States, policy innovation and proofs of concept

Many states are proposing a series of experiments with their health care markets that are aimed at expanding coverage, increasing actuarial value, and limiting provider payments.

Medicaid Buy-ins

  • New Mexico
  • Nevada

Public Options with Medicare-like rates

State based mandates

  • New Jersey
  • Massachusetts
  • Vermont
  • California
  • Maryland

Downpayment Plans

  • Maryland

Expanded Subsidies

  • California


I agree completely with Adrianna.

These states will provide evidence of what can work, what trade-offs are real versus illusive, what some of the unexpected interactions may be, and the challenges of figuring out how to cover more people for roughly the same cost.  The liberal  experience in health policy from 1994-2007 was a long consensus building session as to what could be done within self-identified political constraints and limitations.  Massachusetts with a large Democratic super-majority in both chambers of the legislature was the proof of concept of the three legged stool approach.  The three legged stool was a combination of guaranteed issued/community rated insurance that was backed by significant low-income subsidies to make the insurance affordable and a mandate to get and keep healthy people in the risk pool.  Medicaid was the base of the coverage expansion with the private market taking more of the load up the income scale.  The three major Democratic primary contenders in 2007 all bought into variants of this plan and the major veto players in the Democratic Senate caucus were also on board.

I think that the states are limited in what evidence they can provide on a pure single payer system.  They don’t have the counter-cyclical fiscal capacity nor the expectation of seeing waivers approved to unlock significant federal fund flows for that project.  However they can test the impact of expanding subsidies, offering government price leveraged plans and using Medicaid further up the income scale.  These are all needed and worthwhile policy experiments.


7 replies
  1. 1
    kindness says:

    I haven’t seen Gavin’s numbers. So I don’t know what to think of his plans. What I do know is that Aetna, Blue Cross, Health Net & Kaiser cover the majority of the state’s residents who aren’t straight MediCare/MediCal. The only way to fold those people in to a Single Payer is a Senior Advantage type of thing that they are currently doing with the Commercial companies and MediCare folk. The state does not have the means to administer it all, especially right away. And even if they did set one up, I’m not sure the administrative costs would be less that we pay for the Commercials to do a Senior Advantage thing. We’ll see.

  2. 2
    Betty Cracker says:

    Agree that states are limited in what they can demonstrate on the single payer side. I read somewhere — probably here — that the Canadian system started in a province and was eventually adopted nationwide. Is that true, and if so, does anyone have a link to a source with a credible account of how that happened? I haven’t found much online.

  3. 3
  4. 4
    Betty Cracker says:

    @David Anderson: Thank you!

  5. 5
    rikyrah says:

    Really interested in New Mexico and Nevada. Want to see how it works for them.

  6. 6
    daveNYC says:

    How much proof of concept is actually needed for a public option though? It’s basically government run health insurance, which kinda-sorta exists with Medicare/caid, and is something that other countries have successfully done. Starting up a health insurance company isn’t trivial, not at all, but I don’t think it’s something so far fetched that a state or city government needs to do it first to prove it’s possible.

  7. 7
    Mark says:

    You missed Oregon SB 1067, which limits hospital reimbursement to 200% of Medicare – for state sponsored insurance. That is to say, the Public Employee Benefits specifically…Supposed to go into effect 10/1/19.

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