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State Medicaid programs for low-income individuals typically cover a fuller range of medical services than the federally run Medicare program for seniors. Yet progressive Democrats on Capitol Hill and on the 2020 presidential campaign trail have largely focused on Medicare as they tout various ideas for insuring more Americans. Last week, Sen. Kamala Harris, D-Calif., gave a full-throated endorsement for abolishing private coverage and opening up Medicare to everyone.
It's an idea moderate Democrats are wary of, for a host of reasons.
"I've talked to a lot of people that support Medicare-for-all," freshman Rep. Donna Shalala, D-Fla., who served as Health and Human Services secretary under President Bill Clinton, said. "I said I wanted to do Medicaid-for-all. That's a better program."
Democrats advocating for Medicare-for-all face challenging questions about exactly how they'd fold more people into the program, how it would be paid for and what benefits would be covered. If the goal is more generous benefits, Medicaid could be a more obvious model than Medicare, experts say.
There are several categories of medical benefits covered only minimally by Medicare or not at all, including long-term care, mental-health services and most dental care. Enrollees in Medicaid, by contrast, can access a pretty comprehensive array of inpatient and outpatient services. Medicaid plans cover not only all 10 of the health benefits considered "essential" under the Affordable Care Act but also nursing home care and long-term care services.
"I think a big challenge is people don't really have a concept of how little Medicare offers," said Matt Salo, executive director of the National Association of Medicaid Directors. "Medicare has made a huge difference in the lives of many people over the years, but it falls short in a lot of areas."
As his colleagues have rolled out scores of different Medicare-for-all-style bills, Sen. Brian Schatz, D-Hawaii, has proposed the "State Public Option Act," which would allow people to use Obamacare subsidies to buy a Medicaid-type plan offered in the individual marketplaces.
Of course, this is essentially the same idea as offering a government "public option" plan on the marketplaces - an idea Democrats tried to advance as part of the ACA but eventually abandoned after strong opposition from Republicans.
And there's another potential obstacle. The health-care industry, already up in arms over Medicare-for-all proposals, probably would hate the idea of Medicaid-for-all even more because the program reimburses health-care providers at even lower rates than for Medicare services.
Medicaid has also been the target of criticism and targeted changes from officials because it benefits those on the lower end of the income scale, offering services for Americans earning only up to 138 percent of the federal poverty level (that threshold is lower in states that haven't expanded Medicaid under the ACA). Shalala made this observation, too: Fewer Capitol Hill staffers specialize in Medicaid policy compared to Medicare policy, since Medicaid is run by the states.
There are "just a handful of experts on Medicaid care in Congress, and most of them have retired," Shalala said.
Yet there are some reasons to think expanding Medicaid could stand a better chance of gaining wider acceptance than growing Medicare, as Washington Post reporter Colby Itkowitz wrote Aug. 2. Medicaid is a program run by states - something Republicans favor - plus a number of GOP governors have embraced Medicaid expansion under the ACA.
Heather Howard, a lecturer at Princeton University who also helps states with their health-care systems, said 14 states nationwide have made moves to at least weigh the benefits and challenges of making Medicaid widely available to higher-income earners, Itkowitz reported.
"Why Medicaid?" Schatz wrote in a USA Today piece touting his bill. "Frankly, this program - already serving 69 million people - is underrated. It has a large provider network and the same ratings as private insurance but at a much lower cost to the government . . . Medicaid also gives states the flexibility to adapt services and models of care based on their individual needs."
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