In the twelve years since the Affordable Care Act (ACA) was signed into law, progress toward more equitable insurance coverage has been achieved. In 2010, around 18 percent of the population—more than 46.5 million people—were uninsured.1 The most recent estimates from August 2022 show that number down to only 8.0 percent, or around 26.5 million people, in the first quarter of 2022.2 These gains in health coverage helped close racial disparities in coverage rates. The uninsured rate for Hispanic people fell from 30.1 percent in 2010 to 17.7 percent in 2020, a 12.4-percentage-point decrease.3 (See Figure 1. ) Similarly, the uninsured rate for Black people fell from 17.5 percent in 2010 to 9.9 percent in 2020, a 7.6-percentage-point drop.4
Despite these gains, however, more work is needed to achieve universal health coverage, a necessary component to achieving true health equity.5 As of 2020, Black people are still uninsured at a rate four percentage points higher than for white people (9.9 percent versus 5.9 percent), and Hispanic people are still uninsured at a rate 11.8 percentage points higher (17.7 percent versus 5.9 percent).6
These disparities in coverage result in real differences in health status as well: a survey of self-reported health status found that Hispanic people were more than twice as likely to report fair or poor health than white people and that Black people were around 50 percent more likely to do so.7 The same study found that Hispanic people were around 80 percent less likely to report being in excellent or very good health and that Black people were around 35 percent less likely to do so.8
One way that states can seek to expand health care coverage and close disparities in coverage rates (thus improving health equity) is to introduce public health insurance programs through which residents can purchase coverage—commonly known as “public options.” This report describes the efforts that three states—Washington, Colorado, and Nevada—have taken to enact a public option, including key distinctions between the states’ programs. After this, it discusses findings from analyses of these states’ programs, informed by interviews with stakeholders from across the country. The report then discusses the lessons learned from these findings. Finally, it provides recommendations for policymakers seeking to implement or improve a public option program in their state. The lessons learned from this research will be used by TCF researchers to inform the creation of a health equity tool to help future states improve health equity and health care affordability.
Defining Health Equity Is Essential to Achieving It
Health equity is achieved when all people have the highest attainment of health and well-being, regardless of race, income, gender, or other identities. However, due to the structural racism and inequalities that have been perpetually ingrained in American institutions, including in the health care system, many people experience challenges in attaining optimal health and well-being, particularly communities of color and low-income people, as well as other marginalized groups, such as LGBTQ+ communities, people with disabilities, and people with limited English proficiency. These inequalities drive gaps in health insurance coverage, unequal access to health care services, and disparities in health outcomes.
Furthermore, economic inequality is a key factor in whether or not certain individuals and families can afford health insurance coverage and associated out-of-pocket costs. Affordability continues to be a major barrier to ensuring coverage for millions of people. This report centers health equity in its analysis of public option plans in three states, examined through three lenses: enrollment in coverage, affordability of coverage, and benefit adequacy.
Enrollment in Coverage
Universal coverage is essential to improving health equity. Multiple studies affirm the link between health coverage, access to health services, and improved health outcomes. For example, a Kaiser Family Foundation analysis of 2019 National Health Interview Survey data found that uninsured patients were 3.5 times to 4.25 times more likely to lack a usual source of care than insured patients.9 The same analysis found that uninsured patients were three to five times more likely to postpone seeking health care due to cost.10 The racial disparities in coverage rates in the United States result in impacts in access to coverage as well: research published by the Commonwealth Fund found that, in 2019, Black people were 2.4 percentage points less likely than white people to have a usual source of care (74.7 percent versus 77.6 percent), and Hispanic/Latino people were more than 20 percentage points less likely (56.2 percent versus 77.6 percent).11 Improving health coverage rates is among the most obvious aspects that public options seek to address.
Affordability of Coverage
Intertwined with having health coverage is whether that coverage is affordable. The assessment of coverage affordability is based on two elements: monthly premiums and cost-sharing at the point of care. High monthly premiums make coverage less affordable, and these high premiums are the most common reason why people are uninsured. For example, a 2016 survey of uninsured adults found that nearly two-thirds of respondents cited concerns over affordability as a reason for not having coverage.12 Even for patients who can afford premiums, health coverage that includes high levels of cost-sharing makes that coverage less valuable to a patient, often resulting in them facing similar barriers as uninsured patients. Patients with coverage but high levels of cost-sharing are often referred to as underinsured.
A 2020 study by the Commonwealth Fund found that 43 percent of underinsured patients reported a cost-related barrier to their care, compared to only 23 percent of adequately insured patients.13 People of color were also more likely to report cost-related barriers to care. Since the implementation of Medicaid expansion, the proportion of adults avoiding care due to cost dropped across the board.14 Despite this, however, Black people were still 3.8 percentage points more likely than white people to avoid care due to cost in 2019 (17.3 percent versus 13.5 percent), and Hispanic people are still 9.3 percentage points more likely (22.8 percent versus 13.5 percent).15 The proportion of Hispanic people doing so also increased from 2018 to 2019.16
Underinsurance also leaves patients vulnerable to medical debt, with Black patients nearly twice as likely to have significant medical debt than white patients in 2020.17 This is another aspect of equity that public options seek to address—as discussed below, these plans work to cover more services with less cost sharing or have lower monthly premiums than comparable plans.
Adequacy of Benefits
The final lens that this report examines public options’ impact on health equity through is the adequacy of benefits covered. While the ACA standardized health benefits through its requirement to cover “essential health benefits” in the individual and small group markets,18 these benefits do not necessarily cover the services that historically marginalized groups need to be as healthy as possible. For example, few sources of health coverage include care from doulas, despite their well documented impact on Black women’s maternal health outcomes.19
When a plan does not cover these services or providers, enrollees are either forced to go without access (which exacerbates health disparities) or pay for this care on their own (which further increases out-of-pocket costs and financial burdens on patients). Even if a plan may nominally cover a service, high cost-sharing may functionally keep enrollees from using that benefit.
Three States’ Public Option Programs
In attempts to expand health coverage, reduce underinsurance, and improve the value of care provided to consumers, many states have considered enacting some form of a public option. Public options are public health insurance programs through which primarily higher-income, non-elderly adults can purchase coverage.20 The concept of a public option was first created by health policy researchers in California during the early 2000s21 and has become increasingly popular since. A public option was included in the initial form of the ACA, but it was eventually removed before passage due to opposition from some conservative Democratic senators.22
To date, Washington, Nevada, and Colorado have enacted public option style programs. All three programs operate as public–private partnerships, requiring or incentivizing the sale of specific plans by private health insurers through the marketplace rather than the state taking on risk directly.23 This section briefly describes each state’s program.
Washington was the first state to enact a public option law, which went into effect on January 1, 2021. The law established two types of plans: Cascade Care plans, which are required to offer a standardized set of benefits, and Cascade Select plans, which are required to offer the same standardized benefits and limit reimbursement rates to providers to lower the cost of care.24 The goal of the Cascade Select plans is to increase the availability of affordable coverage throughout the state. To achieve this goal, carriers offering public option plans must limit their aggregate reimbursement rates to providers at 160 percent of the Medicare rate for the same or similar services; primary care, as well as critical access and sole community hospitals, have minimum reimbursement rates of 135 percent and 101 percent of Medicare rates, respectively.
In Washington, the state will contract with at least one private insurer to offer a standardized public option plan, and some hospitals may be required to contract with Cascade Select plans to remain eligible for Medicaid and public employee reimbursement. In an interview with the authors of this report, state representative Eileen Cody (D–34) described the focus on a public option as a pragmatic step toward universal health care that the Washington House Democratic Caucus would be able to achieve at a state level:25
“I remember standing up in caucus and saying ‘Do you guys want Medicare for All? Well I’ll give you the closest thing we can do [at the state level].”
—Representative Eileen Cody
Nevada was the second state to enact a public option law. Starting in 2026, insurers will be required to submit a bid to offer a public option plan in the individual market (and, if the state requires it, the small group market) to remain eligible for Medicaid managed care organization (MCO)26 contracts.27 Around 75 percent of Nevada Medicaid enrollees receive coverage through an MCO, representing a significant revenue stream for carriers operating in the state.28 Learning lessons from Washington’s experience, Nevada requires providers to be in network with at least one public option plan to remain eligible for Medicaid, public employee, and worker’s compensation payments.29 Instead of limiting provider reimbursement rates as Washington did, Nevada set premium reduction targets for its public option plans, with the goal of reducing premiums by 5 percent. The law has four goals: lowering premiums and costs for health care, improving access and reducing disparities in quality of care for historically marginalized communities, increasing competition to improve affordability for rural communities, and promoting value-based health care financing.30
Colorado is the third state to have passed a public option into law to date. Colorado requires individual and small group market insurers to offer a standardized plan for each county in which they operate.31 Colorado’s provider participation approach is arguably the most aggressive: if insurers fail to meet premium reduction targets or network adequacy requirements (because an insufficient number of providers contract with public option insurers), the state commissioner of insurance is empowered to hold a hearing and potentially require participation and set reimbursement rates for hospitals.32 Hospitals who refuse to accept this rate could have their license suspended.
Colorado’s law has three goals: improving access and affordability, improving racial health equity and decreasing racial health disparities, and lowering premiums.33 The premium-reduction goal aims to achieve premiums that are 5 percent lower than 2021 rates in the first year of operation, 10 percent lower in the second year, and 15 percent lower in the third year; after this, premiums cannot increase more than the Consumer Price Index for medical care.
Table 1 compares three essential aspects of each states’ programs: insurer participation, provider participation, and goals.
|KEY DETAILS OF STATE PUBLIC OPTION LAWS|
|Lead agency overseeing public option plans||Medicaid||Medicaid||Division of Insurance|
|Market(s)||Individual market only||Individual market (on and off marketplace); may also be made available in small-group market||Individual and small-group markets (on and off marketplace)|
|Public option plans standardized?||Yes||No||Yes|
|Carrier participation||Voluntary; state to contract with 1+ private carriers to offer public option plans||Mixed mandatory/voluntary; Medicaid MCOs must submit “good faith” bids to administer public option plans; other carrers may submit bids||Mandatory; all carriers in individual and small-group markets must offer public option plans in each county in which they operate|
|Geographic scope||Statewide coverage required beginning in 2023||No mandatory statewide coverage requirements or triggers, but may be achieved through the implementation process||State may order carrier(s) to offer coverage in empty counties following public hearing|
|Primary cost-containment mechanism||Aggregate provider reimbursement caps||Premium reduction targets||Premium reduction targets with threat of provider rate-setting if not met|
|Provider participation requirements||Mandatory participation for some hospitals beginning in 2023 if public option plans not available statewide in prior year||Mandatory participation for some providers||Provider participation may be ordered following a public hearing, with penalties for noncompliant hospitals|
|Provider reimbursement protections||Payment floors for rural hospitals certified as critical access hospitals or sole community hospitals (101% of Medicare rates) and primary care services (135% of Medicare rates)||Provider rates in aggregate must be comparable to or better than Medicare rates, inclusive of add-on payments or subsidies; alternative approaches set for certain providers||Payment floos apply if state is setting rates; floors vary by provider type and specific circumstances but generally above Medicare rates|
|1332 waiver||Authorized||Authorized||Authorized; approved|
|Effective dates||Plans first available in 2021, additional changes coming in 2023||Plans first available in 2026||Plans first available in 2023|
|Source: Christine H. Monahan, Kevin Lucia, and Justin Giovannelli, “State Public Option–Style Laws: What Policymakers Need to Know,” To the Point (blog), Commonwealth Fund, July 22, 2021, https://doi.org/10.26099/acny-0s21.|
Over the course of researching for this report, several themes emerged from reports by state entities and interviews with key stakeholders. This section outlines several of these themes: affordability remains a challenge for consumers, provider participation is a barrier to public option operations, and public options have the potential to transform the existing health care system.
Affordability of Health Coverage and Care Remains a Challenge for Patients
The first theme to emerge is the reality that affordability of both health coverage and the provision of health care services remain challenges for patients. While the ACA significantly improved coverage rates and the value of health coverage, many people are still uninsured, and marginalized populations continue to be more likely to be uninsured. Nevada state senator Nicole Cannizzaro, the sponsor of the state’s public option legislation, emphasized this in an interview with the authors, stating:
“While we have the ACA in place here, through the exchange they can get on there, they can buy health insurance plans. We’ve done Medicaid expansion, so we’ve included more people there. We still have this pocket of individuals who just simply cannot afford insurance.”
—Senator Nicole Cannizzaro
This finding was also affirmed in an interview with Tonie Rutledge, a child care provider and small business owner in Aurora, Colorado. She described how her daughter carefully monitors her income to ensure that she never goes above 138 percent of the federal poverty level (FPL) in a given month to avoid losing eligibility for Medicaid, as she would be unable to afford marketplace coverage:
“My daughter is going to be 32, and she has to make a minimal amount of money to be able to keep getting the state insurance, because if she makes more than that, she can’t afford to pay whatever the health care cost is.”
Tonie spoke candidly with the authors of this report about the challenges she herself has had when it comes to accessing affordable health care, even with health insurance. For example, after needing surgery in 2021, she and her husband accrued significant medical debt, eventually resulting in the couple having to sell their house to make meaningful progress toward repayment:
“We had to sell our house in March 2021. I had almost $60,000 worth of medical bills on credit cards. I was literally just paying to keep the credit card from going ‘not current,’ and all we were doing was making the minimum. We got some ridiculous amount for this company to buy our house and paid off all our debt. I told my husband ‘do it, we don’t have a choice. We will never get this paid.’ So they did, and they paid off every single one of our debts.”
This finding was also seen in examinations of reports on the uninsured population in Washington, Colorado, and Nevada. The 2021 report on the uninsured population in Washington by the Department of Insurance found that households with incomes between $25,000 and $49,999 were the most likely to be uninsured in Washington in 2019, and a 2019 report by the Guinn Center found the same trend in Nevada.34
A survey in 2019 by the Colorado Health Institute found that individuals making between 201 and 300 percent of the FPL were the most likely to be uninsured in Colorado, and the same survey found that people whose income was under the poverty level were about twice as likely to be uninsured as people who make at or above 400 percent of the FPL.35 As shown in Figure 2, people of color are generally more likely to be uninsured in all three states, especially Hispanic people. These disparities persist even though many of the individuals in this income range may qualify for marketplace premium subsidies under the Affordable Care Act, suggesting that affordability remains a barrier for millions of people.
Providers Will Oppose Participation in a Public Option
Another theme to emerge in the research for this report was the reality that many health care providers will oppose participation in a public option, especially if they perceive it as impacting their bottom line. This opposition was most clearly highlighted in the process for passage and implementation of the public option in Washington. For example, the Washington State Hospital Association explicitly listed their opposition to the provider rate reduction as a “concern” with the bill during the 2019 legislative session.36
This opposition continued after the law was passed, even after state officials increased the payment rate from exactly Medicare rates to 160 percent of Medicare rates. Many hospitals refused to contract with any Cascade Select plans, as there was no requirement for them to do so. As a result, more than half of the counties in the state did not have a Cascade Select plan sold in the first year, which other researchers have attributed to a lack of provider participation mandate.37
The idea that providers would oppose a public option that lowered rates was also found in interviews with policy makers. Representative Cody described hospital opposition as one of the biggest issues to expanding the public option throughout the state:
“The real problem has been the hospitals and providers still opposing it. The providers haven’t been as dug in now as they were. The hospitals were still the biggest problem, and really, most of the providers are working for hospitals now…. The carriers can get a network together if they can get the hospitals.”
—Representative Eileen Cody
Public Options Can Lower Health Care System Costs
Finally, public option programs have the capacity to transform the existing health care delivery system and reduce prices throughout. In particular, public options can not only lower premiums but also reduce the cost of care itself.
All three public option bills that have been passed in Washington, Colorado and Nevada included some form of cost reduction as a goal. Though not an explicit requirement in all the laws, insurers may try to meet these affordability goals through reducing reimbursement rates. This makes sense, as high provider rates are widely regarded as one of the root causes of the high cost of care.38 Washington’s reimbursement under Cascade Select plans was set at an aggregate of 160 percent of Medicare’s rates, which are meant to cover the costs that “reasonably efficient providers” would incur delivering care.39
These efforts are not exclusively focused at provider rates, however. In an interview with Colorado state representative Dylan Roberts, the sponsor of Colorado’s public option bill, he described the state’s unique mechanism as aimed at lowering the cost of care throughout the entire health system:
“The reason why we did a minimum [reimbursement rate for providers] is because we didn’t want to just make the savings fall on the backs of the hospitals and the providers. We wanted the insurance companies and the pharmaceutical [companies] to also have a stake in this. The way the Colorado Option will work is there’s a percentage reduction that needs to be achieved, but there’s no specific mandate on who has to reduce their prices in any specific amount. We’re trying to push the entire health care industry—all inputs to a price of an insurance plan—to achieve savings.”
—Representative Dylan Roberts
After discussing the premium reduction goals of the Colorado Option, Tonie Rutledge described how this would impact her family’s ability to make ends meet:
“Five percent cheaper would save me about $500 a year. It’s not a lot, but it’s still $500 a year. That puts money into something else.”
In interviews with advocates in Washington, however, a need for stronger cost reduction goals was highlighted as necessary. Sam Hatzenbeler, a policy associate at the Economic Opportunity Institute in Seattle, said a lower reimbursement cap is an option the state could pursue in the future:
“We did try to get a more aggressive reimbursement rate cap [in 2021], and that was taken out of the original bill. It may be something we try to return to. There’s a question of obviously, large hospital conglomerates are not fans of the 160 percent of Medicare reimbursement rate, but some say that’s not even worth doing, that it’s not aggressive enough and therefore can’t really bring premium costs down significantly enough to actually improve affordability.”
Additional Policy Considerations
There are a variety of other policies that, while not directly related to a public option program’s operations, have a significant impact on their success by further promoting equitable access to affordable health coverage. This section describes several of these related policies’ impact on public options, as well as highlighting the need for federal action beyond state public options.
The American Rescue Plan Act’s Subsidies Have Made Marketplace Coverage Significantly More Affordable
When examining the use of marketplace policies to expand coverage, the impact of the American Rescue Plan Act’s enhanced subsidies cannot be ignored. Passed in early 2021, the American Rescue Plan Act expanded the eligibility for subsidies to more households and made the subsidies already available to lower- and middle-income households more generous.40 Congress recently extended these subsidies through 2025.41
If Congress does not extend these subsidies again or make them permanent, states will need to be prepared to use more state resources if they intend to maintain the same level of affordability after 2025. As will be discussed later in this report, the enhanced subsidies and increased affordability they created significantly drove marketplace enrollment in 2021 and 2022, emphasizing the need for extension.
Medicaid Expansion Plays a Pivotal Role in Expanding Coverage
Medicaid expansion is another essential policy for improving health equity and expanding access to affordable coverage. In turn, it is also related to implementation of an effective public option. Under the ACA, states have the option to expand Medicaid eligibility to all individuals up to 138 percent of the federal poverty level (FPL).42 As of the publication of this report, most states have done so, though twelve states (primarily in the Southeast) have still declined to do so.
Because marketplace subsidies are not available to individuals making less than 100 percent FPL43 ($13,590 for an individual and $27,750 for a family of four, in 202244), expanding Medicaid is a necessary first step to move closer to universal coverage. Without Medicaid expansion, public options would only serve those individuals above the FPL, despite the fact that individuals living in poverty have the highest need for health coverage.
Medicaid expansion has also been shown to be critical to filling the coverage gap, particularly for people of color.45 Despite making up only around 35 percent of the adult population in non-expansion states, Black and Latino adults account for more than 55 percent of those in the Medicaid coverage gap.46 These are the same communities that are more likely to experience income inequality or work in low-wage jobs.47 Research from the Economic Policy Institute found that Hispanic workers were more than twice as likely as white workers to be paid a wage that would put their household under the federal poverty line, and Black workers were around two-thirds more likely.48
Having a public option without expanding Medicaid will leave states with two choices: spend significant state funds on new subsidies to make public option plans affordable for households under the poverty level, or leave these communities out of the equation. Without state-based subsidies, these households will likely lack the financial resources to be able to afford the premiums and out-of-pocket costs associated with public option plans, and these plans would still be the less affordable option when compared to programs such as Medicaid, which can only charge nominal premiums and out-of-pocket costs.
Medicaid expansion is also the most cost effective method of covering households in poverty.
Medicaid expansion is also the most cost effective method of covering households in poverty. Rather than covering the entire premium cost for these low-income families, states would only cover 10 percent of the cost of these enrollees’ Medicaid coverage.49 In fact, the first two years of Medicaid expansion would likely be a net increase in federal funds for the state, even after accounting for the increased spending associated with expansion. In addition to increasing the generosity of marketplace subsidies, the American Rescue Plan Act increased the share of the traditional Medicaid costs the federal government covers by five percentage points for the first two years of expansion.50 Expansion costs tend to constitute around 2 percent of a state’s total Medicaid spending,51 meaning states would receive a net increase in funding on average.
Ultimately, Federal Action Is Necessary to Achieve Universal Coverage
Even if states pursue all the policies described in this report, federal action will still be necessary to achieve universal coverage and work toward true health equity. Federal law bars federal money from being spent to cover undocumented immigrants in Medicaid, and it also prevents them from receiving marketplace subsidies. States are unlikely to be able and willing to cover these populations with state dollars alone. Federal action will likely also be necessary to address the Medicaid coverage gap, as the states mentioned above that have not expanded Medicaid are unlikely to do so, even after recent federal legislation made expansion more financially attractive as explained above.52
Public options have the potential to go beyond merely expanding coverage throughout a state; they can be powerful tools for states to improve health equity. This section synthesizes the research findings into applicable lessons for states seeking to improve health equity.
Equity Must Be an Intentional Goal of Public Options
Improving health equity must be an explicit goal of any public option. Without an explicit mandate to do so, programs will likely not take the steps needed to ensure access to health care and address health disparities in a sufficient manner. Structural racism is pervasive throughout the health care system,53 meaning that broad, neutral attempts to expand health coverage will not eliminate health inequities. For example, the ACA greatly improved access to health insurance for millions of Americans, but vast racial disparities in health coverage, outcomes, and status still exist.
Interviews with state officials for this report have underscored this point. When speaking with Washington Health Benefit Exchange officials, they highlighted the lack of a health equity charge in the law that established Washington’s public option. This lack of explicit charge has limited the exchange’s ability to focus on improving health equity. They described the law’s statutory focus on the value and affordability of the Cascade plans as the primary focus of their efforts:
“I would say that, unlike Colorado’s law, our initial focus in terms of statute was around increasing the value and affordability to ensure that more individuals can get covered without a focused health equity lens. I think that we are continuing to mature as an organization and have a mission statement around health equity, so that does influence all of our work.”
Nevada’s law included two goals centering health equity: improving access to care and reducing disparities for historically marginalized communities, and improving the availability of coverage for rural residents.54 Senator Cannizzaro described these goals as necessary to build on previous coverage expansions:55
“If we create something that doesn’t target those populations that struggle with access to care, then we have only just sort of overlaid what we currently have and we aren’t addressing that population. We wanted to be very mindful of that.”
—Senator Nicole Cannizzaro
This equity language has resulted in the regulatory process for the Nevada public option intentionally including equity in its requirements. One of six public comment sessions on the program was focused on who the target population for the public option should be and what policy tools the state could use to make the program most effective for that population. Presenters explicitly differentiated between all eligible enrollees and those the state is putting special effort into enrolling, a key aspect of ensuring that marginalized populations are included in the development of the public option.56 In particular, presenters highlighted that the uninsured population that is not already eligible for another program to make insurance more accessible was split between undocumented immigrants (around 60 percent of this population) and those for whom marketplace coverage is unaffordable, whether due to family income or the family glitch.57
Colorado’s law also includes improving racial health equity as a goal.58 Colorado’s efforts to improve equity have focused more on the upstream aspects of the program, rather than a target population as in the Nevada public option. The law requires the public option’s network to be “culturally responsive,” going beyond existing network adequacy requirements in the state by requiring coverage of “essential community providers” such as federally qualified health centers as well as certified nurse midwives.59 Over 60 percent of Federally Qualified Health Center (FQHC) patients were people of color in 2020,60 and the impact of midwives on Black women’s maternal health outcomes is well documented,61 making both of these critical to improving racial health equity.
In regulations finalized in March 2022, the state clarified how a plan can demonstrate compliance with this cultural responsivity requirement. In addition to the coverage requirements above, carriers also must report demographic data of both providers and enrollees,62 and include a copy of the information provided to explain why they are collecting this data.63 (Including an explanation of why demographic information is being collected has been associated with higher reporting rates in New York.)64
Carriers in Colorado are also required to offer cultural competency training to providers and staff and provide a summary of this training, a description of providers or services included to assist with lowering disparities, and a description of how the carrier analyzed their network for the anticipated volume of services required to cover with minimal cost sharing.
Carriers in Colorado are also required to offer cultural competency training to providers and staff and provide a summary of this training, a description of providers or services included to assist with lowering disparities, and a description of how the carrier analyzed their network for the anticipated volume of services required to cover with minimal cost sharing.65 At least 50 percent of providers must have undertaken a cultural competency training by the first year of operation, and at least 90 percent must have undertaken such a training by January 1, 2025.66
Public Options Must Function Well
In addition to explicitly including improving health equity as a goal, public options must be well-conceived programs to achieve this goal. The importance of this is highlighted in Washington’s initial experience with Cascade Care. As described earlier in this report, Washington’s initial lack of a provider participation mandate resulted in lower plan availability throughout the state during the first year of operation. This lack of provider participation meant that any efforts to lower the cost of care would be undermined, as few providers would be subject to the reduced rates central to Cascade Select plans.67
As a result of this lack of plan availability and other factors (such as the fact that many consumers are automatically re-enrolled into their current coverage), only around 1 percent of enrollees in 2021 chose a public option plan.68 In response to this lack of provider and subsequent carrier participation, the state legislature passed significant reforms to the program in its 2021 session.
One of these was especially important: if any county does not have a public option plan available in a previous plan year (which was the case for fourteen of the state’s thirty-nine counties for the 2022 plan year), state-licensed hospitals must contract with at least one public option plan to remain eligible for state employee and Medicaid reimbursements.69 Representative Cody stated she is waiting to pass any additional legislation until the effect of this participation mandate is more clearly understood.70 Map 2 shows the availability of Cascade Select plans in 2021 and 2022. The increase in plans sold suggests that just the threat of this mandate may have incentivized more providers to participate. The Washington Health Care Authority recently announced that all but five counties will have a public option plan this year, though the specific counties have not been announced yet.71
Colorado and Nevada demonstrated the importance of taking this lesson to heart with the development of public option bills in these states. As discussed earlier in this report, both states included a strong provider participation incentive in their bill text. Both states’ programs are still in the regulatory process, and in a recent press release, Colorado announced that there will be at least two Colorado Option plans sold in 2023 in every county except Jackson County, which will only have one.72 Colorado Option premiums are expected to be cheaper than non-Colorado Option plans in most counties.73
State Investment Is Necessary to Lay the Groundwork for Success
State investment to improve affordability of coverage is necessary to ensure public options are as successful as possible. As discussed earlier in this report, affordability of coverage remains an issue, even in states that have expanded Medicaid and with the presence of the American Rescue Plan Act’s enhanced subsidies.
Every public option passed so far includes the ability for state officials to apply for a 1332 waiver from the federal government to help fund state subsidies to make coverage more affordable.74 These waivers, named for the section of the Affordable Care Act that established them, allow a state to apply to the federal government for a waiver of certain regulations to test innovative ways to provide health coverage.75 If the waiver reduces the amount of premium tax credit paid by the federal government, states can receive these savings as “pass-through funding.”76
These savings could then be used in a variety of ways to further enhance the program. For example, these funds could be used to further improve affordability of coverage by subsidizing premiums for lower-income enrollees. The state could also opt to use the funds to reduce out-of-pocket costs for care and require public option plans to cover more services without cost sharing. In both of these approaches, states would be improving the affordability for consumers—by lowering their monthly premium cost in the former approach or by lowering their cost sharing at the point of use in the latter.
Bolstering marketing and education campaigns would also be a worthwhile investment of these savings. By targeting these campaigns among marginalized groups that are historically excluded from the health care system, such as low-income people, people of color, and LGBTQ+ people, states can sustain or increase any gains in health coverage access and affordability achieved through a public option, further advancing health equity.
By targeting these campaigns among marginalized groups that are historically excluded from the health care system, such as low-income people, people of color, and LGBTQ+ people, states can sustain or increase any gains in health coverage access and affordability achieved through a public option, further advancing health equity.
Members of these targeted populations should also be actively engaged as partners in developing marketing approaches and acting as validators within their own communities. For example, California has established a “coverage ambassador” program to educate Medicaid enrollees about the end of the public health emergency and its impact on their coverage.77 These ambassadors include community organizations, advocates, and local governments, as well as providers and managed care plans.78 This model could serve as the basis for education around public options. As follow up, campaigns should be evaluated for success and duplicated or modeled as appropriate.
Education should not only focus on health literacy and general knowledge about health plan options, but also on how to use and navigate the systems for signing up for coverage and picking the right health plan. As discussed later in this report, enrollees often focus on the monthly premium a plan has, rather than the average cost they would pay for care; education aimed at highlighting the comprehensive nature of public option coverage can help address this.
High Enrollment Is Essential to Shift the System
In order for a public option to make meaningful progress at any goal, be it improving health equity, expanding coverage, or lowering the cost of care, robust enrollment is necessary. If the public option only represents a fraction of patients in a state, or even a fraction of marketplace enrollees, providers will not be influenced by any training or other health equity-related requirements or incentives that states attempt to put in place through the public option. This need for volume was best put by Emily Brice, a lawyer at Northwest Health Law Advocates, in an interview with the authors:
“[The initial Cascade Care legislation] didn’t have the ingredients that we know are essential to a public option actually making any movement in the insurance market. I see those ingredients to success as being one part volume or incentive for carriers and market participants to take any action above the usual way of doing business. I think volume is a particularly important way to get at that. My kind of rule of thumb is that carriers don’t do anything for under 10,000 enrollees. Typically that’s the volume you need to [get providers to] pay attention. We were hamstrung from the start, because there wasn’t anything in the original legislation that would encourage or require carrier participation.”
By promoting enrollment in public option programs, policymakers can ensure that reforms tied to the public option are incorporated into providers’ regular operations. If enrollment remains low, providers and carriers will likely do the bare minimum to comply only for public option enrollees, rather than addressing the cost of care and health inequities throughout their practices.
This section outlines policy recommendations based on each of the lessons described in the previous section.
Explicitly Include Equity as a Program Goal
States considering a public option should include explicit language on improving health equity within their bills, otherwise they risk maintaining existing trends in inequitable coverage. The efforts to improve health equity should include upstream and downstream factors to ensure that the entirety of the public option is focused on achieving this goal. Requiring the state agency implementing the public option to determine which populations face the greatest barriers to coverage will ensure that the program is focused on the people who most need help in accessing health care.
Similarly, ensuring that carriers are collecting disaggregated racial and income information on patients enrolling in the program and what steps providers and carriers are taking to address health disparities is essential to confirming that this targeting of the program is having its intended effect. This data will also help policymakers monitor implementation of the public option and make improvements over time to further improve affordability, expand access to care, and eliminate disparities.
Include Strong Provider and Carrier Participation Mandates
The experiences of the three states highlighted in this report demonstrate the need for a strong provider and carrier participation mechanism. States should examine the different approaches taken so far to determine which is most appropriate for their state. In most of the country, most Medicaid enrollees are in some form of managed care plan,79 meaning the approach Nevada used to tie Medicaid procurement to the public option plan might be an effective mechanism. While having a state-based exchange may not be necessary for a state to establish a public option, all three states that have moved forward thus far have their own exchange. This offers a host of benefits, such as making it easier to collect and use data and tailor outreach strategies.
Every public option law that has been passed includes some level of cost reduction as one of the goals of the program, which raises the risk that providers will refuse to contract with these plans due to the perceived loss of revenue. Combining this cost reduction goal with minimum reimbursement rates can help avoid this outcome, however. By ensuring that reductions in spending do not come solely at the expense of providers, states can lower the impact of industry opposition to the bill during both the legislative and implementation phases of a bill. Additionally, starting with a more aggressive approach, such as Colorado’s license suspension threat, can make other policies to require provider participation seem less intrusive by comparison.
Provide Generous Subsidies to Make Public Option Coverage Affordable
There are a variety of options that states can take to promote enrollment into a public option program. Each of these options will require some level of initial investment by the state to ensure efficacy, but these investments can eventually be offset by federal pass-through funding. These initial investments represent a sort of down payment by the state, kickstarting the savings that a public option can achieve by making the plan’s premiums more affordable for enrollees.
By ensuring the public option has high enrollment, the state can make other provisions seeking to lower the cost of care (such as lower reimbursement rates and cost-sharing) more effective. Higher enrollment will put more pressure on plans that compete with the public option to also reduce their premiums, spurring more lower-cost options for consumers. As these policies lower the cost of care more effectively, the pass-through savings will accrue more quickly and at a higher rate. These savings can then be used to lower the amount of subsidy the state needs to provide through state funds, or they can be further invested in addition to state funds to promote other cost reduction or equity improvement initiatives, such as those mentioned earlier in this report.
The most important investment a state can make to drive enrollment is direct subsidies to enrollees. Washington Exchange employees emphasized this in an interview with the authors of this report, describing most enrollees’ decision-making process as focused on premium affordability and maintaining access to providers with which they have existing relationships:80
“The Exchange has done some work to understand folks’ experiences and understanding of Cascade Care, specifically from a market shelf and selection perspective. My understanding is that folks generally aren’t leaning into a Cascade Care plan because it’s Cascade Care. They continue to look for the lowest premium and—secondarily—look for providers that they want to see.”
—Laura Kate Zaichkin
Other interviews with advocates from Washington underscored this point as well: Emily Brice discussed a need for additional subsidies to make coverage more affordable.81 She also described Massachusetts’ higher level of subsidies as critical to the state’s ability to work with plans to improve health equity, particularly around cost sharing for services with disparities in access:82
“Massachusetts has required value-based insurance design elements in standard plans: zero cost sharing for substance use disorder services, zero cost sharing for certain diabetes-related treatments. This year, for the upcoming plan year, they just rolled out a suite of cost sharing requirements for carriers that will be explicitly focused around a race equity framework and interventions specifically to target disparities in different health conditions. You kind of see that behavior both as a matter of ‘this is a much more mature program,’ and they have a lot of subsidies. So when they set those cost sharing requirements, the state is helping to subsidize that—it’s not just the carriers.”
Other data support this conclusion as well. The enhanced subsidies provided through the American Rescue Plan Act significantly improved marketplace coverage, and this improvement in affordability drove record-high enrollment. More than 14.5 million people enrolled in marketplace coverage during the 2022 open enrollment period, and new enrollment increased by 20 percent from 2021 to 2022.83 Around 30 percent of enrollees were able to pick a plan with a monthly premium of $10 or less in 2022.84 In a press release announcing the approval of Colorado’s 1332 waiver for its public option, U.S. Department of Health and Human Services officials estimated that the Colorado Option is expected to increase enrollment in individual market plans in Colorado by up to 10,000 people—an 11 percent increase.85
Subsidies to make coverage more affordable should be carefully designed, however. Providing flat subsidies regardless of income or family size, for example, will offer a less meaningful benefit to consumers. This approach is the one Washington has taken with its recent subsidy legislation. Sam Hatzenbeler described the subsidy as fixed regardless of income, reducing its impact:86
“Advocates really pushed hard for a ‘fixed differential’—a subsidy that can be changed depending on different demographic information like income or if people are eligible or not for federal subsidies. The Exchange ended up going with a fixed subsidy, which we really think is unfortunate, because we understand that lower income people will need a higher subsidy for the same level of affordability.”
Using a sliding scale for subsidies would follow the approach the federal government took with the ACA, ensuring that lower-income households paid a lower percentage of their monthly income than higher-income households.87 Utilizing a sliding scale for premium support and other affordability measures can also help ensure that consumers aren’t pressured to artificially keep their income low to remain eligible for more generous support, as was the case with Tonie Rutledge’s daughter (mentioned above).
States have significant opportunities to improve affordability of coverage, and these opportunities can be leveraged to promote enrollment in a public option. Directly subsidizing a public option at a higher level than other plans can help avoid consumers opting for lower-value, lower-premium options. These subsidies should be structured in a way to help support lower income households, as well as other households that the state has included in its target population. By providing an initial investment into public options, states can more meaningfully lower the cost of care, increasing the amount of pass-through savings. These can then be further invested into targeted policies that improve the value of health coverage, as Massachusetts has done.
Align Marketplace Enrollment Policies to Promote Public Options
In addition to subsidizing premiums, states should ensure that enrollment processes are designed in such a way that they promote enrollment in the public option. Two policy solutions are helpful here.
First, states should ensure that consumers are aware of the new public option as part of their open enrollment marketing and outreach campaigns. By using tools such as preferential display to highlight the value of the plan relative to other exchange plans, states can ensure enrollees are aware of the benefit of a public option, even if premiums are similar.
In doing so, states should be strategic in messaging for education campaigns targeting enrollment of historically marginalized communities, ensuring promotion of health equity in messaging language and sharing information among groups that stand to gain the most from enrollment in affordable public option plans. They should also ensure that the unique benefits of the public option, such as lower cost sharing or coverage of more services, are highlighted. Including these requirements in appropriations bills or as a separate regulatory change will help drive the volume necessary to make meaningful change via public options.
Second, states should consider prioritizing the public option in automatic marketplace re-enrollment for the first year or first few years that a public option is available. Federal law allows a consumer to be automatically enrolled in a comparable plan from a different insurer if the insurer that originally covered the consumer no longer operates in their county.88 This process generally tries to enroll consumers in similar network types and metal tiers, but states have the ability to direct the re-enrollment process themselves.89
Around 40 percent of returning consumers were automatically re-enrolled in a marketplace plan in 2022 as a result of not actively selecting a plan in which to be enrolled.90 For states with state-based marketplaces, this number jumped to around 70 percent.91 Because such a high number of enrollees are automatically re-enrolled, they may not be aware of a public option or its benefits over other plans. The effect of this approach can be seen in Washington’s first year: 60 percent of enrollees in Cascade Select plans were new enrollees, despite only making up around 20 percent of marketplace enrollment in Washington.92
States should consider modifying the re-enrollment process to prefer the public option in counties where it is available, especially when the public option is a comparable network type and metal tier. Safeguards should be established to ensure that this re-enrollment does not significantly increase a consumer’s monthly premium, especially for lower-income consumers. Consumers should also be adequately informed about any changes in plan type, coverage, and cost when re-enrolled in plans and given multiple opportunities to opt out of the public option plan and into a plan of their choosing.
Looking Forward: Public Options as the Foundation for Improving Health Equity
Public options are a powerful tool for states to improve health equity in the absence of federal action. Health coverage and health care remain unaffordable, and public options present one way for states to address that. Health equity must be intentionally centered in the program design and implementation, however, otherwise states risk simply maintaining the health inequities that currently exist.
In order to maximize the impact that public options have, they should be carefully designed with the state’s specific circumstances in mind. Creating a carrier and provider participation mechanism that works to leverage existing systems in a state will maximize participation, ensuring that there is sufficient volume in the program to make its innovations affect the entire health system.
States should also be prepared to invest their own dollars in the initial years of the program. Doing so will lay the groundwork for the program’s eventual success, leading to federal savings to be passed through to the states in the future. State investment also represents an immediate way to make health coverage more affordable, especially if the enhanced marketplace subsidies expiring this year are not extended.
As more states enact and implement public options, a more robust body of evidence will develop for how these programs can be used to further achieve health equity. The recommendations in this report should serve as a solid foundation for other states looking to implement these programs.
The authors would like to thank Samara Jefferson and Kristen Batstone for their assistance with this report.
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- Representative Eileen Cody, interview by authors, March 30, 2022.
- Medicaid MCOs are private entities that contract with the state to implement the Medicaid program for a given region or population of the state.
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- Nevada Legislature, “SB 240.”
- Colorado General Assembly, “HB 21-1232,” June 16, 2021, https://leg.colorado.gov/sites/default/files/2021a_1232_signed.pdf.
- Mike Kreidler, “Report on the number of uninsured people in Washington state,” Office of the Insurance Commissioner, December 30, 2021, https://www.insurance.wa.gov/sites/default/files/documents/2021-uninsured-report.pdf; “Nevada’s Uninsured Population” (Kenny Guinn Center for Policy Priorities, 2019), https://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/GuinnCenterNVUninsuredPopulation2019.pdf.
- “2019 Colorado Health Access Survey: Health Insurance Coverage” (Colorado Health Institute, 2020), https://www.coloradohealthinstitute.org/research/2019-colorado-health-access-survey-health-insurance-coverage.
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- Stephanie Carlton, Jessica Kahn, and Mike Lee, “Cascade Select: Insights From Washington’s Public Option,” Health Affairs Blog (blog), August 30, 2021, https://www.healthaffairs.org/do/10.1377/forefront.20210819.347789; “Summary of Washington’s New Cascade Care Law,” Public Option Institute, accessed February 7, 2022, https://www.publicoptioninstitute.org/feed-wa-legislation/summary-of-washingtons-new-cascade-care-law.
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- Ibid; Jamila Taylor, “Fixing the Affordable Care Act’s Family Glitch Will Improve Coverage for Working Families,” The Century Foundation, June 6, 2022, https://tcf.org/content/commentary/fixing-the-affordable-care-acts-family-glitch-will-improve-coverage-for-working-families/.
- Colorado General Assembly, “HB 21-1232.”
- “How Colorado Is Designing Culturally Responsive Networks.” United States of Care, October 12, 2021, https://unitedstatesofcare.org/advancing-equity-through-public-options-how-colorado-is-designing-culturally-responsive-networks/.
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- Carriers are required to collect race and ethnicity data, sexual orientation and gender identity data, and disability status data for both providers and enrollees.
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- Representative Eileen Cody, interview by authors, March 30, 2022. (5:05-5:20).
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- Schwab, “A Fixer Upper”; Ellen Montz, “1332 CO Waiver Amendment Completeness Letter,” Center for Consumer Information and Insurance Oversight, January 3, 2022, https://drive.google.com/file/d/1o8cdg0Q6yu0YA6KxfGSyniYFfABcUh-L/view; Nevada Legislature, “SB 240.”
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- Emily Brice, interview by authors, March 11, 2022.
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- “HHS Announces Historic, First-in-the-Nation Program That Seeks to Expand Coverage to Nearly 10,000 Coloradans,” Centers for Medicare and Medicaid Services, June 23, 2022, https://www.hhs.gov/about/news/2022/06/23/hhs-announces-historic-first-in-the-nation-program-that-seeks-to-expand-coverage-to-nearly-10000-coloradans.html.
- Sam Hatzenbeler, interview by authors, March 10, 2022.
- Davalon, “Everything to Know About Obamacare (ACA) Subsidies,” eHealth, January 21, 2022,
- Ibid; “Lessons Learned from Plan Year 2020 Open Enrollment,” Centers for Medicare and Medicare Services, accessed June 2, 2022, https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/Lessons_Learned_PY20_Open_Enrollment_042920_5CR_042920.pdf.
- “2022 Open Enrollment Report—CMS,” Centers for Medicare and Medicaid Services.
- Sen et al., “Participation, Pricing, and Enrollment in a Health Insurance ‘Public Option.’”