With prospects dim for the US to adopt a single-payer “Medicare for All” program, healthcare reform advocates turned instead to an insurance plan designed by the government that could compete with private insurance plans sold on the healthcare exchanges. The idea behind this“ public option” is that it could ultimately expand healthcare access by making a lower-cost plan available to consumers.

But that public-option plan, though backed by Presidents Joe Biden and Barack Obama, also has gone nowhere because of political opposition in Congress.

Some states have picked up the banner and are creating their own public-option plans. But they, too, are facing formidable from the healthcare establishment, which is resisting the pressure to reduce costs on the back end so that consumers can pay less.

Washington state, in its second year of offering the nation’s first public-option health insurance plan, has learned an important lesson: If you want hospitals to participate, you’re probably going to have to force them.

The Washington public option is more of a public-private partnership: The plan was designed by the state but is offered by private insurance companies. Anyone buying their own policy on the state’s health insurance marketplace can sign up for a public-option plan and, Depending on their income, may receive significant subsidies from the federal government to lower its cost. But two years in, the plans are available in only 25 of the state’s 39 counties, enrollment numbers have been underwhelming, and state leaders blame hospitals.

“The plans had a hard time getting networks put together because the hospitals wouldn’t play,” said state Rep. Eileen Codythe Washington legislator who introduced the public-option bill in 2019. “They’re a big part of the problem.”

Officials from the Washington State Hospital Association said that more hospitals than not are voluntarily participating in public-option plans. But, they noted, the public option relies on cutting payments to hospitals to control costs and ties reimbursement to Medicare rates, which don’t cover hospitals’ cost of providing care.

“If patients opt to join a public-option plan rather than private insurance, over time it could create financial challenges, especially for small, rural providers operating on thin margins,” said Chelene Whiteaker, senior vice president of government affairs for the hospital group .

State legislators voted to mandate that hospitals contract with a public-option plan if public-option plans weren’t available in each county in 2022. That mandate will go into effect for 2023.

Now, other states looking at a public option are learning from Washington’s challenges. Colorado and Nevada, which are implementing public-option plans for 2023 and 2026, respectively, have already incorporated ways of forcing hospitals to participate. And other states considering a public option — including Connecticut, Oregon, New Jersey, and New Mexico — are likely to follow suit.

“One thing that the states have learned is you cannot make it optional for hospitals to participate,” said Erin Fuse Browndirector of the Center for Law, Health & Society at Georgia State College of Law. “Otherwise, there’s just no way for the public option to have a chance. It will never build a sufficient network.”

Washington’s public option was designed to save consumers money primarily by lowering what hospitals and doctors get paid, capping aggregate payments at 160% of what Medicare would pay for those services. By comparison, health plans had been paying providers an average of 174% of Medicare rates.

Public-option plans are available to anyone and come in the same gold, silver, and bronze tiers as private plans on the health insurance exchange. Proponents estimated the cap would result in public-option plans having premiums 5% to 10% lower than traditional plans on the exchange. But public-option premiums were, on average, 11% higher than the lowest silver plan premium available in each county on the marketplace in 2021, and a public-option plan was the silver plan with the lowest premium in just nine counties. Silver plans cover, on average, about 70% of healthcare costs. Only 1% of people buying plans on the exchange chose public-option plans in 2021.

Public-option premiums for 2022 came in about 5% lower than public-option premiums in 2021. This year’s enrollment numbers have not been finalized — the state is waiting to see how many of the people who signed up complete the process by paying their premiums .

“We know premiums are what drive decision-making in terms of enrollment,” said Liz Hagandirector of policy solutions for United States of Care, a nonprofit that advocates for improving healthcare access. “People often don’t look at anything other than the premium. They rarely look at the out-of-pocket costs.”

But exchange officials say that savvy consumers are finding that the public-option plans are less expensive in the long run. Compared with traditional exchange plans, they have lower deductibles and provide more services not subject to the deductible.

“Premium is still king,” said Michael Marchandchief marketing officer for the Washington Health Benefit Exchange. “But we have a lot of people who have gotten a lot smarter about how they’re pricing out something.”

Marchand also said it may take a few years for a new product like the public-option plan to gain traction in the marketplace. Insurance companies may have priced their plans a little high in the first year, not knowing what to expect. Now, with a year under their belt, they have lowered premiums somewhat.

Washington’s stumble out of the gate reflects the difficulty of lowering healthcare costs while working within the current system. Legislators originally wanted to cut payment rates to hospitals and other providers much more, but they raised the cap in the legislation so hospitals wouldn’t oppose the bill. Now, it’s unclear whether the payment cap is low enough to reduce premiums.

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