A lot of folks are talking about the need for a Medicare-for-All style health care reform in Maryland. I've said in the past that I support a Federal single-payer health care system. But I do not support such reform at the state level.
Trying to create a single-payer system at the state level is made problematic owing to the federal programs that exist. Those 65 and over, qualified disabled people under 65 years of age, and people with end-Stage Renal Disease are covered by Medicare and cannot opt out - so they would not be part of a state-based single-payer plan - that's 16% of the state. Then you have those in Medicaid or SCHIP (MCHP in Maryland) which is a Federal and State partnership with each covering part of the cost. The Federal government covers about half of the cost for those 900,000 folks, or about 15.5% of the population.
The Center for Medicare and Medicaid Services would need to approve any program that would opt Maryland out of the Medicaid program and the Federal government may decide to stop providing half the cost of coverage (billions of dollars) if Maryland opts out of Medicaid/SCHIP. About 6% of Maryland is covered by the ACA and receive subsidies from the Federal government. There's no way to know if the Federal government would pay subsidies once those folks moved to a state single-payer plan. The answer is likely "no" as there would suddenly be "affordable" insurance available to them.
So that's over 1/3 of the state covered by some form of public insurance that would require Federal permission to alter and that could result in billions of lost Federal money to Maryland. If, however, all of those folks remain outside the single-payer state program... well you don't actually have single-payer. Rather the single-player plan would focus on the remaining 2/3 of Marylanders.
Of those who remain, most (60% of state residents) get their insurance through their employers. So that network would be disrupted and there's no way to be certain that folks could keep their current doctors or provider network. But with that 60%, plus the 1/3 on Federal programs, we are now at about 92% of the state with health insurance coverage. Add military coverage and we're at 94% of Marylanders with insurance. Of the 6% who lack coverage, roughly 2/3 are eligible under the ACA but have not enrolled.
So 98% of Marylanders are either covered or are eligible for coverage. That leaves 2% who need to be reached. It seems a bit of stretch to suggest that Maryland should completely upend the insurance market, disrupt the coverage of millions, and risk losing billions in federal dollars all to reach that remaining 2%. And keep in mind that unlike the Federal government, a state cannot run a deficit. So if the single-payer program runs out of funding before the fiscal year ends... there's no money to pay for services. Which is why a single-payer system should be run at the Federal level and not the state level. In recent years, California and Vermont considered and ultimately abandoned plans to pursue state based universal coverage. The TennCare program in Tennessee offers a significant cautionary tale.
Maryland doesn't need revolutionary policy change. It doesn't need an overhaul of the state's entire health care system. It needs a pragmatic and reasonable approach to reach the 2% with no options while protecting and stabilizing markets for those with coverage. It needs the type of policy and bipartisan approach that recently secured a waiver to protect the state's individual market under the ACA. Maryland needs its famous middle temperament. Calling for revolutionary change may be a great way to rally voters, but it's not necessarily the most responsible way to govern a state or make policy.
Trying to create a single-payer system at the state level is made problematic owing to the federal programs that exist. Those 65 and over, qualified disabled people under 65 years of age, and people with end-Stage Renal Disease are covered by Medicare and cannot opt out - so they would not be part of a state-based single-payer plan - that's 16% of the state. Then you have those in Medicaid or SCHIP (MCHP in Maryland) which is a Federal and State partnership with each covering part of the cost. The Federal government covers about half of the cost for those 900,000 folks, or about 15.5% of the population.
The Center for Medicare and Medicaid Services would need to approve any program that would opt Maryland out of the Medicaid program and the Federal government may decide to stop providing half the cost of coverage (billions of dollars) if Maryland opts out of Medicaid/SCHIP. About 6% of Maryland is covered by the ACA and receive subsidies from the Federal government. There's no way to know if the Federal government would pay subsidies once those folks moved to a state single-payer plan. The answer is likely "no" as there would suddenly be "affordable" insurance available to them.
So that's over 1/3 of the state covered by some form of public insurance that would require Federal permission to alter and that could result in billions of lost Federal money to Maryland. If, however, all of those folks remain outside the single-payer state program... well you don't actually have single-payer. Rather the single-player plan would focus on the remaining 2/3 of Marylanders.
Of those who remain, most (60% of state residents) get their insurance through their employers. So that network would be disrupted and there's no way to be certain that folks could keep their current doctors or provider network. But with that 60%, plus the 1/3 on Federal programs, we are now at about 92% of the state with health insurance coverage. Add military coverage and we're at 94% of Marylanders with insurance. Of the 6% who lack coverage, roughly 2/3 are eligible under the ACA but have not enrolled.
So 98% of Marylanders are either covered or are eligible for coverage. That leaves 2% who need to be reached. It seems a bit of stretch to suggest that Maryland should completely upend the insurance market, disrupt the coverage of millions, and risk losing billions in federal dollars all to reach that remaining 2%. And keep in mind that unlike the Federal government, a state cannot run a deficit. So if the single-payer program runs out of funding before the fiscal year ends... there's no money to pay for services. Which is why a single-payer system should be run at the Federal level and not the state level. In recent years, California and Vermont considered and ultimately abandoned plans to pursue state based universal coverage. The TennCare program in Tennessee offers a significant cautionary tale.
Maryland doesn't need revolutionary policy change. It doesn't need an overhaul of the state's entire health care system. It needs a pragmatic and reasonable approach to reach the 2% with no options while protecting and stabilizing markets for those with coverage. It needs the type of policy and bipartisan approach that recently secured a waiver to protect the state's individual market under the ACA. Maryland needs its famous middle temperament. Calling for revolutionary change may be a great way to rally voters, but it's not necessarily the most responsible way to govern a state or make policy.
**For what it's worth. Before joining the faculty at St. Mary's College of Maryland I spent a decade in the world of health policy - specifically in the world of Medicare, Medicaid, and SCHIP policy. I was an analyst for the Hilltop Institute at UMBC and the main author of the annual HealthChoice Evaluation conducted for the Maryland Department of Health and Mental Hygiene. I evaluated public health care programs for Maryland and other states and consulted with states such as Georgia and New Mexico. My doctoral dissertation examined whether Maryland's Medicaid program reduced racial and ethnic disparities in the receipt of health care services. It won the 2006 Annual Dissertation Award from the Network of Schools of Public Policy, Affairs, and Administration. I spent two years developing fiscal notes for the Department of Health and Mental Hygiene. All of which is to say, I don't take discussion of health policy lightly.
