DOES 'MEDICAID FOR MORE' TRUMP 'MEDICARE FOR ALL'?

• Author: Kaelin, John
• Position: MEDICINE & HEALTH

DURING the summer of 2017, Nevada confronted the possibility that several rural counties might not have any health insurers offering coverage on the Patient Protection and Affordable Care Act's health insurance exchange. In response, the state legislature passed a bill to permit individuals not otherwise eligible for Medicaid to "buy into" that program. The bill also authorized the state to seek Federal approval for those eligible for PPACA's premium tax credits to use those credits to purchase insurance through the buy-in program.

As this process unfolded, one of the state's insurers stepped in to offer coverage in all of the counties, eliminating the original concern. With the immediate problem resolved and, in light of the precedent-setting implications of such a new extension of Medicaid, the governor vetoed the bill.

Yet, this Nevada episode is notable as it marks one of the first in a recent round of attempts to use Medicaid as a platform for coverage expansion. Since then, various proposals to broaden the scope of the Medicaid program to include individuals who are not otherwise eligible have emerged in about 15 states and in Congress. As advocates of coverage expansion look for opportunities, it stands to reason that many see the Medicaid program as a possible platform.

Medicaid has expanded incrementally over the years and it recently has shown itself once again to be scalable, with the PPACA expansion that has taken place in 32 states. With national enrollment of approximately 70,000,000, Medicaid is our largest health insurance program, covering one in five Americans. Michael Sparer, chair and professor in the Department of Health Policy and Management at Columbia University, has argued that, due to its flexibility, superior coverage characteristics, and more attractive cost structure, "Medicaid for More" trumps "Medicare for All" as a basis for coverage expansion.

For purposes of our discussion, a "Medicaid buy-in" is any initiative that uses part of the structure of the Medicaid program to open coverage, for a fee, to populations not usually eligible for Medicaid. A buy-in may involve the creation of a "public option," a publicly operated insurance plan offered to individuals as an alternative and as a competitor to private plans in PPACA exchanges.

Buy-in proposals may be designed to serve other functions and may take many forms. It should be noted that the idea of Medicaid as a platform is not completely new. Many states long have allowed certain populations--largely, but not exclusively, disabled adults and children--to buy into Medicaid. The incentive for allowing disabled populations to purchase Medicaid coverage would be to provide access to additional benefits not normally offered through private insurance and perhaps to improve the commercial risk pool by removing potentially costly enrollees.

County Medicaid plans have existed in a number of Western states for decades, and largely reflect the efforts of counties to address proactively their responsibility for health care for uninsured residents, which otherwise would take the form of uncompensated care. California and Texas long have had a number of county-financed Medicaid plans, and other areas such as Cook County, Ill., and New York City also have created plans.

The current round of buy-in ideas roughly can be divided into three groups, depending on the problem they are trying to solve. The most incremental seek to expand eligibility to certain populations. Buy-in proposals in the middle and largest category are designed with the goal of stabilizing the individual market that, depending on the state context, can take many...