June 6, 2017


Nevada's legislature just passed a radical plan to let anybody sign up for Medicaid (Sarah Kliff, Jun 6, 2017, Vox)
Nevada, with little fanfare or notice, is inching toward a massive health insurance expansion -- one that would give the state's 2.8 million residents access to a public health insurance option.

The Nevada legislature passed a bill Friday that would allow anyone to buy into Medicaid, the public program that covers low-income Americans. It would be the first state to open the government-run program to all residents, regardless of their income or health status. [...]

Democrats explored the possibility of a Medicare buy-in during the health care debate in 2009 and 2010. The buy-in option was relatively narrow, only allowing Americans over 55 to participate in the program. Those under the age threshold would still be limited to private health insurance plans.

Early versions of the Affordable Care Act included the buy-in provision. But the Senate was forced to drop the Medicare buy-in from its bill when it couldn't get the entire caucus behind the idea. Health industries fought aggressively against the idea, which could disadvantage insurers by cutting into their market share.

In the wake of Trump's election, health policy experts have begun to explore whether it might make more sense to build a national health care system around Medicaid rather than Medicare.

"Medicaid is the better fit," Columbia University's Michael Sparer recently wrote at the New York Times. It has a more generous benefits package, is less costly and is developing more innovative care-management strategies. Moreover, the integration of the Obamacare exchanges into Medicaid would be relatively seamless: Many health plans are already in both markets.

Medicaid and Medicare are similar programs in that they are publicly run and large, covering 62 million and 43 million Americans, respectively. They can use their large membership to negotiate lower prices with hospitals and doctors. Medicaid tends to have the lowest payment rates. On average, Medicaid pays 66 percent of what Medicare pays doctors.

In Nevada, Medicaid pays 81 percent of Medicare rates.

This has the advantage of keeping Medicaid a relatively low-cost program per person -- but also the disadvantage of some doctors deciding not to accept Medicaid's lower rates. A recent federal survey estimates that 68.9 percent of doctors are accepting new Medicaid patients, compared to 84.7 percent accepting new patients with private insurance.

Still, Medicaid enrollees generally report being relatively happy with their coverage. They look nearly identical to people with employer-sponsored coverage in surveys about how well they think their health plan works.

States have significant sway over how their health insurance programs work and whom they cover. Thirty-two states, for example, have historically participated in a Medicaid buy-in program that lets certain disabled Americans who don't otherwise qualify for coverage pay to join the program.

States vary significantly in how much pregnant women can earn and still qualify for the program. Some states cover comprehensive dental benefits, while others cover nothing at all.

This variation is an opportunity for states that want to experiment with the public program by tacking on a buy-in option. If Nevada's bill does become law, it will show other states how such a program might work -- and if it works well, liberal states may be inclined to mimic the idea.

But the variation also makes it difficult to see Nevada serving as the start of a national public option. Yale University's Jacob Hacker argues that while this option might work in a single state, trying to use Medicaid as the model for a national public option would mean people in different states would get significantly different coverage.

"If the argument is this will be a foundation for coverage for everyone, I think that's questionable," he says. "It's going to be difficult to harmonize all the state efforts."

Republicans in Washington will eventually have to harmonize them, having offered no viable alterntives to Obamacare.

Posted by at June 6, 2017 3:33 PM