States Seek to Improve Affordability, Expand Coverage with “Public Option” and Medicaid Buy-in Proposals

January 2020 | Authors: Corlette, S, Schwab, R, Giovannelli J, Curran, E.


Issue: The 2018 election brought with it new energy in statehouses and state legislatures to improve access to insurance coverage and fill gaps in current law. During the 2019 legislative sessions, at least ten states debated “public option” or “Medicaid buy-in” programs as mechanisms to expand coverage, lower premiums, and increase the number of plan options for consumers.

Goal: Assess states’ goals in pursuing public option or Medicaid buy-in programs, the variety of mechanisms proposed, and critical issues for state consideration, such as the impact of such programs on state finances, providers, and consumers of other sources of coverage, including ACA-compliant individual market and employer-group plans.Methods:Analysis of state legislation, laws, and published reports about public option or Medicaid-buy in proposals and structured interviews with state officials, legislators, and advocates in nine states.

Findings and Conclusions: Only one state – Washington – ultimately enacted a public option bill during the 2019 state legislative session. Five other states—Colorado, Maryland, Nevada, New Mexico, and Oregon—tasked agency officials or independent commissions to study and/or develop a Medicaid buy-in or public option program. These states share common goals, such as improving the affordability of insurance, reducing the uninsured, and offering consumers more plan choices. The states also share similar political and practical challenges to enacting and implementing a public option or buy-in proposal. These include stakeholder concerns and fiscal constraints, and considerations regarding the downstream impact on ACA marketplace and employer-sponsored coverage.