Could the Pathway to Repealing & Replacing the ACA Run through Medicaid? Yes.

Last week the Nevada State Legislature handed Governor Sandoval an opportunity to provide the U.S. Senate a template for modifying the Affordable Care Act.

The Nevada Legislature approved a bill and sent it to the Governor's desk that would allow any Nevadan to "buy in" to their state's Medicaid program.   If the Governor signs the bill (and if the Centers for Medicare and Medicaid Services - or CMS -  approves the plan) any Nevadan would be allowed to buy managed care health insurance through their state Medicaid program.  The bill would allow the purchase regardless of income. Nevada residents that qualify for their current Medicaid program would continue to receive services as-is.                  

The actual Bill is called Assembly Bill 374.  If it's signed, the new law would direct the Nevada Department of Health and Human Services to ask CMS for a Waiver allowing their Medicaid agency let Nevadans buy health insurance through their Medicaid managed care program.  If the law is signed by their Governor (and if the approach is approved by CMS) the Medicaid insurance would be available for purchase on the "Silver State Health Insurance Exchange".  The plan calls for folks who qualify for tax credits under the Affordable Care Act to be able to use their credits to help pay for the coverage. 

Nevadans would need to pay an annual premium "... representing 150% of the median expenditure paid on behalf of a Medicaid recipient during the immediately preceding fiscal year".   The coverage would be the same as the coverage for NV Medicaid recipients except it wouldn't cover emergency medical transportation (e.g. ambulance rides).  The measure is written to ensure that no federal funds would be used.

The plan has several advantages that cover many of the consensus areas that most Americans agree with... that folks should have access to reasonably priced health insurance regardless of whether or not they have a pre-existing condition. This relatively simple plan would accomplish that without a complicated overhaul of the healthcare system since all states have existing Medicaid programs. 

I often hear people arguing that a solution to the healthcare debate is to adopt a "Medicare for All" plan...  and I've wondered why there's never been much discussion of a Medicaid buy-in option.  It solves a lot of the issues that the exchanges struggle with because the risk pool is larger and the rate negotiation much bigger than in the individual market today.  That means lower costs and less volatility.

Arizona would be in a good position to lead the way with such a plan.  Our state Medicaid program (called AHCCCS) is widely recognized as an efficient and cost-effective model for providing Medicaid coverage. In addition, AHCCCS' legislation already provides the enabling statutory language to allow state employees to buy into Medicaid- so the buy-in concept isn't entirely foreign. 

To make it work, the actuarial rates would need to be calculated in order to set the premium levels for buying in to AHCCCS.  With ACA tax subsidies and cost sharing reductions, the out of pocket costs per person would be competitive or less expensive than plans currently offered in Arizona’s Marketplace, with less year-to-year volatility in pricing.

Sometimes solutions to complicated problems are staring you right in the face.