In the midst of threats to the Affordable Care Act and pushes for more dramatic shifts to single-payer healthcare, some Democrats in Congress and state legislatures have begun proposing a different option: allowing people to buy into Medicaid. But not all those proposals would achieve their goals in the same way, argue Duke University researcher David Anderson, MSPPM, and Harvard University PhD student and former CMS spokesperson Emma Sandoe.

Writing in a blog for Health Affairs, Anderson and Sandoe said Medicaid buy-in proposals can be largely divided into two camps: those which would require a CMS waiver to create a new eligibility category in Medicaid and policies which would use the framework of managed care contracts to offer a “public option” on ACA exchanges.

Both methods share common goals, like offering a lower-cost option than the current plans on the exchanges, where premiums on popular silver-level plans jumped by an average of 34 percent for 2018 coverage. Pricing those plans would be a challenge, Anderson and Sandoe wrote, and create an unintended consequence for other ACA customers.

“The introduction of more low-price plans may reduce the benchmark plan price, which determines the amount of premium subsidies for those who are eligible,” they wrote. “A lower-cost benchmark would raise effective premiums for many subsidized buyers. This problem disappears if Medicaid buy-in is only offered on a nonsubsidized basis.”

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