Medicaid buy-in support

Friend of the blog, Emma Sandoe and other researchers in Boston, ran a poll on Medicare for All and Medicaid Buy-in programs.

The results are interesting on several metrics:

Medicare for All has about 36% support and 38% opposition. That is a steep hill to climb to build a majority coalition.

Medicaid Buy-in has a majority in at least tepid support and very little passionate opposition.

This is interesting on several levels.

The first is that Medicaid’s branding seems to be stronger than Medicare’s branding.

Secondly, Medicaid buy-in is much easier to implement in at least some states. Right now New Mexico is aggressively pursuing a buy-in investigation. I think Nevada may be tempted to go down that path. Implementation requires a state to be in favor of a buy-in program and a friendly reading of waiver authority from the Center for Medicare and Medicaid Services (CMS). That duality may not be satisifed at the moment but a friendly to this type of waiver CMS is an easier lift than a Medicare for All friendly trifecta.

Medicaid buy-in programs are envisioned as supplements or complements to the Exchange/Marketplace structure. Emma and I looked at the different evaluation questions that need to be asked about these programs last March in Health Affairs:

There are two different policies that can be described as Medicaid buy-in programs. The first would be creating a new eligibility category for direct purchase of Medicaid by individuals with all of the attendant rights, obligations, and services that flow through Medicaid. This version of Medicaid buy-in requires modifications to state plan amendments and likely will require an 1115 waiver. The other policy would be to use the framework of Medicaid managed care contracts and networks to create metal plans for purchase on the Marketplace. Policy makers must identify which type of Medicaid buy-in they intend to use to communicate clearly their goals and objectives. Below, we present the various goals that policy makers may seek to achieve with Medicaid buy-in programs and how these goals should be evaluated…

  • Improve Coverage For The Current Individual Market
  • Provide Options For People Living In Regions With Limited Choices Of Health Plans 
  • Improve The Viability Of The Private Insurance Marketplace
  • Reduce Premiums For Consumers In The Private Insurance Market
  • To Provide People With A Guarantee Of Coverage With State-Mandated Consumer Protections
  • Improve The Financial Viability And Contracting Power Of The Medicaid Agency

A well-designed Medicaid buy-in program won’t achieve all of these goals. It may only intend to achieve one or two of these goals.

I think that Medicaid buy-in is one area of promising state-level experimentation that has a reasonable chance of implementation before 2023. The fact that there is a broad base of support and little concentrated opposition merely increases the probability of state level experimentation. This is where the action will be over the next couple of years for states, politicians, and activists that want to continue to expand coverage.

18 replies
  1. 1
    Ryan says:

    One of the things I noticed was that opinions were much less polarized in the buy-in option, and that got me thinking into how the question was asked. How much of this, do you suppose, is the difference between Medicare and Medicaid, versus:

    a) a buy-in versus an expansion of coverage
    b) “Medicare for All” being explicitly mentioned by Sanders and other politicians, and thus some respondents already primed to support or oppose it on ideological grounds?

    If a Medicaid buy-in was a proposal pursued at the state level, I wonder if we’d see the polarization of that middle group of respondents like with the Medicare option.

  2. 2
    BobS says:

    As I suspected before I clicked on the link, existing Medicare recipients (fearing their ‘slice of the pie’ is going to shrink?) are more likely to be opposed to Medicare-for-All. Just as interesting (to me, at least), would be a breakdown of support/opposition by race and ethnicity. Like many of the problems we’re facing, it’s my guess that it’s old white people who stand in the way of solutions.

  3. 3
    Pamoya says:

    Here in Minnesota, our governor elect ran on a platform to allow buy in to Minnesota Care, the top tier of our two tiers of means tested state insurance. I’ll be interested to see what happens in January!

  4. 4
    daveNYC says:

    How exactly did Medicaid end up with better branding than Medicare?

    I assume that the ease of increasing a Medicaid buy-in is because it’s partially state-run?

  5. 5
    dr. bloor says:

    @Ryan: Good point, I suspect (b) has a lot to do with it, as “Medicaid’s” brand among the general public is not as prestigious as Medicare (i.e., Medicaid is for the poors).

    The cons have done a good job of linking “Medicare for All” to “Lefties Demanding Free Stuff.”

  6. 6
    Dr. Ronnie James, D.O. says:

    @daveNYC: @daveNYC: Medicaid also reimburses at lower rates than Medicare, so it should be cheaper to buy into. The problem is, when you buy into a plan, you buy into its network of providers, and Medicaid’s network is weaker/narrower than Medicare’s, because…it pays less.

  7. 7
    Dr. Ronnie James, D.O. says:

    @dr. bloor: What is Medicare now if not “free stuff for people who’ve survived to 65”? aka “single payer for seniors”…

  8. 8
    Mnemosyne says:

    I would also think that allowing people under 65 to buy in to Medicaid instead of Medicare would require a lot less tinkering since Medicaid is already set up for things like prenatal care and pediatrics that affect people under 65.

    Also IIRC, many of the studies of people who were able to get expanded Medicaid under PPACA showed that they had a high level of satisfaction because many of them had never had any health coverage before and even a limited network was better than zero coverage or bankruptcy.

  9. 9
    Victor Matheson says:

    I think I disagree about attributing this to branding. Here’s what I would assume.

    1. People think opening up these two systems is good for the people getting the new benefit but bad for the people already on the system as there are now more people on the system fighting for the scarce resources provided.

    2. Pretty much everyone already gets Medicare or thinks they will be getting Medicare at some point, so if (1) is true, Medicare for all helps “those people” but potentially makes my own Medicare benefits worse. Thus, I don’t favor Medicare for all.

    3. Not as many people are on Medicaid or believe that they will be on Medicaid at some point in the future, so if (1) is true, Medicaid for all helps “those people” but doesn’t affect my current or future insurance at all. Thus, I favor Medicaid expansion.

    I don’t know if this is right, but it strikes me as plausible.

  10. 10
    Yarrow says:

    I have some questions about how Medicaid works. If you’re old and you need Medicaid to cover the cost of your nursing home then you can’t have any assets. I’ve seen lots of articles and discussions in the eldercare world about trusts and transferring assets and so forth to deal with this requirement. How does it work for younger people? Do they have to sell everything? Can they have assets?

    Also, I saw someone talking about how if you go on Medicaid and then later you are making too much money to qualify for Medicaid that you at some point have to reimburse the government for the time you were on Medicaid. That seems wrong but there are so many things about our healthcare systems that are wrong and make no sense so I don’t know. I’d appreciate some clarification.

  11. 11
    dr. bloor says:


    Do they have to sell everything? Can they have assets?

    Quick primer:

  12. 12
    daveNYC says:

    @Mnemosyne: Medicare isn’t just for people over 65, so it already has the ability to pay for pre-natal care. Pediatrics might require tinkering due to the individual coverage nature of the program.

    The article does note that the specific phrase ‘medicaid buy in’ gets a more positive response from people, as does ‘medicare for all’. I suspect that the positive experiences from the PPACA drive the former and its use as a rallying cry on the progressive side driver the latter. Goosing those numbers shouldn’t be too difficult.

  13. 13
    Barbara says:

    Medicaid is a more rational health benefit plan. It doesn’t fragment coverage artificially between Part A (institutional) and Part B (everything except drugs you buy at retail) and Part D (outpatient drugs not administered in a physician’s office).

    Yes, Medicaid pays less. That could be rectified.

  14. 14
    TomatoQueen says:

    Medicare is for over 65 and the disabled on SSDI (wage credit based), but for the latter does not kick in until 24 months active eligibility for SSDI have passed. Medicaid is used as a stop-gap for those people in some states. Prenatal care on Medicare would be pretty rare (a cancer patient who is pregnant, maybe?), but not a usual coverage. Medicare is not set up for pediatrics at all and would require more than tinkering, especially as it is administered by SSA and we like to muddle things where we can (I work there). Medicaid could pay more in theory, but the egg in the equation is too few doctors accept it. I dream about a system where everybody is covered for everything alla time. I know, let’s invade the VA! Open up Tricare to civilians!

  15. 15
    Kelly says:

    Oregon Medicaid (Oregon Health Plan) is good insurance out here in the hinterlands. All the docs accept it perhaps due the high percentage of low income customers around here. We were on it 2014 and 2015 due to the structure of our retirement income those years. I loved the simplicity. We know a couple that had a baby in Oregon’s top neonatal ICU for it’s first week that were covered by OHP and everything was covered.

  16. 16
    Mnemosyne says:


    Good point. In rural areas where for-profit insurance companies are reluctant to sell policies, Medicaid would probably work well for most people since doctors out in the hinterlands are going to be more likely to accept Medicaid than a doctor in the city or suburbs who gets patients with better insurance.

    A persistent problem with PPACA has been rural coverage, so a Medicaid buy-in might be better for people in those areas.

  17. 17

    @Mnemosyne: Yep, I wrote about using Medicaid as an Exchange backstop in August 2017

  18. 18
    Matt McIrvin says:

    It also sounds like “blow up the existing system” vs. incremental change. People may just be risk-averse about the former.

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