorating measures include supporting telemedicine and telehealth programs and easing administrative burdens for doctors to register as Medicaid providers.

How Medicaid became what it is today

Medicaid was established in 1965 to provide health insurance to certain at-risk groups — including low-income children, their caretaker relatives, the elderly, blind and people with disabilities — under the Social Security Amendments of 1965, which also created Medicare.

The Omnibus Budget Reconciliation Act, passed in 1987, gave states the opportunity to extend coverage to pregnant women and infants whose family income sits at 185 percent of the federal poverty line. Two years later, another act required states to offer coverage to pregnant women and children up to six years old with family income below 133 percent of the federal poverty line.

The Affordable Care Act, passed in 2010, overhauled the nation’s health care system, expanding eligibility to adults with incomes up to 138 percent of the federal poverty level and extended funding for the Children’s Health Insurance Program (CHIP) through fiscal year 2015, and authorizes the program to continue through 2019. The majority of those who lacked coverage prior to the ACA passing were poor and low-income adults, according to the Kaiser Family Foundation.

In 2012, the Supreme Court ruled that the Affordable Care Act was constitutional, but made the Medicaid expansion portion optional on a state-by-state basis. As originally passed, the ACA would have stripped federal Medicaid dollars from states that refused to expand eligibility under the program.

Then, in 2012, Sandoval became the first Republican governor to commit to expand Medicaid under the ACA, and 19 states still have yet to expand the program.

Medicaid vs. Medicare vs. CHIP

Created by the same bill in 1965, Medicare is a single-payer, federally-administered health insurance program for Americans aged 65 and older while Medicaid, by contrast, is state-administered.

Those eligible for Medicaid nationwide include pregnant women, children under 19, the elderly over 65 and people who are blind, disabled or need nursing home care. By contrast, those eligible for Medicare include the elderly over 65, anyone who has kidney failure or long-term kidney disease and people who are currently disabled and cannot work.

There’s a small subset of individuals who are eligible for both programs — low-income individuals who are disabled and cannot work and the low-income elderly over 65.

Because Medicaid is a state-administered program, its implementation varies state by state and someone who is eligible for the program in one state may not be eligible in another.

There are certain groups states are mandated to cover under Medicaid, but states are also allowed the option to provide broader coverage. In Nevada, that includes childless adults, women with breast or cervical cancer who are under 200 percent of the federal poverty line, disabled children who require medical facility care but can be appropriately cared for at home and disabled individuals between 16 and 64 years old who want to work and earn income.

As the program currently stands in Nevada, children 6 to 18, childless adults 19 to 65 and parents/caretakers are eligible for Medicaid up to 138 percent of the federal poverty line, while infants up to age 5 and pregnant women are eligible up to 165 percent of the federal poverty line.

Like the eligibility requirements for Medicaid, there are certain essential health services that states must provide under Medicaid and others that are optional.

Required services include things like laboratory and x-ray services, physician visits and hospital care. In Nevada, optional services that are covered include diagnostic, screening and preventative services, prosthetic devices and eyeglasses and hospice services.

Meanwhile, Nevada’s CHIP program, called Nevada Check Up, covers children up to 200 percent of the federal poverty line if the child is not eligible for Medicaid and they are a U.S. citizen or legal resident.