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Could Medicaid for All Work as a Path to Universal Coverage?

A new study suggests that states already have broad legal authority to expand Medicaid access.
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What if the pathway to universal health care in America isn't Medicare for All—a catch-all phrase for a variety of bills that would enable anyone to buy into Medicare—but instead Medicaid for All? A new study by American University law professor Lindsay Wiley in the Ohio State Law Journal suggests that, under Medicaid statutes, states already have broad legal authority to expand access to the program as they see fit. It's possible for states to take action now, Wiley argues, though she notes that true universal coverage will depend on federal support.

Medicaid for All isn't a new idea. Senator Brian Schatz of Hawaii sponsored the State Public Option Act in 2017, which would have shifted Medicaid from a means-limited program to one that anyone could buy into. Lobbying for the bill in an op-ed, Schatz wrote:

Why Medicaid? Frankly, this program—already serving 69 million people—is underrated. It has a large provider network and the same positive ratings as private insurance but at a much lower cost to the government. Based on partnerships between state and federal governments, Medicaid also gives states the flexibility to adapt services and models of care based on their individual needs.

Medicaid for All has advanced to some degree in 10 different states since the start of the 2017 legislative session. It passed in Nevada, but then Republican Governor Brian Sandoval vetoed it. Colorado, Connecticut, Maine, Massachusetts, Minnesota, New Jersey, New Mexico, and Washington all have active legislation already proposed in the new year. The legislatures in a number of these states, plus Delaware, have already approved or likely will approve funds to produce feasibility studies, an important first step. For example, the Massachusetts "Report on the feasibility of establishing a small employer premium sharing plan for participation in the MassHealth program" argues:

A Medicaid buy-in program recognizes both the strength of the MassHealth program as well as the challenges faced by small businesses in purchasing and administering health benefits. However, its impact on the Massachusetts merged non-group and small group insurance market could have unintended consequences for payers, providers, and enrollees that warrant further study."

In other words, Massachusetts, like other states, sees the advantages of expanding Medicaid through a buy-in program but isn't sure how it would affect the insurance market overall.

Wiley's study assesses the legal powers and limitations guiding how and whether states can change eligibility for federal health-care programs. Over email, she argues that, while states can do a lot already, they "will need some support from an amenable federal executive to repurpose existing federal funds for a public option or single-payer plan." The federal government, for example, could simply "grant a state waiver through a process that's already built into the Medicaid statute and the [Affordable Care Act]. Most experts agree that these experiments aren't feasible without those federal funds."

Wiley says she'd like to see the federal government encourage state-by-state experimentation without threatening Medicaid's current role as the provider of long-term supports and services for disabled people. Indeed, disability rights leaders fought the GOP Congress in 2017 to stop them from gutting funding for Medicaid as part of ACA repeal for just this reason.

Wiley adds that she believes the general public "doesn't fully appreciate the expansive role private insurers already play in programs like Medicaid and Medicare." Sorting out their role in an expanded system requires making difficult choices. In a universal program, goals like "increased access to coverage and a choice of plans can be served by a 'privatized public option'—but others, like lower costs, probably wouldn't be."

On the other hand, Wiley says, if private insurers were limited to administering programs while letting state agencies set costs and handle reimbursements, the potential for lowering costs would be higher, "but would face stronger opposition from health-care providers." As Pacific Standard recently reported, private health-care interests are already trying to kill Medicare for All. It seems unlikely that they'd be any more open to Medicaid for All.