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.

 



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.



Preparing for 2021

New Mexico is preparing for an ambitious future for health policy. Louise Norris notes that New Mexico is looking to move off of Healthcare.gov and open up their own state based exchange.

In order to reduce user fees, the exchange board considered the issue during a September 2018 board meeting, and voted unanimously to transition to a fully state-run exchange in time for the 2021 plan year.

The exchange will put out a request for proposals in early 2019, as they work to find a vendor to create their state-run enrollment platform. The system will be live by the fall of 2020, in time for the open enrollment period for 2021 coverage (November-December 2020).

There are two good reasons to go down this path. The first is the obvious one: it’s cheaper than using Healthcare.gov. Healthcare.gov charges 3.5% of premium as an Exchange fee for states that don’t do anything on their own, and a 3.0% of premium Exchange fee for states that manage significant elements of the enrollment process. New Mexico is one of the “partnership” states that uses the Healthcare.gov front-end but manages a lot of their own back-end. 3.0% of premium is not a good deal. The same fee level would either be used to fund significantly more outreach, advertising and navigators or the same level of outreach and support that Healthcare.gov provides could be funded at a much lower fee which would slightly reduce baseline premiums.

Secondly, New Mexico is getting ambitious. They are the leading innovators in doing the actual hard work of figuring out how a Medicaid buy-in proposal. This would be effectively a state based public option. This would be a major rejiggering of the New Mexico individual market.

The Center for Medicare and Medicaid Services (CMS) has repeatedly stated under both the Obama and the Trump administrations that they can’t do much with the back-end of Healthcare.gov to support unusual or aggressive waiver requests. If New Mexico moves towards a Medicaid buy-in model, their open enrollment, subsidy structure and eligibility structures would be unique. The only way that can work within an Exchange framework is if New Mexico can customize the exchange that their citizens and residents see.

So, this is both an effort to reduce premiums through either attracting a healthier risk pool or lower costs of attracting the current risk pool AND a necessary step in building the infrastructure to support a Medicaid buy-in program.



Purdue Pharma and the Justice Department Knew About Oxycontin in 2006

Purdue Pharma knew the dangers that Oxycontin presented, and so did the Justice Department, as early as 2006. But the George W. Bush Justice Department decided not to prosecute.

Based on their findings after a four-year investigation, [federal] prosecutors recommended that three top Purdue Pharma executives be indicted on felony charges, including conspiracy to defraud the United States, that could have sent the men to prison if convicted.

But top Justice Department officials in the George W. Bush administration did not support the move, said four lawyers who took part in those discussions or were briefed about them. Instead, the government settled the case in 2007.

Of course, current Purdue Pharma officials play down that something a decade ago could have anything to do with today’s opioid crisis.

“It would have been a turning point,” said Terrance Woodworth, a former Drug Enforcement Administration official who investigated Purdue Pharma in the early 2000s. “It would have sent a message to the entire drug industry.”

The Sackler family, who have endowed many museums, have been intimately involved in Purdue Pharma from the start. I’ll never feel the same about those museums.

A spokesman for Sackler family members involved with the company, Linden Zakula, declined to comment. Richard Sackler, who is now a director of Purdue Pharma, also declined to comment.

There were plenty of warnings. The article has much more detail – a long read. It’s the New York Times, but one of the places where they’ve done a good job.

And open thread!



The Mystery Man Revealed – And Open Thread

Quinta Jurecic and Ben Wittes have written their article on outing FBI informants, and several outlets have given the name of the probable informant.

I have the sense that I still don’t fully understand this situation, which I commonly get about revelations of the Trump campaign and its connections to various skeevy people. That is probably because there are more shoes to drop from this centipede, so I can’t fully understand the situation.

That Stefan Halper might be an informant has been publicly discussed since March. His positions and connections should have suggested that possibility to anyone who dealt with him before that. The Washington Post and New York Times articles of Friday night, together with material published earlier, lead to the conclusion that the person being discussed is Stefan Halper.

What Halper did was talk to George Papadopoulos and propose a project with him and also met with Carter Page and Sam Clovis in the summer of 2016. Earlier he met with Michael Flynn. Presumably this was because the FBI had information that Russians were communicating with these folks, and Halper was trying to get information about how that was going down.

The FBI could have sent agents openly to talk to those people, but they probably decided to take an indirect route because of the proximity of the election. Those FBI visits would have gotten out and caused some publicity. This is one of the asymmetries with how the Clinton emails were dealt with.

It would have been good practice for the Trumpies to have notified the FBI themselves when they were contacted by Russians, but, as we have seen in other cases, they did not once see fit to do this.

Since Halper already had a public profile and connections to intelligence agencies, it’s not clear to me why outing him seems to have been such a big deal to those agencies, who were reported to have been working for weeks to minimize the damage if he was outed. It’s possible that he was doing more than what is publicly available, and that those additional activities were much more sensitive.

Part of the concern is that if Congress is willing to reveal intelligence operatives for political reasons, it will be much more difficult to recruit sources and informants. And, of course, the President has now piled on.

It’s not at all clear why Devin Nunes, Trump, and others claim that knowing who this person is will undercut the Mueller investigation. They have claimed a connection between him and the Steele dossier, but, if anything, the information Halper obtained would have gone to the FBI before the dossier did. So, to the extent Halper’s material correlates with what’s in the dossier, it would be independent support.

It’s also not clear how all the information was leaked. Did the leaks start in March? Who are the sources for the Times and the Post stories? Will this be prosecuted the way Valerie Plame’s outing was?

The Jurecic – Wittes article is long and much more closely argued than what I’ve written. Very worth reading.