To reach their goal of universal coverage, the consensus among Congressional Democrats is that Medicaid eligibility will have to be expanded. Kaiser Health News offers some insight into what this might look like. Right now, Medicaid covers roughly 60 million people. One recent estimate from Avalere Health estimates that the House Democrats’ proposal will increase that number to 83 million, reducing the number of the uninsured by 18 million. That would mean all parents and children up to 150 percent of the poverty line would be covered, as would adults earning up to 115 percent of the poverty level. A number of scholars, including Leighton Ku, believe that Medicaid expansion is far preferable to subsidized private coverage as a means of expanding insurance access for the poor. Stephen Somers and Michael Sparer argue that Medicaid offers valuable lessons on containing cost growth across the healthcare system, though they place a great deal of weight on unproven pilot projects. Conservatives tend to prefer subsidized private coverage, but so does liberal Democratic Senator Ron Wyden of Oregon, the driving force behind the Healthy Americans Act, who decries Medicaid as a “caste system.”

The biggest downside of expanding Medicaid is that it is, for all its virtues, a deeply dysfunctional program that incentivizes massive fiscal irresponsibility on the part of the states, which determine Medicaid eligibility and how much providers will be paid while bearing less than half of the costs of the program. If we really do expand Medicaid to the point where it covers 83 million people, we’ll need to either tighten federal control, to better align responsibilities, or make the most generous states bear more of the fiscal burden. But expanding Medicaid without forcing structural reforms seems profoundly unwise.