A Medicare buy-in? Harold Pollack discusses Clinton's trial balloon

Hillary Clinton recently made headlines by expressing openness to allowing not-quite-elderly Americans to buy into Medicare:

“I'm also in favor of what's called the public option, so that people can buy into Medicare at a certain age,” the Democratic presidential front-runner said during a roundtable with local residents at the Mug'N Muffin coffee shop. “Which will take a lot of pressure off the costs.”

That's...confusing, since the public option, as originally conceived and as debated when the Affordable Care Act was being drafted, was a publicly financed health plan that would be offered in the ACA marketplace to prospective enrollees of all ages, competing directly with private plans. It was connected to Medicare only insofar as "strong" versions mandated that the plan would pay healthcare providers at Medicare rates, which are generally lower than those paid by private insurers.

Clinton had previously expressed support for reviving that conventional public option proposal. Since doing so on a national level would require legislation, she also signaled that her administration would be receptive to helping states build their own public options, which they could do without legislation. "To make immediate progress toward that goal," the health reform page of her campaign website states, "Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice." That "flexibility" alludes to the ACA's innovation waivers, which enable states to propose alterations to the basic ACA architecture, subject to HHS approval.

In the conversation at the Mug'N Muffin (in Stone Ridge, Virginia) could Clinton have been suggesting a public option within the ACA marketplace available to older buyers only? Last November, progressive scholars Timothy Jost and Harold Pollack proposed such a program as a transitional step toward an early Medicare buy-in. Jost and Pollack did call their transitional program for older buyers a "public option,," and perhaps their language seeped into Clinton's healthcare brain. But a different account of Clinton's Mug'N Muffin conversation (from NPR) makes clear that she was proposing a straight Medicare buy-in:

"If you were able to let people 55 or 50 [years old] and up who are the biggest users of health care into the Medicare program — they would have to buy in, but they would be buying into such a big program that the costs would be more distributed," Clinton said.

I spoke to Pollack, a professor of social service administration at the University of Chicago and co-author of the ACA 2.0 proposal cited above, about why Clinton might float a Medicare buy-in for pre-seniors (perhaps with the type of 'public option' he proposed for that age group alone in the background) when she has already proposed a public option for all ages. He suggested that given the likely control of at least half of Congress by Republicans in 2017, the necessity of working on a state level, or on a demonstration program level, might be shaping Clinton's polymorphous approach.

"I do think there's a value in throwing a bunch of stuff against the wall," Pollack said. "I think there's two things going on. First, how can we facilitate what states can do, and Clinton's signalling that she's going to let states do a lot. And then there's what Congress is likely to do, and that depends on the balance of power.  There's a tension: You want to come out with things that are programmatically sensible, and hang together. At the same time, she's going to be president with a likely Republican House majority and it's not clear what's going to happen in the Senate. She can put down a marker for a programmatic agenda, while for many of these ideas I think she can say, "I'm totally receptive to a state doing this."

I would interject here that while a state could not initiate a true Medicare buy-in, it could propose a public option for older buyers only, via ACA innovation waiver. Pollack also pointed to the Center for Medicare and Medicaid Innovation (CMMI), a branch of the Center for Medicare and Medicaid Services created by the ACA, as a vehicle for demonstration projects.

Pollack noted that the environment in which healthcare is debated now is very different from that of the pre-ACA debate in 2006-8. At that time, "all the stakeholders were actually getting together knowing that reform was going to happen, or might happen. There's a different conversation now, and I'd love to see states that have the ability to do it, try things, and some of those things will succeed and some will fail. I'd like to see Republican governors try Republican things too, by the way. "

To some extent, that's already happening, Pollack suggested. "Bipartisan health policy right now is being made between the Obama administration and Republican governors. It's happening in Medicaid, and in pretty much everything that doesn't involve key ideological touchstones. There's plenty of Republican governors interested in different disability management strategies, options for special populations, stuff that is gloriously boring in terms of the overall political debate. I think that President Obama and President Clinton will continue that, which I think is great."

Pollack added that he personally  gets calls from Republicans "who say, you might not like what we're doing about poor people, but tell us about the implications for people living with disabilities. There's a lot of scope for experimentation and collaboration...I think that we have to be very pragmatic in this."

Stepping back, Pollack, made a broader case for incrementalism, experimentation and pragmatism. "Some people see health policy as a long struggle leading to some ultimate destination, whether it's all payer or some other objective. I don't see it that way. I see it as a series of problems we're trying to solve. and we don't necessarily know how to do it. We're trying to control costs, limit out of pocket payments, improve  the cost-effectiveness of care, and it's going to take a variety of approaches to get there."

There is no shortage of variety in Clinton's array of proposed patches to the ACA.

Related:
Clinton on public option
Clinton on capping insurance premiums for all Americans