Thursday, May 18, 2017

A Sparer means to universal health insurance

Last November Michael Sparer, chair of Columbia's Mailman School of Public Health, proposed that managed Medicaid programs be used as a fallback for regions of the country in which no insurer was participating in the ACA marketplace.  Today Sparer went one better and proposed, in a NYT op-ed, that managed Medicaid replace the ACA marketplace:
Some liberals have proposed using Medicare, the federal health care program for the elderly and disabled, as the basis for providing universal health insurance. But Medicaid is the better fit. It has a more generous benefits package, is less costly and is developing more innovative care-management strategies. Moreover, the integration of the Obamacare exchanges into Medicaid would be relatively seamless: Many health plans are already in both markets...

Moderates in both parties recognize that the chance of success for an insurance marketplace that serves only the self-employed, part-time workers and small businesses, as Obamacare does now, is small. So why not eliminate the insurance exchanges — enabling Mr. Trump to claim he “repealed” Obamacare — while allowing exchange beneficiaries to buy into Medicaid, using tax credits to pay the premiums. Recent surveys showing that Medicaid beneficiaries are generally satisfied with their coverage, more so than their exchange counterparts, makes the case even more persuasive.
Of course this excites me, since so far as I can tell the only person who has consistently suggested that managed Medicaid, or something close to it, is the best way to serve those currently dependent on the individual market I have argued that using a solo public option to push private insurers' costs down is pushing on a string; that marketplace enrollees have given ample testimony to Medicaid envy; that insurers are happier in markets in which government effectively sets rates (happier than in the individual market, at any rate); and that managed Medicaid is the only path to fulfilling Trump's healthcare promises (not that those promises are worth anything).

Sparer makes pretty much all these points, along with a defense of Medicaid's performance nationally which he portrays as uneven but broadly effective. To his argument I would add only that a kind of precedent and transitional object for extending Medicaid to higher income levels exists in the two Basic Health Programs formed or recast under the ACA -- MinnesotaCare (which long pre-existed the ACA) and NY's Essential Plan. In both cases, the participating insurers are pretty much the same group as participate in the ACA marketplace. I've looked at those plans in some detail here and here.

Serious consideration of Medicaid as a basis and model for an "all-public" -- or, as Sparer more accurately casts it, public-private -- marketplace is rare among progressive healthcare scholars. I find Sparer's advocacy encouraging.  May it impact the conversation as Democrats regroup and prepare for their next turn in power.


  1. Andrew
    The commentary elevates Medicaid widespread adoption to too lofty a perch. Of course its 25% cheaper. But it serves a demographic less discriminating; and encompasses a network of providers who by definition, will see folks at a marked discount and in settings far removed from what many folks expect.

    To advance with his plan, the major hurdle for states and feds will not be just logistical with switch flips. It's backfilling the reimbursement shortfalls to staff the networks. And once you speak in those terms, you are no longer talking Medicaid. It's the prices.

    If the response is, "folks, take it or leave it" and patients have no other options and providers have excess capacity to fill, okay. But the objections from industry and trade groups will be nuclear in force. Unless its incremental steps so the transmogrification won't be felt for years down the road, I dont see this happening. I don't think that's the timeline he has in mind.


  2. I think that Medicaid costs are on the way up to $6000 a person. Tax credits will not be enough to pay the whole premium. We fall back into the muck of individual enrollments and collections. Not the end of the world, of course.
    It is hard to see how a universal Medicaid will not contain some extra cost to states. The hard core anti ACA states are going to fight every nickel.

    Final small point -- of course the recipients like Medicaid. It's friggin' free.