Progressives Tout 'Medicare-For-All' But States Eye 'Medicaid Buy-In'
February 26, 2019
Laura Lucero Y Ruiz De Gutierrez has a heart condition and fibromyalgia and is in danger of developing diabetes. She has health insurance through her husband's job. But, between the $800 monthly premium for the couple's coverage and the $2,100 deductible she has to pay down before insurance starts picking up the tab, she doesn't feel she can afford to go to the doctor when she needs to.
She hopes that may soon change. Identical bills proposed in recent weeks in the New Mexico House and Senate would make Gutierrez eligible to buy in to a public health plan modeled on Medicaid. She also could receive state-funded assistance that would save her hundreds of dollars a month on premiums.
As "Medicare-for-all" has become a rallying cry for progressive Democrats, New Mexico is one of several states looking at offering consumers a different government-sponsored plan to provide a more affordable health option. The proposals, often referred to as "Medicaid buy-in" plans, would typically offer benefits similar to what is available in Medicaid, the state-federal health plan for low-income people.
"Medicare-for-all is not going to happen legislatively in the next couple years. But in the meantime states are saying, ‘What about "Medicaid for more"?'" said Heather Howard, who directs Princeton University's state health and value strategies program and is working closely with some of the states.
A report commissioned by New Mexico projected that up to 16,000 people would enroll in a program like the one originally proposed in the bills, and their premiums would be 15 to 28 percent lower than plans sold on the individual market.
Gov. Michelle Lujan Grisham favors a Medicaid buy-in option. She doesn't have a position on the current bill, but she is following it closely, said Nora Sackett, the governor's deputy press secretary.
In addition to the governor's and lawmakers' interest, other stakeholders have been deeply involved, increasing the odds of success, Howard said.
Lawmakers in Colorado, Oregon, Washington and Minnesota are among others exploring similar options, said Howard. Nevada lawmakers passed a bill last year that would have set up a Medicaid buy-in plan, but the Republican governor vetoed it.
"The proposals take on different flavors depending on the state" and what officials are trying to accomplish, she said, whether it's increasing the number of people with insurance, making coverage more affordable or helping states avoid "bare" counties where no marketplace plans are offered.
States that want to offer a buy-in option might opt to try to expand Medicaid directly, or offer a plan that builds on but is not part of their Medicaid program, with similar benefits, providers and reimbursement rates. Or they may offer a public option insurance plan that isn't based on Medicaid. Depending on how they structure their plan, states may have to get approval from the federal government to move ahead.
A federal bill that would allow states to open up their Medicaid programs to all residents was reintroduced earlier in February by Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Luján (D-N.M.).
In New Mexico, the buy-in plan would be similar to the state's Medicaid program. It would be offered outside the exchange and would not require federal approval to implement. The state would provide financial assistance to help low-income people buy in to it.
New Mexico's bill would target individuals who aren't eligible for Medicaid or Medicare or those who can't get the Affordable Care Act's premium subsidies because their incomes are above 400 percent of the federal poverty level (about $50,000 for one person or $103,000 for a family of four). It also includes immigrants who are in the country without legal status.
The measure would also help people, like Gutierrez, who are vulnerable to the ACA's so-called family glitch. Her husband's $100 monthly premium for single coverage is considered affordable under the law because it costs less than 9.86 percent of their family income of about $46,000 a year. That makes her ineligible for premium subsidies on the exchange, even though the $800 premium for the two of them far exceeds that affordability percentage. Their three children already have Medicaid coverage.
"Right now, I pay to have the health care, but I can't afford to use it," said Gutierrez, 42.
The bill would provide premium and cost-sharing assistance for people with incomes less than 200 percent of the federal poverty level, or $60,340 for a family of five. The new coverage would take effect by January 2021.
Gutierrez, whose family lives in Albuquerque, would be eligible for financial assistance to help her buy in to the Medicaid option, while her husband stayed on his employer plan. Because their $46,000 annual income is just above 150 percent of the federal poverty level, her monthly premium would likely be about $160 per month for a comprehensive plan with a $150 deductible, according to estimates by Manatt Health, which did the original state analyses of buy-in options that were published before the bills were introduced in January.
New Mexico has high levels of poverty, and 40 percent of all New Mexico residents are already enrolled in the state Medicaid program, compared with about 23 percent nationwide.
"It's the cornerstone" of our health care system, said Colin Baillio, director of policy and communication at Health Action New Mexico, an advocacy group. The legislation would use "those levers that Medicaid has to provide comprehensive coverage and a comprehensive provider network."
The bills were passed by two legislative committees in mid-February, with instructions for further study to examine expanding the buy-in plan to more groups. They now move to two other legislative committees for consideration, Baillio said.
Hospitals and other health care providers would be reimbursed at Medicaid rates, which are lower than those for commercial plans. Still, to the extent that people who are uninsured enroll in the new plan, providers stand to gain financially.
"We're obviously very supportive of anything that expands coverage," said Jeff Dye, president of the New Mexico Hospital Association. "It's the issue of getting some payment versus no payment for services rendered."
If the Medicaid buy-in bill passes, Blanca Ivon Rodriguez and her husband, Hugo Montes, could have health insurance for the first time since they moved to New Mexico 14 years ago. The couple and their oldest son, now 18, are immigrants from Mexico who are in the state without proper legal status. Their two younger children, who were born in the United States, are enrolled in Medicaid.
Montes works as a plumber and Rodriguez is studying early childhood development at a community college near their home in Albuquerque. Because they're undocumented, they're not permitted to buy health insurance on the exchanges, even if they're willing to pay full price.
Like many people without insurance, they wait until they're really sick before seeking help. When Rodriguez developed pneumonia a few years ago, the waiting lists for an appointment at community clinics that would see her without insurance were long. Finally, when she could no longer breathe comfortably, she went to the emergency department.
"It would bring us peace of mind not having to worry about our health care situation," said Rodriguez, 41, through a translator.
Providing health care for residents who are undocumented is "an underlying issue with many states that are considering a Medicaid buy-in," said Chiquita Brooks-LaSure, managing director at Manatt Health, who co-authored the reports evaluating Medicaid buy-in options for New Mexico.
The New Mexico bill also would provide some relief for Leah Steimel's family. Neither she nor her husband has employer-sponsored coverage, and with family income of about $100,000 they don't qualify for ACA premium tax credits. They pay more than $1,900 a month for a silver-level plan with a $10,000 deductible to cover themselves and two of their kids (the third is over age 26).
Buying in to Medicaid would be tempting, said Steimel, 59, who works as a community health consultant with some of the groups advocating for the buy-in. Sure, she said, she wonders if the Medicaid plan would be as easy to use as a regular commercial plan and have access to as many providers.
"But being able to pay into something that would reduce by even a third what I'm paying now, I'd love that," she said.