Public option plans in Colorado, Nevada and Washington offer residents another way to purchase health insurance.
Photo by Adamkaz, courtesy iStockphoto
“The public option has shown a lot of promise when you think about those overarching goals of access, equity and affordability.”
— Laura Kate Zaichkin
Despite decades of federal reform, tens of millions of Americans continue to go without health insurance coverage. Many of those who do have it have trouble paying expenses, leading them to skip preventive care, prescriptions and needed medical treatment. Some states are now working to create their own solutions.
This year, Nevada became the third state to launch what is known as a “public option,” following in the footsteps of Washington and Colorado. Nevada's Battle Born State Plans, which began this year, are designed to provide lower-cost options to residents.
“The Battle Born State Plans represent a new approach to improving affordability and access in Nevada's individual health insurance market,” Stacie Weeks, JD, MPH, director of Nevada Health Authority, told The Nation's Health.
Under the public option model, states partner with insurance companies and set terms with providers to manage costs, essentially regulating how much stakeholders can charge customers for health insurance. Customers are usually those without employer-based care who earn too much to qualify for Medicaid but too little to afford a plan through the federal health insurance marketplace.
“A public option is a mechanism through which states can introduce pricing limits on insurers, hospitals and providers,” Christine Monahan, JD, assistant research professor and faculty member at the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy, told The Nation's Health.
Last year's federal budget included Medicaid provisions that will push hundreds of thousands off the rolls when they go into effect in coming months and years, experts say. Other provisions will increase paperwork and shorten enrollment windows. The changes are expected to cause 3 million customers to lose coverage, according to the Congressional Budget Office.
In addition, Congress allowed marketplace enhanced tax credits begun during the COVID-19 pandemic to expire last year. Millions of Americans have lost health coverage, while others are paying much higher rates.
In 2021, Washington state debuted its public option, known as Cascade Select. As with Medicaid, potential enrollees must qualify based on their income. Premium assistance and cost-sharing subsidies are available.
The first open enrollment drew about 2,000 customers, or 1% of the marketplace, according to the state exchange. The poor debut was caused not only by its newness, but also that many hospitals declined to take part, creating a network provider shortage. As a remedy, Washington passed legislation creating a provider participation requirement for hospitals receiving Medicaid payments.
Some states are looking to public option plans to reduce costs and make health insurance more affordable for their low-income residents.
Photo by SDI Productions, courtesy iStockphoto
For 2026 open enrollment in Washington, 115,000 people signed up, representing 40% of customers on the state marketplace. Average cost for a Cascade Select comprehensive plan for a 40-year-old nonsmoker was $500, while the average cost offered by other plans was $662, according to an internal study.
In nearly every Washington county, Cascade Select offers the lowest premium, said Laura Kate Zaichkin, MPH, director of competition and affordability at the Washington Health Benefit Exchange. Moreover, some former Medicaid users impacted by federal actions joined Cascade Select. Most of them took advantage of a state-offered financial assistance subsidy.
“The public option has shown a lot of promise when you think about those overarching goals of access, equity and affordability,” Zaichkin told The Nation's Health.
Colorado launched its public option in 2023. The plans are priced competitively with no cost for preventive primary care or mental health visits, according to Kyla Hoskins, MPH, deputy commissioner of the Colorado Division of Insurance.
Learning from Washington state, Colorado made it mandatory that all private insurers on the marketplace offer the public option. Insurers must negotiate with providers for lower prices. State regulators step in to impose provider rate reductions if an impasse occurs. In the first year, open enrollment attracted 41,000, or 15% of market customers.
In 2024, open enrollment for the Colorado Option attracted about 80,700 customers, or 34% of market participants. That year, a policy brief by Brown University's Center for Advancing Health Policy Through Research found that the Colorado Option offered a $101 reduction in monthly premiums in the two plans researched.
In the run-up to the 2026 open enrollment, Colorado launched a campaign to promote the plan and a new state-funded financial assistance program. Colorado Option attracted nearly 139,000 customers, or half of the marketplace, Hoskins said.
Battle Born plan debuts in Nevada
Nevada's Battle Born State Plans seek to achieve a 15% premium reduction over four years, compared to a benchmark plan on the Nevada health insurance marketplace. Taking a page from Washington state, Nevada also required health care providers tied to Medicaid reimbursements to be in-network on at least one Battle Born plan.
“If providers do not comply, they risk losing their continued eligibility to contract with Medicaid and the state's public health employee coverage program as a network provider,” Weeks said.
In addition, Nevada established a reinsurance program, in which the state reimburses insurers on high-cost claims, to entice carriers, and financial subsidies to entice customers.
The Battle Born State Plans attracted nearly 10,800 customers during 2026 open enrollment, about 10% of the market, which was less than expected. But modest participation is common for new plans due to the market's auto-enrollment process, which keeps customers insured but also is a barrier to their shopping around for a less expensive plan, Weeks said.
Nevada Health Link's free enrollment assistance was a bright spot. During open enrollment, exchange brokers and navigators assisted 70% of customers.
In February, the state waived the requirement that Medicaid-contracted providers be in-network for a public option plan. The waiver ensures that customers receive appropriate health care access in the first year.
“We anticipate that in the next plan year, we will be able to implement fully this requirement,” Weeks said.
Minnesota is ready to launch a public option in 2027. But a handful of other states have backed out or put efforts on hold.
Zaichkin advises hesitant states that patience is needed because a viable public option can take years to establish, and tweaking the program as it unfolds should be expected. Also, federal subsidies are available to states to reduce costs.
“In Washington's experience, it's taken time to see the results we're seeing today,” Zaichkin said. “It takes a lot of political will, collaboration with partners, thoughtful design and implementation. It is a long-term investment that states can make to lower health care premium costs.”
For more information, visit https://nevadahealthlink.com/bbsp, www.hca.wa.gov and https://doi.colorado.gov.
- Copyright The Nation’s Health, American Public Health Association
