Montana, Massachusetts and Medicaid Buy-in

Over at Health Affairs, Dan Polsky and his co-authors looked at the breadth of networks and availability of initial PCP appointments for Employer Sponsored Insurance (ESI), broad Exchange networks and Medicaid in ten states in 2016.  Their results are valuable and not surprising in general.  Network breadth and appointment availability roughly coincide with the rates paid by the different types of insurance.  ESI has the most, Exchange is in the middle  levels of network breadth and availability while Medicaid tends to be skimpiest.

However, their Exhibit 3 and 5 intrigued me for two states.

Montana’s Exchange network were statistically indistinguishable from the Medicaid networks.  Montana’s Exchange PCP appointment availability were indistinguishable from Medicaid PCP appointment availability.  Massachusetts saw its Exchange products have similar PCP appointment availability than its Medicaid networks.

Medicaid buy-in is gaining popularity as a discussion subject.  I know New Mexico is aggressively exploring the possibility and other states are thinking about it. Emma Sandoe and I wrote about the evaluation lenses states need to have for buy-in proposals.

One of the challenges with a Medicaid buy-in is that it usually involves trade-offs.  Premiums tend to be lower as doctors and hospitals get paid less.  Lower payments usually implies skinnier effective networks and longer wait times.

In this study, Montana is not facing strong trade-offs between its Exchange and Medicaid.  Massachusetts is facing a network breadth trade-off but not an appointment availability trade-off.  This makes Medicaid buy-in an easier lift in these two states.

I bounced this idea off of some Montana folks, and they told me that the current focus for the Big Sky State is on the re-authorization of Medicaid expansion in 2019.  After that, there may be political and intellectual space for more ambitious proposals.

If Medicaid buy-in proposals get off the ground, the easiest lift will be in states where the Medicaid versus Exchange trade-offs are minimal.  Montana and Massachusetts are two plausible candidates.