History in the making.
On the books. Screengrab from TVW

Last Thursday Gov. Jay Inslee signed a proposal sponsored by Sen. Emily Randall and co-authored by Alliance for a Healthy Washington that would establish a permanent universal health care commission to help the state replace its expensive and broken multi-payer health care system with a cheaper and unified single-payer health care system "once the necessary federal authority has become available."

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That "necessary federal authority" would come in the form of waivers allowing Washington to use federal health care funds to set up its own (or a regional) system, a process we'll discuss a little in a second.

But before we do, I'll say that it's normally difficult to get too excited about another commission, since lawmakers often stand up commissions as a way to delay action on an issue. This commission, however, holds more promise than others—at least as far as Dr. William Hsiao is concerned.

Hsiao, a Harvard economist and actuary who President Jimmy Carter tapped to design a national heath care system in the U.S.—and who went on to design Taiwan's single-payer system, along with eight others around the world—called Randall's new law "the strongest" universal health care legislation he'd seen "in a decade."

Part of the legislation's strength lies in the composition of the commission itself. The commission includes lawmakers from both sides in both chambers, as well as the Insurance Commissioner, the Department of Health secretary, the head of the Health Care Authority, the CEO of the health benefit exchange, the Office of Equity director, plus six experts. The law limits the appointed committee chair's term to three years, so an incremental reformer can't just camp out on top and slow down progress for long.

By November of 2022, this commission must write a big baseline report that lays out the status of the current system; presents a detailed strategy for lowering health care costs and increasing access, including but not limited to implementing a single-payer system; provides some assessment of how ready we are to make the jump to that single-payer system; and runs down a detailed list of recommendations for how much to reimburse health care providers, what the benefits packages should look like, and how to fund that single-payer program. They can't just drag their feet on this report, either. The law requires the commission to begin work three months from now.

Then the commission must continue finding ways to lower costs and increase access to health care, publishing annual reports that we all get to hold up and scream about if the state doesn't implement their recommendations.

Speaking of which, the law allows state agencies to "implement specific elements of any report issued" if those recs fall within a given agency's authority. That means the Health Care Authority or the Department of Health could create some serious programs that would take steps toward implementing a single-payer system without first needing to run them through the creaky Legislature. (The legislation, however, specifically forbids the commission from just full-on implementing single-payer without "further action by the legislature and the governor.")

For Dr. Hsiao, the report the commission must draw up amounts to the "most comprehensive" one he's seen in a decade, and the reforms he imagines possible under this law could be "quite bold."

If the commission recommends it, for instance, the state could form a central purchasing alliance to negotiate with pharmaceutical companies on drug prices, or require all health care providers to move toward a uniform clinical record system to reduce administrative costs, he said.

(The state is already doing the latter through its Clinical Data Repository, but only for Medicaid patients. As for the former suggestion, lawmakers proposed a bill to establish a prescription drug affordability board to negotiate prices, but Inslee vetoed it last year due to the pandemic.)

These measures, Hsiao stressed, would help eliminate administrative waste in the system, which, on average, costs every single American $2,500 per year.

Other potential measures—such as expanding Medicaid, setting up a system to cover undocumented immigrants, or including an actual public option on the exchange—would require much more money, which brings us back to that original question of securing "necessary federal authority."

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To fund those kinds of programs, Washington lawmakers could of course raise taxes ha ha ha, or the state could ask the Feds to allow us to redirect federal dollars to other programs, or otherwise waive certain rules to accomplish our own goals.

Washington's new law actually requires the state to "begin any necessary federal application process within 60 days of its availability." So a literal reading suggests that the Washington Health Care Authority must begin applying for various "necessary" Medicaid and Employee Retirement Income Security Act (ERISA) waivers in a couple months if we need them to increase access to health care or lower costs.

The Feds don't have to grant those applications, but the point is the language of the bill compels the state to seek those waivers. Next month California Congressman Ro Khanna plans to re-introduce the State-Based Universal Health Care Act of 2021, which would greatly streamline the waiver application process. If Biden signs that bill, and if the state's universal health care commission presents a realistic and reasonable plan for using those Federal funds to expand Medicaid or what have you, then we could be well on our way to a much cheaper, much more comprehensive, and much more humane health care system in the very near future.

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