One of the lessons the pandemic keeps pounding into our heads is how much our private, employer-based health insurance system sucks.

Last year COVID-related job losses kicked millions of Americans off their health insurance, leaving them without coverage precisely when they needed it most. In Washington, those losses likely drove thousands to the state’s health care exchanges, where expensive premiums and high deductibles still reign despite recent efforts to lower costs through a price control program Gov. Jay Inslee likes to call "a public option," and where many in need still make too much money to qualify for a subsidy.

Even with that safety net in place, the Office of Financial Management estimates about half a million Washingtonians remain uninsured—down from nearly a million last May—including approximately "125,000 undocumented immigrants" who lack access to basic care, according to a new report from the state's Universal Health Care Work Group.

On top of all that, analysts predict health care spending will continue skyrocketing, with costs rising on average twice as fast as wages.

Probably the most galling part of that cost comes from paying health insurance CEOs millions of dollars to devise new and innovative ways to deny coverage to the poorest and sickest Americans. We pay eight health insurance CEOs over $100 million per year for that courtesy.

In short, we've never needed cheaper health insurance that covers everyone more than we do now. Though dozens of studies show a single-payer system would meet both of those needs, no one is holding their breath for action on that front from President-elect Joe Biden and his 50/50 Senate. However, Washington could build its own single-payer program by 2026, so long as the Legislature passes an omnibus proposal that would lay the foundations for the program.

The Omnibus Proposal That Would Lay the Foundation for State-based Single-Payer

According to a draft of the legislation, a forthcoming omnibus proposal would start building the pieces necessary to establish a publicly administered health insurance system that would cover every single person in Washington while saving the state lots of money in the process.

One section of the proposal establishes a health care affordability account, where the Legislature could collect federal and state revenue to expand programs that increase affordability or access to health insurance.

Another section of the proposal starts on that work by lowering prices for plans on the state's health care exchange and by expanding coverage to include some people who would otherwise make too much money to qualify for a subsidy.

Yet another section requires lawmakers to apply for "state innovation waivers" from the federal government so the state could use federal health care funds to pay for the programs Washington wants to expand in the future.

Following in the footsteps of Washington's universal children's health care law, the bill also includes some language stating that the Legislature intends to create a program that will ensure "all residents of the state have comprehensive, equitable, and affordable health care coverage under a publicly financed and privately and publicly delivered healthcare system" by 2026. Such "intent" language would essentially codify in state law the idea that health care is a human right, which may reduce future foot-dragging on the issue as it did with the universal children's health legislation back in the mid-aughts.

Finally, the proposal would establish a Universal Health Care Commission that would draw up a report in 2024 on the status of the health care system. At that time the commission would also submit a nuts-and-bolts plan for implementing the publicly funded, publicly-run system.

The Status of Our Current Health Care System

In the new report from the state's Universal Health Care Work Group, which was a product of a 2019 budget proviso, Optumas Actuarial Services spit out cost estimates for three different public health insurance models, plus the status quo.

Optumas found that Washington will spend over $61.4 billion on health care in 2022. (To help put that in perspective, Gov. Inslee's proposed two-year budget for the whole state weighs in at around $58 billion. So Washington spends less money in two years than we all collectively spend on health care in one year via public and private medical coverage programs.) If we do nothing, then our health care expenditures will jump to $82.4 billion by 2027.

If the state switches to a publicly run and publicly financed health care system (i.e. single-payer), Washington could cover everyone and save approximately $2.5 billion in the first year. After the state covers implementation costs and gets the ball rolling, we would save an estimated $5.6 billion per year.

As with other single-payer proposals, these cost savings come mostly from reduced administration costs and the state's increased power to negotiate lower prices with hospitals, medical equipment sellers, and drug companies.

If the state switches to a publicly funded system administered by nonprofits, Optumas estimates the state would save "approximately $783 million in the first implementation year."

If we want to keep the private insurance system but just pay to cover all uninsured residents in the state, including undocumented immigrants, the actuaries say we'd need to find $617 million per year.

The Universal Health Care Work Group—which included representatives from insurance companies, health agency heads, House Reps from both parties, labor, tribal health boards, rural providers, and others—generally agreed that a publicly funded and publicly run system would best achieve the goal of universal coverage. However, they also mostly agreed that switching to single-payer would be the least-feasible option politically. Since filling the gap by only covering the uninsured seemed to be the most politically feasible option presented, several members saw a pathway from filling that gap in the short-term to then more slowly transitioning to single-payer.

For Vicki Lowe, executive director for the American Indian Health Commission for Washington State, finding a way to implement a single-payer system is an equity issue, and it's urgent. Noting that many American Indian and Alaska Natives "do not have access to health care simply because they do not live in the right place," Lowe said "implementing universal health care in Washington State will bring many AI/AN Washington State Citizens access to care."

"I know that people feel that in a changed system, they might lose something they currently have," she added. "But the current system is inefficient and ineffective, with many of the resources spent on administration of benefits instead of services. In a changed system, I hope that people can see the possibilities of a healthcare system that is focused on healthcare."

A Few Things to Consider

Although switching from a private insurance system to a public insurance system would make health care cheaper in Washington, it wouldn't make health care free. Under a single-payer system, everyone above a certain poverty line would probably pay a tax (or a "personal premium," if you will) for health insurance that would cover all essential health benefits as defined by Obamacare. But that's it. No copays, no deductibles, no lapses in coverage as we wait for enrollment windows to open, and no hunting around for in-network specialists. Rather than navigating fragmented and opaque corporate bureaucracies, we'd navigate a more transparent (but still massive) state bureaucracy.

A few more things to consider:

• Optumas excludes in its health care expenditure tally a handful of major federal insurance programs, such as "Tribal members, federal employees, members of Taft-Hartley plans, veterans and active military, and the incarcerated." The state would need to secure waivers from Congress to use federal funds to pay for those programs. The report notes that "President-elect Biden’s Health and Human Services nominee, Xavier Becerra, has previously expressed support for universal health care programs and may be receptive to state proposals to waive Medicare requirements." We'll have to see about the other program waivers.

• The savings depend on the state investing "in staff and tools to aggressively identify, pursue, and prevent fraud, waste, and abuse under the new paradigm." As Republicans and conservative Democrats will point out every chance they get, people may try to abuse the system. For instance, in his feedback to the work group, Republican House Rep. Joe Schmick speculated that implementing a single-payer system may prompt people in border states to attempt somehow to access medical benefits in Washington without paying for them. It's hard to square that concern with the Republican assumption that a publicly administered health insurance system would lead to horrible care that no one would want (and, of course, fraud, waste, and abuse pervade the private sector) but, considering Washington's recent bureaucratic blunders, it's worth highlighting the call to spend generously on enforcement.

• Washington levies a 2% tax on insurance premiums, which raised about $1.2 billion in 2017-2019 and accounted for nearly 3% of the money in the state's general fund. Booting the health insurance industry would obviously cut into those revenues. Still, the state could presumably make up for that lost revenue with the savings of switching to single-payer, because the money people save on health care would be spent on lattes and carbon steel pans and second homes and whatever else people buy.

• Because xenophobia runs rampant in this country of immigrants, states cannot use federal funds to pay for the health care of undocumented immigrants, so the commission would need to figure out a way to only use state money to pay that bill.

That said, we don't have to wait until 2026 to cover the undocumented. Last week Rep. My-Linh Thai and a bunch of cosponsors introduced House Bill 1191, which stands up a state-funded Medicaid-like program for undocumented immigrants, and also allows them to buy health plans on the exchange if they make too much money to qualify for Medicaid. I'm sure Republicans will have an absolutely normal response to that bill if it ever gets a hearing.

That said, the idea of covering undocumented immigrants has friends in high places. According to a spokesperson, WA Insurance Commissioner Mike Kreidler believes that the undocumented "should be able to access health care, especially during a pandemic."

Aside from being the morally right thing to do, Kreidler pointed out that providing access to preventative care for immigrants will lower costs to citizens and to the undocumented in the long run, since many only seek treatment in emergency rooms when ailments become life-threatening.

"Other countries do this and so should we," Kreidler's spokesperson said. "We think the new administration will be more likely to want to help immigrants rather than penalize them for the color of their skin," she added.

Does This Omnibus Bill Stand a Chance?

Sen. Emily Randall, who was elected majority whip this session, is generally supportive of the proposal but admits her "crystal ball is even fuzzier than it has been in previous sessions" given the number of competing priorities and the fact that lawmakers expect fewer bills to get through this year due to the slower and more glitchy nature of the remote session.

As it's still early in the process, she's not sure whether the proposal would have an easier time getting to the floor as a big omnibus package or as a bunch of little pieces.

As for the proposals themselves, Randall said the idea of increasing subsidies on the exchange for those "closer-to-middle-income families" has "a lot of interest" in the caucus, and that budget writers are currently discussing how much money they could "reasonably" dedicate to increasing those subsidies.

People have "a lot of ideas" for how to pay for the subsidies, Randall said, but none are anywhere near set in stone.

Some revenue ideas proposed or soon-to-be proposed this year include a capital gains tax, a wealth tax, a statewide payroll tax, and a tax on health insurance plans, among others. Every lobbyist looking for money to fund one of the state's seven or eight active crises (education funding, public health funding, mental health funding, wildfires, housing/homelessness, the fucking culverts, etc.) will be after all those same pots, so securing funds will be tough as ever.

Randall said she feels more confident about bills that restore proposed programs Inslee cut at the end of last session, such as her bill to extend Apple Health (Medicaid) coverage for mothers for a year after the baby's born.

Senate Majority floor leader Marko Liias said increasing subsidies, inserting intent language into the RCW, and continuing the work of the universal health care work group "seem like the least difficult lifts" at the moment, though he admits that challenges abound. Setting up a health care account in the treasury and figuring out how to cover all Washingtonians "are the bigger challenges that cost more, but that's our mission," he added. "How much of it happens this year versus the future is the open question there."