Last week, I wrote about the Swiss health care system as a potential model for the United States. For those who haven’t read it: Switzerland has an all-payer system in which private insurers together negotiate set prices with providers for each given service. The sum of individual and insurer payments for any medical service is the same across all insurance companies and health care providers, hence “all-payer.” The system operates on a regional basis and helps to keep health care costs low.
All-payer rate setting is a policy option well worth exploring for both Democrats and Republican moderates, and it is promising in that it appeals to conservatives looking for state control over health care as well as liberals looking for universal health coverage. Unlike single-payer, it has a decent shot of passing a Democratic congress with some Republican support, or perhaps a Republican congress with a Democratic president. But it doesn’t seem likely that a serious proposal for a federally coordinated all-payer system will arise from a Republican congress with Trump in the White House, especially given the far-right repeal-and-replace bills voted on earlier this year.
That doesn’t mean, though, that states don’t have to worry about health insurance until the next administration. State governments face constituents that, much to the chagrin of the right, need health insurance and have come to expect government help in getting it. As long as Obamacare remains the law on the books, states still have to implement it, even while seeing funding run dry and insurance markets increasingly destabilized. There is, therefore, a need for innovative state-level initiatives to secure access to health insurance. Several states have begun to implement minor tweaks that better stabilize Obamacare; for example, Alaska has a reinsurance program for high-risk patients that has helped insurance companies cope with the stress of being forced to cover chronically sick, and thus more expensive, consumers. Maryland has experimented with all-payer on a state level. California and New York have explored state single-payer programs.
Nevada’s state legislature recently proposed a creative policy, known as “Sprinklecare,” that would allow individual residents to buy into the state Medicaid program. (Medicaid is federally funded health insurance for low-income citizens, but states are actually responsible for its implementation). This amounts to putting a public option in competition with the private market, with several advantages to recipients. Most important, Medicaid can better negotiate lower costs for services than most private insurers can. It can do so for the same reasons insurer blocs can negotiate lower prices in an all-payer system—their large size means heath service providers won’t turn down their patients, even if Medicaid or the insurer bloc will pay less than what a provider would otherwise charge. Health costs remain affordable as a result, although some doctors will refuse to take the lower price, and so patients may have slightly less choice in where they get their care. Health care providers will presumably lose out a little as well, though there isn’t much research to suggest something like a Medicaid buy-in will hurt providers enough to be concerning. The program isn’t predicted to increase federal spending, and offering a public option will theoretically incentivize private insurers to remain affordable as well.
The program actually passed the state legislature—and Nevada is far from totally blue—but Republican Governor Brian Sandoval vetoed it. We won’t, in the immediate future, know how the program would have worked, if at all. However promising it may sound, its logistical feasibility remains a little unclear. That it was vetoed also shows the political difficulty of passing even a center-left bill in a state that isn’t as liberal as New York or California. But Nevada’s initiative foreshadows what may be the inevitable direction of health policy in the next few years—increasingly local, increasingly experimental, increasingly piecemeal. In the absence of federal policy reform and without any federal attempt to make sure Obamacare actually works, states will be left to fend for themselves. People, especially the sick, poor, or both, will almost certainly be hurt in the process, which is all the more heartbreaking because Washington doesn’t seem to care enough to do anything, and Trump seems vicious enough to actively sabotage programs that currently function.
There is reason to hope that some states will step up to the challenge. There is reason to hope that programs like Nevada’s Medicaid buy-in will reinvigorate the health insurance debate from the bottom up. I am hopeful that come 2020, we’ll have tried out a host of state-level health care initiatives that can inform a robust and bipartisan bill at the federal level. But this is a silver lining in an otherwise sad story of a political party willing to abandon its constituents for the sake of winning—though it’s unclear what, precisely, the Republican party is winning by hurting the most vulnerable of its voters.