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Public Options Will Improve Health Equity Across the Country

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The COVID-19 pandemic has exposed and exacerbated health inequities—particularly those along racial and ethnic; rural and urban; and socioeconomic lines.1 While these inequities have been long-standing, the disproportionate impact of the coronavirus crisis on underserved communities has recently driven public momentum to meaningfully address the social determinants of health.2 Doing so requires commitment and intention from all levels of government and a collaborative approach in which community members direct and contribute to these plans and conversations.

State and federal policymakers have the power to address the full scope of health disparities—both by increasing coverage and access to affordable care and by addressing the social, economic, and structural roots of inequity that drive health disparities. Achieving universal coverage and lowering consumer costs are key elements of meaningful change, and mindful policymakers can also use public options to address an even broader range of health inequities. A public option for health insurance—a reform that would give people the option to enroll in publicly backed health insurance plans instead of private insurance—has been proposed at state and federal levels. Not only is a public option an important tool to negotiate lower prices that will reduce out-of-pocket costs, but it can also be used to create significant and sustainable equity improvements.

Health care industry groups opposed to public options have argued that reforms could decrease coverage options in rural areas, leading to a two-tier health system—one public, one private—and worsening health disparities.3 What these critiques seem to miss is that the current health system is riddled with health inequities and unaffordable care for those who are not healthy and wealthy.4 From the ubiquity of people turning to crowdfunding to afford care, even when privately insured, to affluent Americans securing COVID-19 vaccines ahead of low-income, Black, Hispanic, and Native communities who have faced the brunt of the pandemic, health care access and optimal health outcomes under the current system are unattainable privileges for many Americans.5 Yet these analyses of service provision and unmet needs mask one of the biggest beneficiaries of the U.S. health care system: powerful health care industry leaders.6 In spring 2020, a time of the greatest job loss since 1975, some of the largest insurers doubled their earnings from the year prior.7

Public option and other similar reforms can improve health equity by bringing down care costs and ensuring that those savings reach consumers and underserved communities. A public option would introduce more competition into the health insurance market, and it would use its market power to negotiate lower payment rates, driving down costs for its public plans as well as private commercial plans. These cost savings can be passed to consumers through lower premiums and cost sharing and reinvested in broader equity initiatives to address social determinants of health. Public options that make health care more accessible and affordable and that invest in dismantling the underlying conditions that contribute to health inequities can be key to creating a more equitable nation—one in which all Americans are able to learn, grow, and thrive.

Many factors drive health disparities and inequities

Many noncoverage factors—called social determinants of health—play a critical role in whether a person is likely to remain healthy.8 Discrimination in and out of the medical system has driven health inequities for centuries—ranging from discrimination in housing and job opportunities to challenges accessing culturally competent health care.9 Crowded conditions, unstable housing, access to nutritious food, and environmental dangers put underserved populations at increased risk.10 Disparate access to education, employment, and paid leave, as well as income and wealth gaps, also contribute to health inequities.11 These deeply rooted problems must be addressed through policies that seek to foster health equity beyond bolstering health care coverage and affordability.

Nevertheless, lack of adequate coverage does affect access to affordable, quality health care and reinforce these insidious inequities. Despite the Affordable Care Act’s (ACA’s) narrowing of racial and ethnic coverage disparities, Black, Hispanic, and American Indian and Alaska Native communities remain far more likely than non-Hispanic white people to be uninsured.12 For example, in 2018, Hispanic people were more than 250 percent more likely to be uninsured than non-Hispanic white individuals.13

Even those who have insurance struggle with affordability. According to the Kaiser Family Foundation, at least 1 in 4 adults report each of the following measures: difficulty affording routine health care costs, not taking prescriptions as prescribed due to cost, and struggling to pay medical bills.14 In 2018, people with incomes below 250 percent of the federal poverty level—$30,000 for a single person and less than $63,000 for a family of four at the time—were twice as likely to feel unconfident about their health insurance helping them afford care.15 Tragic stories about delaying treatment or inability to take leave from work have proliferated in recent years,16 and unaffordable health care costs continue to burden Americans. In 2020, 27 percent of insured nonelderly adults reported problems with medical bills or debt.17

Compounding coverage and financial disparities, many U.S. residents struggle to access high-quality, culturally competent care.18 People living in rural and low-income communities have limited access to hospital care. In fact, half of low-income communities do not have any intensive care unit beds—a problem with devastating consequences during the COVID-19 crisis.19 Both a history of racist policies and spending cuts and the contemporary closure of hospitals in rural and low-income communities have led to so-called health care deserts, disproportionately limiting access to care for Black and Hispanic families in particular.20

Intersections between identities make it increasingly difficult to access identity-affirming care. LGBTQ individuals often face health care discrimination, which can decrease their likelihood of seeking care. Due to discrimination in health care settings, 15 percent of LGBTQ individuals, including nearly 30 percent of transgender individuals, have postponed or avoided medical treatment.21 One in 4 transgender people reported a provider refusing to see them due to their gender identity.22 Nationally, physician workforces do not reflect the diverse populations they should be serving, lack cultural competency, and will continue to reinforce these inequities and discriminatory practices if left unchecked.23

Building on the successes of the Medicaid program, public options can provide comprehensive benefits that meet the needs of their most at-risk enrollees and begin to address key inequities.24 Black, Hispanic, and American Indian/Alaska Native families are more likely than non-Hispanic white people to be covered by Medicaid, as are LGBTQ individuals compared with their non-LGBTQ counterparts.25 The Medicaid program has been a lifeline for low-income and other underserved communities: It covers half of all births, nearly half of children and adults with disabilities, and more than 60 percent of nursing home residents.26 Critically, Medicaid offers benefits that reflect the needs of its diverse populations. For example, Medicaid programs cover speech and occupational therapy for children with autism and other disabilities and prenatal and delivery costs for pregnant people.27 A public option can similarly meet the needs of its enrollees.

States are considering public options

While various public option proposals carry different features, this issue brief discusses the public option as an umbrella term that includes plans to improve coverage and bring down costs through greater competition.28 Common characteristics of state public option reforms include a state-backed public option that competes with private plans in the individual market for health insurance; government-regulated rates for provider payments; and income-based financial assistance in addition to that currently available through federal subsidies. There are also federal public option variations, such as President Biden’s proposal, of similar design.29

Several states are developing public options or taking other steps to make health plans more affordable.30 Washington state launched its Cascade Care public option for the 2021 enrollment period, through which private carriers offer affordable, standardized plans that “provide more services with reduced cost-sharing” than nonstandardized plans and offer lower deductibles and more pre-deductible services.31 The state has set aggregate payment caps at 160 percent of Medicare rates for all medical services, accounted for differences in service types and shortage areas, and projected 5 percent to 10 percent premium cost savings. However, Washington has not met its premium savings goal in its first enrollment period.32 While public and nonpublic standardized plans—both new additions to the state’s marketplace for 2021—were more expensive than nonstandardized plans that are not beholden to the same rigorous quality standards, public option standardized plans were less expensive than nonpublic option standardized plans in all but one county in which they were offered.33

In 2019, Colorado lawmakers passed legislation that directed state agencies to develop a public option proposal. The state recently introduced another bill that34 would require private insurers to offer individual and small-group market standardized benefit plans in every county in which the insurer offers other, nonstandardized individual and small-group market plans and that would set premium reduction goals over three years.35 A previous iteration of the legislation called for a state-run public option contingency in the case of unmet premium reduction goals. Under the most recent text, if insurers fail to meet the premium reduction goals, the Colorado Division of Insurance will hold a public hearing and, based on evidence offered at the hearing, may set provider payment rates if necessary to reach the premium reduction target or meet network adequacy requirements. The legislation would also set a floor based on a percentage of Medicare payments, below which the state could not lower payment rates.36

Efforts to enact a public option are also gaining momentum in several other states. The Oregon Legislature received study results evaluating three public option proposals in December 2020 and is considering a bill that would direct the Oregon Health Authority to develop a public option implementation plan, although additional legislation would be needed to enact the public option.37 Nevada enacted a resolution to study public option possibilities in 2019.38 Similar in design to Washington state’s Cascade Care, Nevada legislators recently introduced a new bill that would require private insurers that bid to operate Medicaid plans in the state to offer public option plans and require providers that accept Medicaid and the Public Employees’ Benefit program to participate in the public option program.39 With increased market power and competition, the Nevada bill plans to lower premiums by at least 15 percent over five years.40 Connecticut legislators have introduced two public option bills previously and plan to bring another bill up for consideration this year.41 Several other states, including Delaware, Massachusetts, and New Mexico, have initiated or completed studies of pursuing public options in their states.42

Public option reforms can improve health equity and disparities

Public options or other related reforms would drive competition and efficiency into the existing health care market, lowering prices within the public option plan with ripple effects of lowered prices in the private market. These savings can be passed on to consumers and reinvested into equity initiatives that target social determinants of health. Governments have a ripe opportunity when designing state-backed plans to integrate benefits, services, and community investments that tackle insidious inequities into their public option plans.

Bringing down prices for care while bolstering access

A key element of the projected success of the public option is lowering payment rates for both public option and private plans. This provision would be particularly salient in hospital settings. Recent trends of hospital consolidation and diminished competition have added to health systems’ market power, allowing hospitals to take in large profits and set high prices for commercial insurers.43 Indeed, according to an analysis by the RAND Corp., commercial issuers pay nearly 2 1/2 times as much as Medicare does for hospital care.44 Not only does high-priced hospital care drive countless stories of medical debt and sky-high bills, but it also results in higher premiums.45

A public option drives competition into the insurance market. With a significant number of enrollees and state pressure, the public option can use market power to negotiate provider reimbursement levels below current commercial rates. Knowing that enrollees can switch to the public option, commercial insurers would have an incentive to negotiate lower payment rates to stay in competition. The savings from lower rates could be passed on to enrollees in both the public option and commercial insurance plans through lower premiums and reduced cost sharing.

This downward pressure on prices could help make universal coverage sustainable under a public option. A public option that itself offers lower premiums could also drive down premiums for competing private insurance plans. These lower costs would also generate potential savings for the federal government because ACA subsidies are pegged to plan premiums. Using federal Section 1332 waivers, states could apply to receive pass-through funding to put expected savings toward policies to expand coverage to the uninsured or improve affordability for those covered through the individual market.46

Bringing down costs for care does not have to be at the expense of struggling providers and hospitals; payments can be adapted to meet the needs of safety-net providers and others that need it. For instance, policymakers could offer higher or additional payments to community health centers—key to providing care to underserved populations—to improve access to care.47 Washington state’s Cascade Care plan sets a payment floor of 135 percent of Medicare rates for primary care services to prioritize access to and sustainability of primary care.48

Policymakers must also consider hospitals and providers on the front lines of the pandemic and ensure that payment rates are adequate to keep those providers afloat. Since the onset of the coronavirus crisis, 60 percent more rural hospitals have been at risk of closure.49 Coverage expansion has been key to sustaining rural hospitals: From 2013 to 2017, rural hospital closure rates were double previous rates in non-Medicaid expansion states, while expansion states experienced little change in rural hospital closures.50 Even at Medicaid payment rates—which are well below those of private insurers, at an average of 72 percent of Medicare rates for common procedures—greater coverage plays a large role in improving the vitality of rural hospitals.51 Washington’s Cascade Care plan sets a payment floor for rural hospitals at 101 percent of Medicare rates, suggesting expanded coverage will continue to improve the financial vitality of struggling hospitals.52

By overseeing provider contracting, state and federal governments can ensure that public option payments support providers that provide care to underserved, at-risk community members. Providing higher payment rates for these providers would incentivize them to continue providing this care and augment their ability to stay afloat.53 Using this payment system to equitably distribute resources would require upfront analysis of which providers serve at-risk communities. As the Massachusetts Office of the Attorney General describes, states can use cost-growth benchmarks, modified global budgets, and grant funding for patients receiving no-cost coverage to support safety-net hospitals and health centers.54 States could also offer add-on payments to certain providers, such as those that meet certain thresholds of treating low-income or uninsured patients. Finally, these equitable payments would require ongoing monitoring to ensure that the additional funding is reaching the right providers and adequately supporting health care resources.

Improving affordability for individuals

As detailed above, a significant proportion of U.S. residents struggle to afford their health care, especially those in historically marginalized communities, including Black, Hispanic, Native, and LGBTQ individuals and people living in poverty.55 By regulating provider payment rates, governments can pass on savings to consumers through lower premiums, deductibles, and other forms of cost sharing. States can also play a more active role in benefit design. Using data from public health agencies, the public option could offer certain services that would improve population health at no out-of-pocket cost or pre-deductible. For example, following Washington state’s lead, pre-deductible coverage for services such as primary care and behavioral health and no-cost prescription drugs for chronic conditions could benefit underserved communities.56

The government could also design plans to include nonclinical services that address barriers to accessing care. Numerous studies point to lack of transportation as a driver of delayed care, missed appointments, and missed prescription refills, especially among low-income individuals.57 In a 2013 study, 1 in 4 lower-income patients reported missing or rescheduling health care appointments due to transportation constraints.58 These barriers are felt unequally; people of color are more than twice as likely as white people to live in a household without access to a vehicle.59 A public option could include nonemergency transportation as a benefit and apply the same framework to address similar barriers.

Applying savings to other equity initiatives

By creating a more efficient and high-value health insurance system, the government can reinvest savings to address social determinants of health. Targeted investments in key nonclinical drivers of inequity, such as housing, transportation, and education, would not only reduce health inequities but also potentially decrease health care expenditures, as these initiatives improve health outcomes and encourage people to seek care before conditions become acute.60 For example, under the Super-Utilizer Pilot Project in rural Montana, community health workers and nurses contacted people using hospital care at high rates; identified barriers to health and health care; and connected participants with services and resources, collaborative care plans, and other supports.61 The program saved more than $1.8 million in hospital costs by serving just 36 participants.62 The savings from addressing broader barriers and inequities can be both passed to consumers and reinvested in further equity initiatives.

Effectively addressing social determinants of health requires coordination and collaboration between community stakeholders. Some local nonprofit hospitals and public health departments already assess community needs; bringing together independent groups and organizations to identify shared community priorities and needs is key to creating a meaningful impact.63 With additional funding, local health departments can serve as the epicenter for community-based equity initiatives, working with other agencies and community organizations with specific expertise on particular social determinants.

Prioritizing equity before and after implementation

State and federal policymakers designing public options must prioritize equity at every opportunity. From the very beginning of idea generation, meaningful community engagement—especially with communities of color and other high-risk populations—is integral to designing plans that will prioritize interventions in the ways affected communities find most valuable and urgent. Rather than just serving as approvers or endorsers, representatives from underserved communities must be welcomed as decision-makers throughout the entire process. To accomplish this, public health departments and other government actors must publicize opportunities for community involvement and invest in engaging at-risk and underserved individuals.64

Federal and state governments developing and implementing public options must dedicate resources to thinking through data collection, monitoring, and evaluation. Public option plans can best address inequities with data that accurately assesses community needs. As these programs are implemented, government actors will need to evaluate improvements in access and other measures of equity. Disaggregated data will be key to ensuring that equity initiatives reach in-need communities. Meaningful community engagement is as necessary to evaluating initiatives as it is to developing them—patient reported measures are some of the most critical data to evaluate.65

Conclusion

The coronavirus pandemic has made it clear that the status quo of health coverage is not working for everyone. To reimagine the United States as a country with affordable and accessible coverage for all, policymakers need to make significant investments—not only to achieve universal coverage but also to address inequities in nonclinical factors that contribute to poorer access and worsening health disparities. Public options designed with equity in mind can be an important part of creating a healthier nation in which basic needs are met and opportunities to thrive are abundant.

Nicole Rapfogel is a research assistant for Health Policy at the Center for American Progress. Maura Calsyn is the managing director of Health Policy at the Center.

Endnotes

  1. Centers for Disease Control and Prevention, “Health Equity Considerations for Racial and Ethnic Minority Groups,” available at https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html (last accessed April 2021).
  2. Victoria Knight, “Events of 2020 Moved Medical Students to Political Activism,” Kaiser Health News, April 7, 2021, available at https://khn.org/news/article/events-of-2020-moved-medical-students-to-political-activism/.
  3. Karl Evers-Hillstrom, “Big Pharma, Insurers, Hospitals Team Up to Kill Medicare for All,” Center for Responsive Politics OpenSecrets.org, March 7, 2019, available at https://www.opensecrets.org/news/2019/03/big-pharma-insurers-hospitals-team-up-to-kill-medicare-for-all/; FTI Consulting, “Assessing the Impact of a Public Option on Market Stability and Consumer Choice” (Washington: 2019), available at https://americashealthcarefuture.org/wp-content/uploads/2019/11/FTI-Public-Option-Issue-Brief-FINAL.pdf.
  4. Nicole Karlis, “The health gap: The rich enjoy ten more years of good heath compared to poor,” Salon, January 16, 2020, available at https://www.salon.com/2020/01/15/the-wealthy-get-10-more-years-of-good-health-study-finds/.
  5. Barney Jopson, “Why are so many Americans crowdfunding their healthcare?”, Financial Times, January 10, 2018, available at https://www.ft.com/content/b99a81be-f591-11e7-88f7-5465a6ce1a00; Nathan Heller, “The Hidden Cost of GoFundMe Health Care,” The New Yorker, June 24, 2019, available at https://www.newyorker.com/magazine/2019/07/01/the-perverse-logic-of-gofundme-health-care; Shawna Chen, “Wealthy people are takingCOVID-19 vaccines allotted for others,” Axios, March 13, 2021, available at https://www.axios.com/covid-vaccine-wealthy-people-fd47f852-0e92-4581-aaf2-e0690877116a.html; Mary Van Beusekom, “Race, income inequality fuel COVID disparities in US counties,” Center for Infectious Disease Research and Policy,” January 20, 2021, available at https://www.cidrap.umn.edu/news-perspective/2021/01/race-income-inequality-fuel-covid-disparities-us-counties; Peter J. Cunningham, “Why Even Healthy Low-Income People Have Greater Health Risks Than Higher-Income People,” The Commonwealth Fund, September 27, 2018, available at https://www.commonwealthfund.org/blog/2018/healthy-low-income-people-greater-health-risks.
  6. Elisabeth Rosenthal, “Insurance policy: How an industry shifted from protecting patients to seeking profit,” Stanford Medicine, Spring 2017, available at https://stanmed.stanford.edu/2017spring/how-health-insurance-changed-from-protecting-patients-to-seeking-profit.html#.
  7. Heather Long and others, “The COVID-19 recession is the most unequal in modern U.S. history,” The Washington Post, September 30, 2020, available at https://www.washingtonpost.com/graphics/2020/business/coronavirus-recession-equality/; Reed Abelson, “Major U.S. Health Insurers Report Big Profits, Benefiting From the Pandemic,” The New York Times, August 5, 2020, available at https://www.nytimes.com/2020/08/05/health/covid-insurance-profits.html.
  8. Samantha Artiga and Elizabeth Hinton, “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity” (San Francisco: Kaiser Family Foundation, 2018), available at https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
  9. Sofia Carratala and Connor Maxwell, “Health Disparities by Race and Ethnicity” (Washington: Center for American Progress, 2020), available at https://www.americanprogress.org/issues/race/reports/2020/05/07/484742/health-disparities-race-ethnicity/; Ericka Stallings, “The Article That Could Help Save Black Women’s Lives,” O, The Oprah Magazine, October 2018, available at https://www.oprah.com/health_wellness/the-article-that-could-help-save-black-womens-lives#ixzz5VRnkBHiz.
  10. Azza Altiraifi and Nicole Rapfogel, “Mental Health Care Was Severely Inequitable, Then Came the Coronavirus Crisis” (Washington: Center for American Progress, 2020), available at https://www.americanprogress.org/issues/disability/reports/2020/09/10/490221/mental-health-care-severely-inequitable-came-coronavirus-crisis/.
  11. Jamila Taylor and others, “Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint” (Washington: Center for American Progress, 2019), available at https://www.americanprogress.org/issues/women/reports/2019/05/02/469186/eliminating-racial-disparities-maternal-infant-mortality/.
  12. Arielle Bosworth, Kenneth Finegold, and Joel Ruhter, “The Remaining Uninsured: Geographic and Demographic Variation” (Washington: U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation, 2021), available at https://aspe.hhs.gov/system/files/pdf/265286/Uninsured-Population-Issue-Brief.pdf.
  13. Samantha Artiga, Kendal Orgera, and Anthony Damico, “Changes in Health Coverage by Race and Ethnicity since the ACA, 2010-2018 (San Francisco: Kaiser Family Foundation, 2020), available at https://www.kff.org/racial-equity-and-health-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/.
  14. Ashley Kirzinger and others, “Data Note: Americans’ Challenges with Health Care Costs” (San Francisco: Kaiser Family Foundation, 2019), available at https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/.
  15. Sara R. Collins and others, “Americans’ Confidence in Their Ability to Pay for Health Care Is Falling,” The Commonwealth Fund, May 10, 2018, available at https://www.commonwealthfund.org/blog/2018/americans-confidence-their-ability-pay-health-care-falling.
  16. Michael Sainato, “The Americans dying because they can’t afford medical care,” The Guardian, January 7, 2020, available at https://www.theguardian.com/us-news/2020/jan/07/americans-healthcare-medical-costs; U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation, “2018 Poverty Guidelines,” available at https://aspe.hhs.gov/2018-poverty-guidelines (last accessed April 2021).
  17. Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, “U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability” (New York: The Commonwealth Fund, 2020), available at https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/looming-crisis-health-coverage-2020-biennial.
  18. Georgetown University McCourt School of Public Policy Health Policy Institute, “Cultural Competence in Health Care: Is it importance for people with chronic conditions?”, available at https://hpi.georgetown.edu/cultural/ (last accessed April 2021).
  19. Genevieve P. Kanter, Andrea G. Segal, and Peter W. Groeneveld, “Income Disparities In Access To Critical Care Services,” Health Affairs 39 (8) (2020): 1362–1367, available at https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00581.
  20. George Aumoithe, “The racist history that explains why some communities don’t have enough ICU beds,” The Washington Post, September 16, 2020, available at https://www.washingtonpost.com/outlook/2020/09/16/racist-history-that-explains-why-some-communities-dont-have-enough-icu-beds/; Tarun Ramesh and Emily Gee, “Rural Hospital Closures Reduce Access to Emergency Care” (Washington: Center for American Progress, 2019), available at https://www.americanprogress.org/issues/healthcare/reports/2019/09/09/474001/rural-hospital-closures-reduce-access-emergency-care/; Joseph P. Williams, “Code Red: The Grim State of Urban Hospitals,” U.S. News and World Report, July 10, 2019, available at https://www.usnews.com/news/healthiest-communities/articles/2019-07-10/poor-minorities-bear-the-brunt-as-urban-hospitals-close; Eli Saslow, “‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles,” The Washington Post, September 28, 2019, available at https://www.washingtonpost.com/national/out-here-its-just-me/2019/09/28/fa1df9b6-deef-11e9-be96-6adb81821e90_story.html; Randy Dotinga, “‘Health Care Deserts’ More Common in Black Neighborhoods,” Health Behavior News Science, May 4, 2012, available at https://www.newswise.com/articles/health-care-deserts-more-common-in-black-neighborhoods?ret=/articles/list&category=medicine&page=2&search%5Bstatus%5D=3&search%5Bsort%5D=date+desc&search%5Bsection%5D=10&search%5Bhas_multimedia%5D=.
  21. Sharita Gruberg, Lindsay Mahowald, and John Halpin, “The State of the LGBTQ Community in 2020: A National Public Opinion Study” (Washington: Center for American Progress, 2020), available at https://www.americanprogress.org/issues/lgbtq-rights/reports/2020/10/06/491052/state-lgbtq-community-2020/.
  22. Ibid.
  23. Barbara L. McAneny, “Why the AMA is committed to a diverse physician workforce,” American Medical Association, April 24, 2019, available at https://www.ama-assn.org/about/leadership/why-ama-committed-diverse-physician-workforce; Kevin B. O’Reilly, “Effort aims to create cadre of physician LGBTQ health specialists,” American Medical Association, February 14, 2020, available at https://www.ama-assn.org/delivering-care/population-care/effort-aims-create-cadre-physician-lgbtq-health-specialists.
  24. Manatt Health, “Medicaid’s Impact on Health Care Access, Outcomes and State Economies,” Robert Wood Johnson Foundation, February 1, 2019, available at https://www.rwjf.org/en/library/research/2019/02/medicaid-s-impact-on-health-care-access-outcomes-and-state-economies.html.
  25. Kaiser Family Foundation, “Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity, Timeframe: 2019,” available at https://www.kff.org/medicaid/state-indicator/nonelderly-medicaid-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (last accessed April 2021); Caroline Medina and Lindsay Mahowald, “Repealing the Affordable Care Act Would Have Devastating Impacts on LGBTQ People,” Center for American Progress, October 15, 2020, available at https://www.americanprogress.org/issues/lgbtq-rights/news/2020/10/15/491582/repealing-affordable-care-act-devastating-impacts-lgbtq-people/.
  26. Robin Rudowitz, Rachel Garfield, and Elizabeth Hinton, “10 Things to Know about Medicaid: Setting the Facts Straight” (San Francisco: Kaiser Family Foundation, 2019), available at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/.
  27. Ibid.
  28. Nicole Rapfogel and Emily Gee, “4 Myths About the Public Option,” Center for American Progress, November 20, 2020, available at https://www.americanprogress.org/issues/healthcare/news/2020/11/20/493105/4-myths-public-option/.
  29. Samantha Liss, “Biden’s most ambitious health policy: a public option plan,” Healthcare Dive, January 20, 2021, available at https://www.healthcaredive.com/news/bidens-most-ambitious-health-policy-a-public-option-plan/593342/.
  30. Jen Mishory, “Three States Make Progress on Public Option Proposals,” The Century Foundation, June 3, 2019, available at https://tcf.org/content/commentary/three-states-make-progress-public-option-proposals/?session=1&session=1.
  31. Patricia Boozang and Kyla Ellis, “The State of Play: Public Option at the Federal and State Level and What to Expect in 2021,” State Health and Value Strategies, January 7, 2021, available at https://www.shvs.org/the-state-of-play-public-option-at-the-federal-and-state-level-and-what-to-expect-in-2021/; Washington Health Benefit Exchange, “Washington Health Benefit Exchange certifies health plans for 2021 market; Offerings introduce Cascade Care and the nation’s first public option,” Press release, September 24, 2020, available at https://www.wahbexchange.org/washington-health-benefit-exchange-certifies-health-plans-for-2021-market-offerings-introduce-cascade-care-and-the-nations-first-public-option/.
  32. Mishory, “Three States Make Progress on Public Option Proposals”; Louise Norris, “Washington health insurance marketplace: history and news of the state’s exchange,” HealthInsurance.org, available at https://www.healthinsurance.org/health-insurance-marketplaces/washington/ (last accessed April 2021).
  33. Norris, “Washington health insurance marketplace”; Boozang and Ellis, “The State of Play.”
  34. Proposal for Affordable Health Coverage Option, H.B. 19-1004, Colorado General Assembly 2019 Regular Session (May 17, 2019), available at https://leg.colorado.gov/bills/hb19-1004; Eli Kirshbaum, “Lawmakers set to hold initial discussions on Colorado’s new public option bill,” State of Reform, March 22, 2021, available at https://stateofreform.com/featured/2021/03/lawmakers-set-to-hold-initial-discussions-on-colorados-new-public-option-bill/; Standardized Health Benefit Plan Colorado Option, H.B. 21-1232, Colorado General Assembly 2021 Regular Session (March 18, 2021), available at https://leg.colorado.gov/bills/hb21-1232.
  35. Colorado Standardized Health Benefit Plan Act, H.B. 21-1232, House Committee on Health and Insurance Amendment, Colorado General Assembly 2021 Regular Session (April 27, 2021), available at https://s3-us-west-2.amazonaws.com/leg.colorado.gov/2021A/amendments/HB1232_L.046.pdf.
  36. Ibid.; Standardized Health Benefit Plan Colorado Option, H.B. 21-1232, Colorado General Assembly 2021 Regular Session (March 18, 2021); Eli Kirshbaum, “No more ‘public option’ for Colorado,” State of Reform, April 27, 2021, available at https://stateofreform.com/featured/2021/04/no-more-public-option-for-colorado/.
  37. Relating to health care; declaring an emergency, H.B. 2010 A, Oregon State Legislature 2021 Regular Session (February 23, 2021), available at https://olis.leg.state.or.us/liz/2021R1/Measures/Overview/HB2010; Boozang and Ellis, “The State of Play.”
  38. S.C.R 10, Nevada Legislature 2019 Regular Session (June 1, 2019), available at https://www.leg.state.nv.us/App/NELIS/REL/80th2019/Bill/7087/Overview.
  39. S.B. 420, Nevada Legislature 2021 Regular Session (April 28, 2021), available at https://www.leg.state.nv.us/App/NELIS/REL/81st2021/Bill/8151/Overview.
  40. Ibid.
  41. Ibid.; State of Connecticut Comptroller, “Broad Statewide Coalition Announced Urgent Health Care Reforms Efforts,” Press release, November 12, 2020, available at https://www.osc.ct.gov/public/news/releases/20201112.html.
  42. Harris Meyer, “Colorado, Connecticut, New Mexico consider public-option plans,” Modern Healthcare, June 1, 2019, available at https://www.modernhealthcare.com/providers/colorado-connecticut-new-mexico-consider-public-option-plans.
  43. Emily Gee, “The High Price of Hospital Care” (Washington: Center for American Progress, 2019), available at https://www.americanprogress.org/issues/healthcare/reports/2019/06/26/471464/high-price-hospital-care/.
  44. RAND Corp., “Private Health Plans in the U.S. Pay Hospitals 247% of What Medicare Would Pay,” Press release, September 18, 2020, available at https://www.rand.org/news/press/2020/09/18.html.
  45. Jessica Wapner, “COVID-19: Medical expenses leave many Americans deep in debt,” British Medical Journal 370 (3097) (2020), available at https://www.bmj.com/content/370/bmj.m3097/rr; Gee, “The High Price of Hospital Care.”
  46. Jessica Schubel, “Frequently Asked Questions About ACA Section 1332 Waivers and Medicaid” (Washington: Center on Budget and Policy Priorities, 2019), available at https://www.cbpp.org/research/health/frequently-asked-questions-about-aca-section-1332-waivers-and-medicaid.
  47. Bradley Corallo and others, “Community Health Centers’ Role in Delivering Care to the Nation’s Underserved Populations During the Coronavirus Pandemic” (San Francisco: Kaiser Family Foundation, 2020), available at https://www.kff.org/coronavirus-covid-19/issue-brief/community-health-centers-role-in-delivering-care-to-the-nations-underserved-populations-during-the-coronavirus-pandemic/.
  48. Joint Select Committee on Health Care Oversight, “Update on Cascade Care: Standard Plan Designs and Next Steps” (Olympia, WA: Washington Health Benefit Exchange, 2019), available at https://www.hca.wa.gov/assets/program/hbe-cascade-care-update-20191212.pdf.
  49. Hannah Nelson, “COVID-19 Increases Rural Hospital Closure Risk, Care Access Concern,” RevCycleIntelligence, February 3, 2021, available at https://revcycleintelligence.com/news/covid-19-increases-rural-hospital-closure-risk-care-access-concern.
  50. Ibid.
  51. Rapfogel and Gee, “4 Myths About the Public Option”; Stephanie Zuckerman, Laura Skopec, and Joshua Aarons, “Medicaid Physician Fees Remained Substantially Below Fees Paid by Medicare in 2019,” Health Affairs 40 (2) (2021), available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00611; Ramesh and Gee, “Rural Hospital Closures Reduce Access to Emergency Care.”
  52. Joint Select Committee on Health Care Oversight, “Update on Cascade Care.”
  53. Noam Yossefy and Sandra Wolitzky, “Guest Blog: Attorney General Issues Recommendations to Address Health Inequities,” National Academy for State Health Policy, December 7, 2020, available at https://www.nashp.org/guest-blog-massachusetts-attorney-general-issues-recommendations-to-address-health-inequities/.
  54. Sandra Wolitzky and others, “Building Toward Racial Justice and Equity in Health: A Call to Action” (Boston: Office of the Massachusetts Attorney General, 2020), available at https://www.mass.gov/doc/building-toward-racial-justice-and-equity-in-health-a-call-to-action/download.
  55. Medina and Mahowald, “Repealing the Affordable Care Act Would Have Devastating Impacts on LGBTQ People.”
  56. Washington Health Plan Finder, “New 2021 Health Plans Including Cascade Care,” available at https://www.wahealthplanfinder.org/_content/new-2021-health-plans-including-cascade-care.html (last accessed April 2021); Yossefy and Wolitzky, “Guest Blog: Attorney General Issues Recommendations to Address Health Inequities.”
  57. Imran Cronk, “The Transportation Barrier,” The Atlantic, August 9, 2015, available at https://www.theatlantic.com/health/archive/2015/08/the-transportation-barrier/399728/.
  58. Ibid.
  59. National Equity Atlas, “Car access: Everyone needs reliable transportation access and in most American communities that means a car,” available at https://nationalequityatlas.org/indicators/Car_access#/ (last accessed April 2021).
  60. Artiga and Hinton, “Beyond Health Care”; Jessica Kent, “Costs Fell by 11% When Payer Addressed Social Determinants of Health,” Health IT Analytics, June 5, 2018, available at https://healthitanalytics.com/news/costs-fell-by-11-when-payer-addressed-social-determinants-of-health; Beth Jones Sanborn, “Hospital needs greater understanding, better programs for social needs, Deloitte study says,” Healthcare Finance, July 20, 2017, available at https://www.healthcarefinancenews.com/news/hospitals-need-greater-understanding-better-protocols-programs-social-needs-deloitte-study-says; Center for Health Analytics, Research and Transformation at New Jersey Hospital Association, “Chronic Conditions: Eroding the Fabric of a Healthy Society” (Princeton, NJ: 2019), available at http://www.njha.com/media/546633/CHART-Chronic-Conditions.pdf.
  61. Rural Health Information Hub, “Super-Utilizer Pilot Project,” available at https://www.ruralhealthinfo.org/project-examples/985 (last accessed April 2021).
  62. Ibid.
  63. Wolitzky and others, “Building Toward Racial Justice and Equity in Health.”
  64. E. De Weger and others, “Achieving successful community engagement: a rapid realist review” BMC Health Services Research 18 (285) (2018), available at https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3090-1.
  65. Tina Kauh, “Can Capturing More Detailed Data Advance Health Equity?”, Robert Wood Johnson Foundation Culture of Health Blog, August 30, 2018, available at https://www.rwjf.org/en/blog/2018/08/can-capturing-more-detailed-data-advance-health-equity.html.