Nevada Is Considering a Revolutionary Health-Care Experiment

By Ed Kilgore
New York, June 6, 2017

There’s a new idea percolating up in Nevada: letting anyone without health insurance buy into the state’s Medicaid program. This would include people who qualify for Obamacare tax credits, which could be used to pay for the buy-in; in effect, that would make Medicaid a public option — a phrase you might remember from Obamacare deliberations, when it was a Medicare buy-in — for individual insurance purchasers. Because of Medicaid’s low reimbursement rates for doctors and other health-care providers (significantly lower than Medicare), it should provide an economical alternative to private insurance, though at the cost of narrower provider options (a significant number of physicians do not accept Medicaid patients). Medicaid also has a broad range of benefits, with no co-pays or deductibles.

A bill to create this new Medicaid buy-in has cleared the legislature, and is awaiting action by Republican governor Brian Sandoval. It is unclear what he will do, though it is noteworthy that he has long been a staunch supporter of the expanded Medicaid program the Affordable Care Act created. Since the legislation leaves a lot of crucial details — e.g., the pricing of the buy-in and the possibility of cost-sharing measures like co-pays or deductibles — to future state regulation, Sandoval may be in a position to shape the proposal to his own liking. Nevada would also need to secure a waiver from the federal Department of Health and Human Services to implement the buy-in; initial indications are that the feds might not have a problem with it so long as it has no impact on federal Medicaid spending in Nevada.

In theory you might expect private insurers to fight a Medicaid buy-in tooth and nail, just as they successfully fought a public option, and also a Medicare buy-in (for people over 55), in the original Affordable Care Act debate. But the vast majority of current Nevada Medicaid beneficiaries are in managed-care plans operated under contract by private insurers, who might view a buy-in as simply a way to get a large number of new customers who might otherwise be uninsured.

It’s also worth noting that during the ACA debate both the Medicare buy-in idea and the more general concept of a public option were quite popular, especially among progressives. So it might also have some bipartisan support.

“Yale University’s Jacob Hacker argues that while this option might work in a single state, trying to use Medicaid as the model for a national public option would mean people in different states would get significantly different coverage.” (Vox, June 6)

http://nymag.com…

Nevada A.B. 374 – Requires the Department of Health and Human Services, if authorized by federal law, to establish a health care plan within Medicaid for purchase by persons who are not otherwise eligible for Medicaid:

https://www.leg.state.nv.us…

Many single payer supporters who have become impatient waiting for enactment of a single payer Medicare for all program are supporting the introduction of a public option – a Medicare-like plan that individuals not otherwise eligible for other programs could purchase. The Nevada legislature has moved forward with this concept by passing A.B. 374 which would allow a buy-in – not for Medicare but for the state Medicaid program instead.

This in no way should be considered to be a satisfactory substitute for a single payer system. All of the profound administrative excesses and inequities of our multi-payer system would remain in place. Funds authorized for this program would be only $89,000 for each of the first two years – for administrative expenses only – so premiums would have to cover all medical costs of the program (although the state would ask for waivers to allow the use of federal premium tax credits and cost sharing reductions that would be available to those who would otherwise qualify under the Affordable Care Act). Since many individuals would not be able to afford the premiums, a large number of Nevadans would remain uninsured.

Though this program does fall far short of what is needed, nevertheless any program that reduces physical suffering and financial hardship as an interim measure while we are working on our goal of health care justice for all should be supported. The primary caveat is that we cannot let it reduce in the least our efforts to enact a national single payer program – an improved Medicare for all.

(I contacted Gov. Brian Sandoval’s office and, as of 11:00 AM PDT today, June 8, S.B. 374 was still sitting on his desk without a signature.)