What about Sen. Brian Schatz’s proposal for a Medicaid buy-in?

We asked 7 experts about Sen. Brian Schatz’s big new Medicaid buy-in plan

By Jeff Stein and Dylan Scott
Vox, August 23, 2017

In a recent interview, Sen. Brian Schatz (D-HI) laid out his plan to allow every American to buy into Medicaid if their state allows it. It could be a significant expansion of the program, at the least as a public option for Obamacare’s marketplace. At the most, it could set up a road that leads to Medicaid as the vehicle for single-payer health care.

But it also raises a bunch of questions, about both the plan’s ideological goals and its policy mechanics.

We asked seven health policy experts, in the middle and on the left and right, what they thought.

Adam Gaffney, Harvard University:

Though the Affordable Care Act has so far withstood the Trumpcare battering ram, 28 million remain uninsured in the United States, an entirely unacceptable state of affairs. Might a Medicaid-based "public option," as proposed by Sen. Brian Schatz (D-HI), be the answer?

Unfortunately, the bill would not rectify our nation's serious health care woes. While it could potentially expand coverage, its impact would probably be modest, or even marginal: After all, in 2013 the Congressional Budget Office scored a somewhat similar public option and found that it would have no significant impact on the number of the uninsured. Moreover, Schatz's bill would be optional for states and so would likely be declined by many, further limiting its impact. It is also probable that even with subsidies, some will find the premiums and deductibles of this plan unaffordable, as they have under the ACA.

Just as importantly, the bill would not solve the issues faced by Americans with insurance: narrow networks of doctors and hospitals, unaffordable drug prices, paltry access to dental and long-term care, and rising out-of-pocket costs (e.g., copayments and deductibles) that are squeezing household finances and creating an epidemic of "underinsurance" in America. And finally, it would not create the greater administrative efficiencies of a single-payer system, which by one estimate would be greater than $500 billion a year.

The only answer to those myriad issues is a universal single-payer "Medicare-for-all" system, which would ensure equitable access to comprehensive health for everyone in the nation. Medicare-for-all should thus remain the Democrats' central health care goal in the coming months and years.

Robert Frank, Cornell University:

Anything you can do in this direction is a step forward.

Larry Levitt, Kaiser Family Foundation:

I read this as basically a public option delivered through Medicaid.

Loren Adler, Brookings Institution:

To me, the fundamental question here is whether you intend to create a level playing field or not.

Matt Bruenig, People’s Policy Project:

Up to this point, the liberal establishment, including Barack Obama and [the] Center for American Progress, has only endorsed what I would call the Loser Public Option.

David Anderson, Duke University:

I need to see the details.

Avik Roy, Foundation for Research on Equal Opportunity:

It's completely unworkable.



By Don McCanne, M.D.

Sen. Brian Schatz (D-HI) is currently drafting legislation that would allow Americans to buy into the Medicaid program, supposedly providing them with a “public option” and perhaps a path toward a single payer system in the United States. Vox has published the responses of seven “experts.”

Comments varied from those who approve based on the fact that any incremental improvement should be supported, to those opposed primarily based on conservative ideology. Those responses are recorded above with cryptic excerpts.

The response of Adam Gaffney is reproduced in its entirety since it is exceptional in that it clarifies how far off topic the current debate on reform has become. We should be discussing reform that corrects the serious defects in our overpriced and underperforming health care system. Instead the conversation has turned to disturbingly inadequate proposals such as the public option or buying into a public program.

It is not that even minimally beneficial measures should be opposed, rather we should not be burning up our resources for advocacy on these lesser measures when a single payer national health program - an improved Medicare for all - is an absolute imperative that requires urgent action. The crime is that it has required urgent action for decades while we have diddled around with deficient measures that have unnecessarily perpetuated financial hardship, physical suffering and even death.

Suppose we pass a public option or a buy-in. Those in support will celebrate success and then walk away. But what about the promise that this would lead to single payer? “Are you kidding? I support single payer, but that’s not feasible. I’m tired of you Bernie people trying to tell us liberals what to do. Get lost!”

Well, we’re more than just the Bernie people. We are a majority of the nation. We did get lost when they gave us ACA, and that didn’t lead to single payer. We can’t make that mistake again.

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