He picked the public option.
He picked the public option. RS

As I suspected, at a press conference Tuesday morning Governor Jay Inslee announced his support for Cascade Cares, "a public option health plan" being introduced to the legislature by Rep. Eileen Cody.

This is a big deal. It's also a frustrating thing to think about. If the bill passes, then health insurance costs on the state exchanges will be cheaper, which will make health care affordable and more accessible for thousands of Washingtonians. However, many different health care plans will be floating around Olympia this session. Why did the governor—who enjoys healthy Democratic majorities in the House and the Senate—pick this one, which will likely be the least progressive option? Is it because he wants to back the bill with the highest chance of success to boost his cred before a possible run for the presidency? Is it because he thinks it's a better policy than single-payer bills or bills that would set up infrastructure for a state-based single payer system? Is it a little bit of both? And what's even in this bill? Does it suck? WELL I'M GLAD YOU ASKED.


Unlike other "public option" bills we've seen in other states, this one doesn't allow everybody to buy into Medicaid, nor does it allow everybody to buy into a health care package available to government employees, such as the Public Employees Benefits Board. Instead—according to an early draft subject to change—the state will partner with private insurance companies to create a new, cheaper health care plan that people can buy on the health care exchange.

If the bill passes, the Washington State Health Care Authority and the Office of the Insurance Commissioner will draw up a contract with interested carriers. The state will demand that, by 2021, any company who wants to sell insurance on the exchange must offer something called a "Cascade Care" plan. This plan will include all the essential benefits required by the Affordable Care Act, but it will—probably—be cheaper than any of the other plans on the exchange. Deductibles and premiums will be lower because the state will share health care costs with the insurance companies, reimbursing them at Medicare rates (which are, incidentally, higher than Medicaid rates), according to a summary of the bill.

A representative for the Commissioner told me that insurance companies will have to provide this plan in every county of the state, so there shouldn't be any provider deserts or problems accessing a doctor or hospital. And the insurance companies can sell whatever gold, silver, or bronze plans they want on the exchange for a few years, but by 2025 they'll only be able to offer the Cascade Care plan. If they want to play ball on the exchange, then they'll have to agree to all of that.

There's also this other thing. A lot of people—exactly 68,632, according to the state's fall enrollment report—make too much money to qualify for Medicaid but not enough to afford the premiums for the current plans on the exchange. If you're a single person making more than $48,560, for instance, then you don't get a subsidy. Your choice then is to pay high premiums on the private insurance market or pay high premiums on the exchange. Either way, you're basically screwed.

To begin to address that problem, Inslee's bill calls for a study to determine how much it would cost to "implement and fund" subsidies for those people, with the goal of having them "spend no more than 10 percent of their incomes on premiums."


The challenge for Washington state Insurance Commissioner Mike Kreidler lies in trying to convince enough carriers to agree to the deal. If the companies don't sign on, people with Cascade Care might have problems trying to find hospitals and doctors who will accept their insurance. Right now, according to Kreidler, "Kaiser seems interested," but we'll see about any others.

Moreover, carriers are "mad," Rep. Cody said in a brief interview following the press conference, because they think this bill "gets rid of competition." If all the insurance companies in the state eventually have to offer the same plan on the exchange by 2025, then why would anyone pick one insurance company over another on the exchange? And doesn't the competition keep prices low?

Cody's answer to their first concern is: "They'll need to compete on quality." My answer to that second concern is: the competition hasn't stopped premiums from rising, nor has it stopped carriers from making bank off selling high-deductible packages to young people who think they're impervious until they break a leg and have to pay like $4,000 out of pocket because they have this stupid "bronze plan" that doesn't cover anything. So, no, the competition doesn't seem to be working very well at all.

But insurance companies aren't the only ones who are a little "mad." Cody says some doctors and hospitals have also expressed displeasure because they're not going to make a lot of money off the new plan. To which I say: yeah, well, welcome to my world.

That said, now that the Republicans have removed the individual mandate from Obamacare, insurance companies are worried that people are just going to start dropping out of the exchange. That'll hurt their bottom line, and also, you know, leave a lot of people uninsured. "I am most worried about those people who don't receive the subsidies," Kreidler said. "Those individuals, in particular, are more likely to be forced economically to drop health insurance."

Furthermore, Washington state still has about 400,000 uninsured people. That's 400,000 more potential customers for the insurance companies if the plans become affordable enough.

Still, Kreidler admits a public option will be "a challenge to enact" and "a challenge to implement," but he thinks it's "worth the cost because there are people out there still hurting."


At the press conference, Inslee called the bill "another significant step to the goal of universal heath care in the state of Washington." It will only be a "significant step" toward universal health care if the bill's success (or failure) inspires him to back a single-payer system later on.

The bill doesn't offer options for anyone who doesn't qualify to buy into the exchange. It doesn't serve the state's undocumented population, which is about 250,000 according to the American Immigration Council. Cody says coverage for undocumented Washingtonians will have to be taken care of in another bill because they're not eligible to buy on the exchange. But lawmakers could add a provision that funds health care for undocumented workers to this bill if they wanted to. (They still can, by the way. The bill is still in draft form.)

And, since "Washington's public option" is based on a private-public partnership, we'd be gambling with the caprice of profit-driven companies. If insurance companies want to stop doing business on the exchange—or even in the state of Washington—they could just decide to dip. Then the state would be stuck with a bill. How would we come up with those dollars? State-based systems are subject to changes in political power, so they're not completely stable either, but Inslee's public option only stabilizes the ACA so long as we have private providers willing to operate on our exchange. How are we going to address the idea of insurance companies pulling out of the exchange, or pulling out of the state entirely?

And is a kind-of public option really the best we can do? Compared to New York City Mayor Bill de Blasio's plan, which he suprise-announced Tuesday morning, Inslee's bill kinda seems a little weak. NYC will now be straight-up guaranteeing comprehensive health care to 600,000 New Yorkers, including 300,000 undocumented immigrants, starting this summer. To be fair: NYC isn't offering health insurance. They're just giving people a card and paying for their health care, which will cost $100 million per year. It's unclear how much Inslee's bill will cost, but it likely won't be that much. It also won't cover 600,000 people, including immigrants.

The bill will, however, expand access to coverage to more people. That's not nothing. But it's not the only option.