By Adam Gaffney, M.D., M.P.H.
On Monday, lawmakers in Colorado passed a bill that would establish what some might call a “state public option” plan, although that’s not what it is. The bill would require, as the Colorado Sun and Denver Post describe, private insurance companies to offer a health plan on the individual and small-marketplaces with premiums that are 15% lower in 2025 than they are today after adjustment for medical inflation; if that goal was not met, the state could potentially regulate payment rates under these plans.
The bill was heavily opposed by state Republicans and, variably, by healthcare industry players. Its advocates tried to achieve more. But unfortunately, the impact of the law is likely to be paltry, potentially even difficult to perceive. If that pans out, it could be used to discredit the notion of true public health insurance.
For one thing, as the Colorado Sun describes, the source of the 15% savings is not entirely unclear. It quotes one of the bills’ chief sponsors: “The spirit of this bill is to ask everyone to come to the table to work on decreasing cost and increasing access.” But these plans would still be run by private insurers, so there is no reason to expect any savings on insurer administration — the primary source of savings under Medicare for All according to the Congressional Budget Office. On the other hand, government rate-regulation (or the threat of it) might give insurers more leverage to reduce reimbursements to providers. Whether this process will succeed, however, is uncertain. After all, Colorado is following in the footsteps of Washington state, which passed a quasi-public option in 2019. Premiums for these “public option” plans (which are actually private insurance plans sold on the marketplaces that pay rates tethered at a percentage above Medicare) were actually 5% higher in 2021 relative to 2020 ACA marketplace plans, per Bloomberg Law.
But the reach of these plans, even if they achieved modestly lower premiums, will also be highly limited. They are available only to those buying insurance on the individual and small-business market. They would hence provide no benefits for those with employer-sponsored coverage and high premiums or deductibles, or for those with holes and gaps in their public insurance plans. Moreover, although they have been advocated as a tool to expand coverage, they are unlikely to be more affordable for the vast majority of uninsured individuals even if they achieve lower premiums. That is because, under the ACA, premium contributions for marketplace plans are set as a proportion of income for all those earning under 400% of the federal poverty level, which is now also the case for those of any income under Bidens’ America Rescue Plan (at least through 2022). Hence, there is no real popular constituency for these programs: at best, if totally successful, they would mostly serve to bring about a modest reduction in government expenditures on ACA subsidies, with little gain in coverage, access, or affordability of care for patients.
And that is not just a policy problem, but a political one. To bring about meaningful change in healthcare, you need a powerful popular constituency behind you, because invariably you encounter opposition from powerful interests. This sort of reform, however, fails to generate such a constituency; its weakness is, in this sense, a feature and not a bug of its design. In contrast, although single-payer reform poses far larger political obstacles for passage, it is unique in that it could benefit nearly every segment of society, and hence potentially help generate the constituency needed to achieve it.