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

• Colorado
• Washington State

State based mandates

• New Jersey
• Massachusetts
• Vermont
• California
• Maryland

Downpayment Plans

• Maryland

Expanded Subsidies

• California

 

My strongest prior on public option/single-payer is that we need someone to be what Massachusetts was for the ACA—proof of concept. https://t.co/bmm8wlKdpt

— Adrianna McIntyre (@onceuponA) January 8, 2019

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.