Thursday, July 27, 2017

Managed Medicaid for all? A compendium

In an illuminating string about what she's learned from ACA enrollees, Sarah Kliff highlights a point that's come sharply into focus in the last year:
Medicaid is *way* more popular than marketplace plans. No deductibles or co-pays! (6/15)
This point has been driven home by enrollee surveys and focus groups as well as by good reporting from many, including Kliff. The negative counterpoint to Medicaid enrollees' satisfaction is Medicaid envy among those forced to pay more than they consider affordable in premiums and out-of-pocket costs -- particularly those on the wrong side of the ACA's deductible cliff.

In early 2016, a few facts about the ACA marketplace began coalescing in my mind: 1) many insurers struggling in the marketplace -- including the largest -- were doing very well in managed Medicaid and/or Medicare Advantage; 2) marketplace experience and satisfaction were deteriorating, as out-of-pocket costs rose and networks narrowed; and 3) Medicaid enrollees were more satisfied than marketplace enrollees. I began to think that the problem was not that the marketplaces lacked a strong public option, but that it lacked a core feature of managed Medicaid and Medicare Advantage: de facto rate-setting by government. Around this time I also learned that early iterations* of the public option concept envisioned the PO as an 800-pound gorilla that private insurers would kindly be allowed to compete with if they so desired.

I have therefore at various times made the case for a marketplace of "all-public" or public-private options modeled on managed Medicaid, or the Basic Health Programs established in New York and Minnesota that pay rates somewhat higher than Medicaid's. Since I've made the case piecemeal, I want to aggregate my posts on this, for myself if no one else. What I should do is get some scholarly help fleshing out/testing its premises. Anyway, here's the index.

What if all ACA options were public? 2/15/16
A more affordable Affordable Care Act?  2/23/16 (focused on BHPs as model/vehicle)
The public option is inside out  7/13/16
Replacing the ACA with "something terrific" 11/12/16
Medicaid is cheaper. Ergo... 5/2/17
A Sparer means to universal health insurance 5/18/17
An American road to single payer 6/17/17

If any reader wants to help me move this idea beyond reiteration -- or throw up caveats, cautions, debunks -- please let me know.

* These two links are pdf downloads that can be accessed by right-clicking and copy-pasting the links rather than simply clicking on them.

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