As the federal government considers New Mexico's requests to impose new premiums on some of the state's 830,000 Medicaid recipients, a growing number of cities and counties across the state are pledging support for a Medicaid-based public insurance plan open to everybody, possibly the first of its kind in the nation.  

Beginning next July, the state anticipates that some of the 265,000 New Mexicans who enrolled in Medicaid as part of the federal government's expansion since 2014, as well as enrollees receiving transitional medical assistance, will have to start paying a $10 monthly premium if their yearly income is between 100 and 138 percent above the federal poverty level. That's $1,012 to $1,397 a month for an individual, and $2,092 to $2,887 a month for a four-person household.

This will be the first time that Medicaid patients in New Mexico face the prospect of losing benefits if they're unable to pay. The state plans to offer a grace period for people who fall behind, but a slide produced by the Human Services Department doesn't say how long it would be.  The department has also suggested premiums could rise to $20 in subsequent years, but a spokesperson for HSD did not respond to questions about the grace period or future increases.

Last year, the department held several public hearings about new premiums and co-pays for Medicaid enrollees. After collecting feedback, it reduced the income bracket wherein people would be charged premiums. Enrollees who go to the emergency room for "non-emergent" reasons and who opt for brand name drugs instead of generic equivalents would also pay $8 co-pays.

The proposed premiums and co-pays are contingent upon approval from the federal Centers for Medicare and Medicaid Services. The agency has approved waivers in at least four other states that would introduce work requirements (though a federal court blocked them for Kentucky.) New Mexico hasn't proposed work requirements for Medicaid, but it joins several other states with pending waivers that would allow them to kick people off Medicaid because of missed premium payments.

Republican administrations in various states have justified things like work requirements and increased premiums as necessary to "encourage more personal responsibility," as Arkansas Gov. Asa Hutchinson put it. (That state has charged premiums for Medicaid patients since 2016.) Critics argue that these types of requirements are a means of removing people from public benefit rolls, part of a broader effort to undermine the Affordable Care Act (Obamacare) after it resulted in about 11 million people nationwide getting onto Medicaid since 2014.

"This is just another insult to the Affordable Care Act, by the federal government allowing states to have more leeway in terms of how they use their Medicaid program," says Dr. Lawrence Lazarus, a physician in Santa Fe who writes extensively about America's health care system.

At an Albuquerque gathering last week for health care professionals who help people determine their eligibility for public benefits, hosted by the New Mexico Primary Care Association, one Medicaid enrollment counselor told SFR he was surprised to learn about the new premiums for Medicaid recipients, despite HSD's public hearings last year. He says he wasn't the only one who felt blindsided.

“There were a number of questions about how this would work exactly, because how do you prove income when it changes month to month?” said the counselor, who asked SFR not to print his name. “A lot of people have either cognitive limitations or just difficulty because they don’t have checking accounts or lack stability” and could lose benefits during life-saving procedures, he added.

There are about 150 such enrollment counselors (labeled "presumptive eligibility determiners" by the state) in New Mexico, and 40 working in hospitals and clinics in Santa Fe County, according to Eileen Goode, CEO of the New Mexico Primary Care Association. Goode says her organization attended HSD's public hearings last year and questioned the premiums.

“The premium is still a new concept [and] we aren’t sure how that’s going to impact families in New Mexico,” Goode tells SFR.

HSD is holding a few public forums throughout New Mexico for the rest of the month to inform people about the changes to the state's Medicaid program, known as Centennial Care 2.0, which goes into effect Jan. 1.

In the meantime, health advocates in the state under the umbrella group NM Together for Healthcare have gone on a public relations offensive to garner support from cities and counties for a "Medicaid buy-in" program that would allow anybody to obtain health coverage offered through Medicaid, regardless of their eligibility.

There isn't a set design for how this program might look, says Abuko Estrada, a staff attorney at the New Mexico Center on Law and Poverty. In January, state Sen. Jerry Ortiz y Pino, D-Albuquerque, introduced a bill encouraging the legislature to explore the financial implications of a buy-in program.  

“It could be offered directly on the [state health care] exchange” as a state-backed public insurance plan, “or off the exchange,” Estrada says. “It could look sort of like a hybrid between what’s offered by the Affordable Care Act [exchange] plans now and a Medicaid benefits package. At the end of the day, it’s supposed to be an option to allow any New Mexican to buy into the Medicaid program.”

So far, officials in Bernalillo and McKinley counties, as well as the cities of Anthony and Sunland Park, have passed resolutions supporting potential legislation to create a Medicaid buy-in program. Last week, the legislative liaison for Santa Fe, Jesse Guillén, sent a letter about the buy-in proposal to Bernalillo County to ask for information.

Estrada says NM Together for Healthcare has contracted the research group Manatt Health to outline "several different options for New Mexico as to how the state can design a Medicaid buy-in option." The results should be ready by the end of this month.

Editor's note: A previous version of this story overestimated the dollar amounts for people enrolled in Medicaid who will see their premiums rise. The story has been updated with accurate numbers.