Health policy in 2020 will be made in the states

Illustration: Aïda Amer/Axios

With legislation in Congress likely to be blocked by partisan division and interest group opposition, much of the real action in health care this year will be in the states.

The big picture: States don’t have the money or purchasing power the federal government does, but their decisions nevertheless affect millions of people, and they could signal the future of federal reform.

What to watch: Colorado and Washington are implementing public insurance options that could be a model for Democrats at the federal level.

  • Both plans would be privately administered, and would pay providers 160% of Medicare rates, or more.
  • It’s not yet clear whether they’d be open to very many people with employer-based coverage, or how many providers will accept this coverage.
  • Pennsylvania and New Jersey are taking over their Affordable Care Act marketplaces from the federal government.
  • California is embarking on an ambitious state-financed coverage expansion.

State interest in Massachusetts-like cost controls may grow, as could interest in using Medicaid to pay for non-medical services for high cost patients, as North Carolina is doing.

The other side: Idaho and other red states are promoting short-term insurance plans as an alternative to the Affordable Care Act.

  • Georgia is seeking ACA waiver plan to ditch the state’s marketplace, with consumers enrolling through insurers and web brokers, and a subsidy scheme allowing healthier consumers to choose skimpier plans that do not meet all ACA standards. 
  • Tennessee is seeking a form of per capita cap within Medicaid, with broad flexibility and favorable terms for the state.
  • Red states’ efforts to implement work requirements for Medicaid appear to be faltering in the face of adverse court decisions and opposition. But the Trump administration is still approving them.

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