By NextBestFitPhase 4: Wave 4: everyone · Step 4.3
Fold Medicaid and CHIP into UHP
Year 4 (dual eligibles and children earlier) · States; UHADiscuss this step
Pros & cons of this step
Pros
- +Ends Medicaid's lower payment rates, the main reason 26% of physicians don't accept new Medicaid patients.
- +Ends redeterminations and churn.
- +Removes $45.5B of managed-care overhead and $40.1B of Medicaid administration.
Cons
- −Medicaid managed-care plans (Centene, Molina, Elevance, UnitedHealthcare) lose a large business.
- −States lose control over a major program and their ability to tailor it.
- National uniformity vs. state flexibility.
high confidence
Access for Medicaid enrollees and the uninsured
The largest gain. 28 million uninsured people get coverage, and 84 million Medicaid enrollees go from a payer many physicians refuse to one every participating physician accepts.
Today
About 26% of physicians don't accept new Medicaid patients, and only about 35% of psychiatrists do. The uninsured delay care and often get it through emergency rooms.Under the plan
Same card, same rate, same access as everyone else.Who gains
- About 112 million people on Medicaid or uninsured
- Safety-net hospitals and community health centers (rates rise)
Who loses
- No group directly
Magnitude: Large. The Oregon experiment found Medicaid coverage reduced depression and catastrophic spending and raised use of preventive care.
- U.S. Oregon experimentCoverage increased outpatient use and prescriptions, nearly eliminated catastrophic out-of-pocket spending, and reduced depression.
- U.S. Medicaid fee bump (2013–14)Raising Medicaid primary-care fees to Medicare levels increased appointment availability.Sources: Polsky et al., NEJM (2015)
Risk that remains: If capacity doesn't grow, gains for these groups come partly at the expense of longer waits for others.
Jobs affected by this step
- State Medicaid eligibility & managed-care oversight staff: 30k of 60k jobs displaced. Income-based eligibility determination and annual redeterminations end. Some staff move to state UHP regional offices or SNAP/TANF.
- Marketplace call centers, navigators & enrollment assisters: 14k of 15k jobs displaced. The Marketplaces close.
Trade-off behind each cost item
- Federal share of Medicaid+$596.7BExisting public money keeps flowing, now to UHP instead of separate programs.
- Shrinks as each wave moves people off legacy systems.
- Mostly Years 2–4.
- Accepted under the plan's ground rules; cushioned by the worker transition program and hiring preference at UHA.
- Accepted under the plan's ground rules; cushioned by the worker transition program and hiring preference at UHA.
Trade-off behind each system change
- Medicaid (acute care)Enrollees go from the lowest-paying payer to the same rate as everyone; states lose program control.
- Medicaid non-medical supportsKeeps innovation in social supports; continues some state-by-state variation.
- ACA Basic Health Program (NY Essential Plan, MN MinnesotaCare, OR Bridge)Simplification; states lose a policy tool they built.
- State Medicaid agenciesAdministrative savings; job losses in state government.
- County indigent-care programs & public hospital subsidiesLocal budget relief; counties must decide whether to keep public hospitals.