Public Options: Big Things Are Happening in New Mexico & Minnesota!

Things have been happening so quickly of late that I'm getting farther and farther behind on some important healthcare policy developments, particularly at the state level. There are two extremely important Public Option announcements which could be game changers if they make it through the legislative process.

Since I don't have time to do full write-ups on either one right now, I'll just present these summaries:

My friend and colleague Colin Baillio, policy director of Health Action New Mexico, has been working on this for a long time, and it looks like this project has finally entered the legislative stage:


Today, Assistant Speaker Ben Ray Luján (NM-03) released the following statement on the introduction of HB 416 in New Mexico, which calls on the Health and Human Services Department to create a Medicaid Buy-In program that would be ready for customers in 2021. Congressman Luján introduced federal Medicaid Buy-In legislation, The State Public Option Act, on the federal level with Senator Brian Schatz (D-HI) last year, and plans to do so again this Congress. The bicameral legislation would allow states to create a Medicaid Buy-In program for all their residents regardless of income, giving everyone the option to buy into a state-driven Medicaid health insurance plan.

“Congratulations to all of the advocates, subject matter experts, and State Legislators for the introduction of The Medicaid Buy-In Act,” said Luján. “HB416 is not only good for New Mexico, it raises the bar for the rest of the country. Introducing an option for individuals and families to purchase Medicaid will increase competition, give consumers choices, and provide an affordable coverage option for people struggling to pay premiums. We’re one step closer to ensuring all New Mexicans have access to health care. I look forward to seeing this legislation signed into law in New Mexico, and introducing a version of it on the federal level later this year.”

Here's the actual legislative text of HB 416. Interestingly, the whole thing is only twelve pages long, which is a testament to one of the major benefits of going this route: It's simply opening up an existing, well-established program to other people. I'll be publishing a more detailed write-up next week, but the bottom line is that the NM Medicaid Buy-In Act would allow any New Mexico resident to enroll in the state's Medicaid program who isn't currently eligible for Medicaid, Medicare, ACA subsidies and who isn't enrolled in Employer coverage.

For the most part, it's targeted (for now) towards those earning over 400% FPL, although the next provision states that it can be expanded to other groups in the future. I don't see any hard numbers for premiums, deductibles or co-pays; the text just states that the HHS Dept. shall "establish an affordability scale". According to Baillio, premiums would be around 25% lower than comparable ACA exchange individual market policy premiums. Here's a link to the Quantatitive Evaluation of the proposed bill.

Thanks to last November's election results, Democrats now have a trifecta control of the New Mexico government, so things are looking pretty good for HB416 at the moment.

Meanwhile, in Minnesota, after similar debate within the state legislature, a different type of Public Option legislation has been introduced by state Senator Matt Klein:

Package of MinnesotaCare Buy-In Legislation Introduced

St. Paul, Minn. – A package of bills expanding access to affordable, high-quality health care for all Minnesotans were introduced by Senator Matt Klein (DFL – South St. Paul) on Thursday. The bills would allow different options to buy into MinnesotaCare, which currently helps over 90,000 Minnesotans receive high-quality health care.

“We must make expanding access to affordable, high-quality health care a top priority in 2019, and this legislation will move us forward,” said Senator Klein. “Across the state of Minnesota, high-quality health care remains out of reach for too many people, putting their health and well-being at risk. MinnesotaCare provides a critical lifeline for over 90,000 Minnesotans already, and it’s time we make it an option for everyone.”

The three bills that were introduced provide different buy-in options for MinnesotaCare:

  • SF 684: Allowing MinnesotaCare buy-in for Minnesotans who live in a county where only one plan is available.
  • SF 719: Allowing MinnesotaCare buy-in for Minnesotans across the state regardless of available plans or income level.
  • SF 720: Allowing MinnesotaCare buy-in for Minnesotans who are not currently eligible for federal tax credits on the exchange.

While two of the three bills would require a federal waiver for approval, SF 720 (allowing a buy-in for those ineligible for tax credits) does not, and would provide immediate relief for those individuals who make too much to currently qualify for MinnesotaCare. Together, the legislation would expand health care options for thousands across the state and enjoys public support of 70% of Minnesotans according to recent polling.

This is excellent news, and introducing all three variants at once is an interesting move. By presenting all three options, it immediately positions the third bill as the most reasonable/practical, since a) it doesn't require any federal approval and b) it addresses the most pressing problem (>400% FPL enrollees) right away.

Unlike New Mexico, while Democrats do hold the MN Governor's office and state House, Republicans still hold a small majority in the state Senate, so this is likely a longer shot...but could still be doable.

Here's the legislative text's even shorter than the New Mexico Medicaid Buy-In bill, just three pages:

A bill for an act relating to health care; creating a MinnesotaCare Buy-In Option for individuals with income greater than 400 percent of the federal poverty guidelines; proposing coding for new law in Minnesota Statutes, chapter 256L.



Subdivision 1. Request for federal authority. (a) The commissioner of human services shall seek all necessary federal waivers to establish the MinnesotaCare Buy-In Option under this section.

Hmmm...I think I'm missing something here; this (along with some additional language later in the bill) certainly seems to say it would require federal approval.

(b) The commissioner shall also seek all necessary federal waivers to:

(1) offer the MinnesotaCare Buy-In Option through the MNsure website as a coverage option and to be compared with qualified health plans offered through the MNsure website; and

(2) maintain MinnesotaCare program requirements and funding mechanisms that provide coverage to persons eligible under section 256L.04.

(c) The commissioner is exempt from the requirements in chapter 16C to contract for actuarial services that satisfy the waiver submission requirements under this subdivision. The commissioner may utilize existing contracts to satisfy the waiver submission requirements of this subdivision.

Subd. 2. Administration. (a) The commissioner shall:

(1) coordinate administration of the MinnesotaCare Buy-In Option with the MinnesotaCare program, as described in section 256L.04, to maximize efficiency and improve continuity of care for enrollees;

(2) implement mechanisms to ensure the long-term financial sustainability of MinnesotaCare and mitigate any adverse financial impacts to the state and MNsure and mitigate any adverse financial impacts to the individual and group insurance markets. These 2.7 mechanisms must minimize adverse selection, state financial risk and contribution, and negative impacts to premiums in the individual and group health insurance markets; and

(3) establish a cost allocation methodology to reimburse MNsure operations in lieu of the premium withhold for qualified health plans under section 62V.05.

(b) An individual who is determined eligible for enrollment in a qualified health plan according to Code of Federal Regulations, title 45, section 155.305, paragraph (a), and whose income is greater than 400 percent of the federal poverty guidelines is eligible to purchase and enroll in a MinnesotaCare Buy-In Option health plan.

(c) The MinnesotaCare Buy-In Option shall be considered the MinnesotaCare program for purposes of the requirementsfor health maintenance organizations undersection 62D.04, subdivision 5, and providers under section 256B.0644.

(d) The commissioner has the authority to accept and expend all enrollee premiums and federal funds made available under this section upon federal approval.

Subd. 3. Establishment of health plans. (a) The commissioner shall establish two MinnesotaCare Buy-In Option health plans: one health plan shall provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the health plan, and one health plan shall provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the health plan. The benefits of the health plans shall be based on the benefits provided in section 256L.03.

(b) The same annual open and special enrollment periods established for individual health plans under section 62K.15 shall apply to enrolling in the MinnesotaCare Buy-In 2.28 Option health plans. The MinnesotaCare Buy-In Option health plansshall be offered through the MNsure website as defined in section 62V.02,subdivision 13, and may be offered outside of MNsure.

(c) The commissioner may contract with vendors to provide services consistent with 2.32 sections 256L.12 and 256L.121, or contract directly with health care providers.

Subd. 4. Premium administration and payment. The commissioner shall establish an annual per-enrollee premium rate sufficient to coverstate administrative costs and payments by the state to participating entities under sections 256L.12 and 256L.121, or to health care providers.

EFFECTIVE DATE. Health plans established under this section shall be offered beginning January 1, 2021, or upon federal approval, whichever is later. The commissioner of human services shall notify the revisor of statutes when federal approval is obtained.