KEYSTONE — Colorado Insurance Commissioner Michael Conway, his face bearing the golden-retriever smile of someone who is used to getting yelled at but not taking it personally, opened the floor to comments with a suitably open-ended question: As Colorado designs a publicly backed health insurance plan, what should it look like?

State lawmakers this year passed a bill making Colorado one of the first states in the country to create such a plan. It would guarantee consumers have at least one comprehensive health insurance option across the state, even if private carriers pull out. It would offer coverage at prices competitive to or below current rates. Access and affordability were its buzzwords.

But lawmakers left the rest of the details blank. It would be up to Conway and Kim Bimestefer, the head of the state’s Medicaid department, to make it all work, a task no state official anywhere in the country has ever actually done.

So here they were last week in Keystone, at the fifth of at least 11 stakeholder meetings across the state, looking for input. What should this be? Conway asked.

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And then came a deluge of opinion that showed how hard it will be to create a plan with broad support.

A man said it has to start by slashing what doctors and hospitals get paid. A representative from the Colorado Hospital Association said that would force hospitals to reduce pay to workers or cut back on other services.

A woman said the plan needs to cover immigrants, including those in the country without documentation. The man responded by arguing to close the border and “eliminate sanctuary cities.”

The head of the Colorado Consumer Health Initiative said the plan’s costs to patients should be capped at a percent of their income. An employee at Delta Dental wondered how his company could compete with a government-backed plan that undercuts them on price. A councilwoman from Glenwood Springs spoke about how desperately needed a more affordable insurance option is. A representative from the Jefferson County Economic Development Corporation asked Conway not to go forward with a plan.

Michael Conway (Courtesy of the Colorado Division of Insurance)

“We feel it is a solution that creates more problems than it solves,” she said

People at the meeting disagreed on whom the plan should be open to, where it should be offered, how it should be priced, how many options it should provide, whether the state should directly run it and whether taxpayer dollars should help fund it.

Throughout it all, Conway and Bimestefer, helped by a moderator from the Keystone Policy Center, kept an even bearing. After one multi-minute statement from a man expressing disgust with the health care system in general but raising questions about the feasibility of a public option, Conway smiled.

“So,” he said, “you have some concerns.”

A patient at UCHealth Memorial Hospital Central recovers from open heart surgery at the Colorado Springs hospital in August 2018. (Mark Reis, Special to The Colorado Sun)

Somewhere between single payer and status quo

A “public option,” as this type of plan is called in wonk-speak, is a holy grail of the slightly-left-of-center health policy world.

While politicians and advocates further to the left back single-payer models, such as Vermont U.S. Sen. Bernie Sanders’ Medicare for All, supporters of a public option say their plan combines the choice of the free market with the security of government support.

A public option allows private plans to continue but also introduces a government-backed plan to compete alongside them. The thinking among its supporters is that this will keep the private plans honest on price, while ensuring that consumers always have at least one choice amid the turmoil of the private insurance markets.

(That last week’s meeting was held in Summit County, where Kaiser Permanente has announced it is leaving the market in 2020, was coincidental but underscored the point.)

Opponents of a public option often see it as a Trojan horse for single-payer healthcare. If the government offers a cheaper plan, what stops the public option from becoming the only option?

Until recently, these debates have almost always taken place at the national level. A public option was a key component of the original designs for the Affordable Care Act, a.k.a. Obamacare. But it had to be scrapped in order to win enough votes for the bill to pass.

Several Democratic presidential candidates support versions of a public option — including Colorado U.S Sen. Michael Bennet, with a plan he has dubbed Medicare-X.

But the real action on public options has suddenly shifted to the states, where Colorado is one of at least three states working seriously to create one, with several others considering the idea. Washington is the clear frontrunner among the group, after Gov. Jay Inslee signed a bill in May that puts the state on track to be the first to offer a public option, for coverage starting in 2021.

But the plan actually enacted by Washington differs significantly from what lawmakers initially proposed — mainly because officials had to increase what the plan will pay doctors to satisfy concerns that no doctor would accept the coverage otherwise. Even still, it’s unclear how many doctors and hospitals will accept the prices that Washington’s plan will pay, which are still well below what private insurers pay.

“When I see candidates talking about the public option, I don’t think they’re really grasping the level of opposition they’re going to face,” Washington state Sen. David Frockt, who sponsored the bill, told The New York Times for a story where it examined Washington’s “watered down” plan.

And there’s an additional hurdle. Depending on how a public option is structured and funded, it could need approval from the federal government.

The dome of the Colorado Capitol on July 26, 2019. A “public option,” as this type of plan is called in wonk-speak, is a holy grail of the slightly-left-of-center health policy world. (Jesse Paul, The Colorado Sun)

Full speed ahead, unless …

Conway and Bimestefer have until November to develop a plan that will then be submitted to the legislature, but they are hoping to move faster than that. The pair will hold stakeholder meetings like the one in Keystone through the end of August — upcoming dates include stops in Pueblo, Alamosa, Glenwood Springs, Grand Junction, Durango and Cortez, as well as at least one meeting on the Eastern Plains. They are hoping to have draft recommendations ready by the end of September, with another period for public comment following that.

Kim Bimestefer (Provided by the Colorado Department of Health Care Policy and Financing)

After the report is submitted to the legislature, the bill passed this year instructs Conway and Bimestefer to move forward with implementing the plan unless lawmakers tell them not to. There is no deadline in the bill by which the public option must become available to consumers, but backers have said they hope coverage under a public option will be available for 2021.

It’s possible, at the end of all of this, that Conway and Bimestefer could conclude a public option won’t work and recommend that the legislature not go forward with one. But Conway said that’s not a likely outcome: “We are going to do something,” he said.

And, despite the variety of viewpoints during the Keystone meeting, he said he heard general consensus in some areas. People want the plan to be sustainable, he said. They want there to be simple benefit designs and clear costs. They want to make sure the plan helps the uninsured or others most in need of comprehensive coverage, and they want to make sure it does that without harming existing private plans or consumer choice.

“We do have a special opportunity here,” Conway said at the close of the nearly six-hour Keystone meeting. “We have an opportunity to create some fundamental change that will help a lot of people.”

It’s just still very uncertain what exactly that change will be.

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