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.