That idea is gaining popularity among state lawmakers. Last year, a "Medicaid buy-in" or "Medicaid-for-all" bill made it as far as the governor's desk in Nevada. Gov. Brian Sandoval vetoed it, but it inspired similar efforts around the country.
Six states -- Iowa, Massachusetts, Minnesota, Missouri, New Jersey and Washington state -- have active legislation to establish a Medicaid buy-in program. In four others, bills were proposed but stalled. New Mexico has set up a task force to study a Medicaid buy-in program, and Connecticut may do the same.
The premise of these buy-in bills is like Nevada’s: Medicaid plans would be offered on each state's insurance marketplace, and people who don't traditionally qualify for Medicaid could pay premiums and co-pays. In Missouri, though, the Medicaid buy-in plans would only be expanded to people who have a disability and are employed.
According to experts, each state likely has a different reason for considering this option.
"States are still exploring what it would even mean," says Heather Howard, director of State Health and Value Strategies. “For one state, it could be about addressing a bare county. For another, it could be an affordability issue. For another, it could be about expanding competition. In the absence of federal legislation on health care, states are asking: 'What tools do we have?'"
For left-leaning lawmakers, Medicaid buy-in is considered a step toward single-payer health insurance. But conservatives are wary of expanding the government's role in health care and of funneling more money into Medicaid, which is already a huge slice of state budgets.
New Mexico state Sen. Jerry Ortiz y Pino -- who co-sponsored a bill to study the issue -- says Medicaid buy-in makes sense there because the majority of residents (54 percent) already have Medicaid or Medicare. It’s the only state where more than half the population uses government health care.
"Besides Medicaid, we have a high Medicare population, high VA [Veterans Affairs] population and high numbers in the Indian Health Service," says Ortiz y Pino. "So when we talk about non-governmental insurance, it’s a small number. That small population means it's hard to attract private insurers, particularly in the marketplace."
New Mexico's marketplace has four insurers covering the state, which is actually more than many part of the country. About half of Americans only had one or two insurers last open enrollment season. Still, like most other states, New Mexico's marketplace is facing increased premiums and possible insurer dropouts this year.
Despite the spike in interest, Medicaid buy-in is unlikely to be implemented -- or even passed -- in any state this year. The bills that still have a chance have barely moved. There’s even hesitation in blue states -- like Maryland, which killed buy-in bills this year. As health care uncertainty on the federal level continues -- Congress reportedly may try again this year to repeal the Affordable Care Act -- some think it's too risky of a proposition to take on right now. And it’s unlikely the Trump administration would agree to pay for additional costs of a buy-in, putting any new financial burden squarely on states.
“It’s hard to say if it’ll catch on. It’s a crystal ball question. But I will say that states are interested. We had a session at the end of our conference about Medicaid buy-in, and it was packed,” says Anita Cardwell, a policy associate with the National Academy for State Health Policy.
If New Mexico does move forward with a buy-in option, it wouldn’t be the most generous of plans, says Ortiz y Pino. He expects they would offer all that's required, like mental health and maternity care, but that the plans would be more like “Medicaid lite."
"It would cover the basics. I don’t think we could have long-term care, for instance. But I do think we could put together a nice package of benefits,” he says.
New Mexico’s study is expected to be complete by Thanksgiving. Depending on the results, Ortiz y Pino hopes the legislature can file an official Medicaid buy-in bill in early 2019.
“This is our shot at this," he says. "If the numbers look right, of course."
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