Washington, Oregon universal healthcare representatives working to overcome federal barriers to plans


Shane Ersland


Washington and Oregon are both working to create universal healthcare systems, and representatives of those efforts shared their progress during a Washington Senate Health and Long Term Care Committee meeting last week. Both states are considering ways to address federal barriers to their proposals.

The Washington Universal Health Care Commission was created with the passage of Senate Bill 5399 in 2021. Commission Chair Vicki Lowe said its goal is to create immediate and impactful changes in healthcare access and delivery in the state, and prepare it for the creation of a healthcare system that covers all Washingtonians.

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“And we’re really getting close to that,” Lowe said. “There’s a lot of challenges in our current healthcare system: affordability, workforce shortages, and health inequities. Federal legal and financial barriers often keep us from doing the things we need to do to be more effective and efficient, and that’s one of the goals of the commission; to make healthcare more effective and efficient. Not everyone has the same access to healthcare across our state. Benefits and services are different across different coverages.”

The commission is currently studying governance, infrastructure, enrollment, eligibility, and service factors to determine the right path to transitioning to a unified healthcare system, which will take some time, Lowe said. 

“We want to make sure we’re bringing along all our citizens as we’re making this change. It may seem painfully slow to some people but that’s because we’re being really careful. We’re looking at Medicaid, even though we can’t make changes to Medicaid until we get some federal changes. We can look at (the state’s Public Employees Benefits Board program) and private insurance plans, and see what is best to provide care for all our citizens, especially looking at cost.”

— Lowe

The commission recently began collaborating with Whole Washington, a grassroots organization that advocates for universal healthcare as well. Whole Washington presented a comprehensive plan for developing a state-governed health plan that would cover all residents to the commission in August. The plan centers on developing the Washington Health Trust, which would create public options that any individual or company could enroll in for coverage.

“We’ve met with them, got a presentation, looked at their proposal, and are aligning it with the work we’re doing to make sure we’re all working together,” Lowe said.

The commission adopted a health equity framework in June to evaluate different policies and proposals, and ensure equity is the center of its work. 

“The framework is designed to eliminate inequities and negative outcomes by making policy changes or initiating new policies,” Lowe said. 

Mandy Weeks-Green, board and commission director at the Washington State Health Care Authority (which houses the commission), discussed commission reports to the legislature, which are due each year. It recently filed its second annual report.

“This one gives updates on what the commission has done in the past year and what it will be doing in the future. In the past year, we established the Finance Technical Advisory Committee (FTAC). We identified transitional solutions to work on, which were funded by the legislature. We’re looking at eligibility right now. After that we’ll move into benefits and services, provider reimbursement, and cost containment. We’ll also look at how we can begin financing that system.”

— Weeks-Green

Pam MacEwan, FTAC liaison to the commission, said the committee was established when commission members voted to utilize finance experts to address the overwhelming challenge of researching different finance streams for healthcare coverage, and barriers to building a universal healthcare system. 

“The committee was charged with considering policy and finance options in designing a universal system,” MacEwan said. “The first task the commission sent us was to look at eligibility. How do we decide who’s in, and bring them in? What is the federal government’s responsibility versus the state’s responsibility, particularly looking at Medicare, Medicaid, and ERISA (the Employment Retirement Income Security Act of 1974)?”

FTAC has met barriers to working on universal healthcare initiatives with federal agencies, particularly with Medicare and ERISA.

“I’m sorry to report we’ve identified more barriers than pathways in reaching these groups, particularly in Medicare and ERISA,” MacEwan said. “The federal authority is absolute on those programs. Therefore, what the state can do is quite limited. Medicaid, however, provides the better pathway. The state has a lot of authority on Medicaid. It has a lot of ability to be creative. We’ve seen a history of innovation on Medicaid in our state. There’s also much more latitude.”

Oregon’s single-payer efforts

Oregon lawmakers created the Joint Task Force on Universal Health Care through Senate Bill 770 in 2019. They continued universal healthcare efforts through the passage of Senate Bill 704 in the 2023 legislative session. The bill established the Universal Health Care Governance Board, which aims to design an administrative structure for a universal health plan to assess the readiness of public institutions and infrastructure to implement a single-payer program.

John Santa, a retired primary care physician and a member of the task force, said Oregon’s  focus is on a single-payer system (Washington is currently moving forward with a single-payer/universal hybrid model). He said the state would need to acquire waivers around Medicare and Medicaid to implement the model. 

“The federal issues are there; they’re robust,” Santa said. “But my sense is that the federal government will look first at how serious Oregon is about this.”

The board will need support from Oregon communities and the legislature.

“It would be important to do a macroeconomic analysis on implementation approaches,” Santa said. “That would allow us to have a robust and continuous engagement process with Oregon communities. The governance group’s ultimate goal would be to prepare a bill draft for the legislature that would implement a universal health plan. For this to be considered seriously, the legislature would need to make decisions that made it clear it supported these approaches.” 

A proposal the task force made that was not adopted in SB 704 was that board members would be employed by the state, Santa said. 

“We really saw this as a start-up effort, so board members would be employees. You would have a chief financial officer and a chief operating officer. We didn’t succeed in that effort, but I think it’s one we need to work more on, and understand the advantages of. The universal health plan entity would need to collaborate well with state agencies. But it would not be [housed] within any state agencies. It would be an independent public nonprofit corporation.”

— Santa

Daniel Dietz, senior analyst for the Oregon Legislature, said healthcare providers would be reimbursed directly by the state’s health plan under the universal system. 

“A key feature of our plan is it would eliminate different reimbursement rates by payers across the state,” Dietz said. “In Oregon’s health policy landscape, we hear a lot about the challenges facing rural hospitals where the payer mixes lean toward Medicaid.”

The board will present a comprehensive plan for the implementation of the universal health plan to the legislature by no later than 2026, Dietz said. The state aims to hire an executive director for the board in 2024, and the governor’s office will appoint board members. An interim status report is due to the legislature by Dec. 1st, 2024.