Proponents believe there are pragmatic options for working around federal barriers to establish a universal healthcare system in Washington.
Whole Washington Executive Director Andre Stackhouse discussed the Washington Health Trust (WHT) during last week’s Universal Health Care Commission (UHCC) meeting. The WHT would create a public option that any individual or company could enroll in for health coverage.
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The WHT was initially introduced as a public initiative in 2018. It has been introduced through state legislation several times, with the latest version encapsulated in Senate Bill 5335, which is currently in recess. Stackhouse believes it provides an ideal path for establishing universal healthcare in Washington, and hopes to garner support for it from UHCC members and lawmakers.
“Our hope is to co-develop real universal healthcare policy that gets recommended to the legislature and voted into law, so we can actually get people the care they need,” Stackhouse said. “We have a complex system we’re dealing with. We propose the creation of new programs, such that everyone in Washington is eligible for enrollment in a public plan.”
Whole Washington envisions the public option offering easy enrollment, uniform billing, and a single essential benefits package that coordinates with state and federal programs like Medicaid and Medicare.
“Through the acquisition of waivers, we can achieve all of this through a unified program,” Stackhouse said. “This is something that can only happen through sustained effort and will. Enrollment is not highly specified in SB 5335. But the responsibility and authority to implement that is given to the WHT board and the Washington State Health Care Authority, and can be done through existing infrastructure like Washington Healthplanfinder.”
All Washington residents would be eligible for the WHT. Some nonresidents would be eligible, including students attending college in the state, workers who are employed in Washington but do not live there, and certain family members.
There are many federal barriers to establishing a universal healthcare system in a state, however. Medicaid would likely present fewer challenges to enrolling members in the WHT than other programs, Stackhouse said.
“We have a federal innovation waiver to give us flexibility. There’s already a robust enrollment system through Washington Healthplanfinder that provides a great model for enrollment. We can begin by raising the coverage of Medicaid up to that single benefits package, which would cover all medically-necessary care. We would raise the reimbursement rates. And through the acquisition of (an 1115 waiver), we would be able to fully integrate Medicaid into the WHT, rather than manage them as two separate programs.”— Stackhouse
Medicare presents a greater challenge, as the federal funding it provides cannot be transferred into a state plan, and its members cannot easily be enrolled into the WHT.
“Long-term, we believe we can fully integrate Medicare into the WHT through the acquisition of a federal demonstration waiver,” Stackhouse said. “But in the immediate future, we can simply allow Medicare to continue to function as it does today. In the medium-term future, we believe we can supplement Medicare with a publicly-funded and managed Medicare Advantage plan. Through that supplemental plan, we would be able to raise the coverage of Medicare up to that single benefits package and give Medicare members a way to voluntarily enroll into the WHT.”
The state would not be able to apply for or acquire the federal waivers needed for that until it passes legislation allowing it, however. A waiver must apply to existing legislation, Stackhouse said.
Whole Washington would prefer to see the federal funds Washington Healthplanfinder uses to subsidize and sell private health insurance to the public applied to the WHT, Stackhouse said.
“We would prefer to see that applied to a public plan that everyone is eligible to enroll in and provides universal coverage,” he said. “Once we achieve 51 percent enrollment across all state-managed plans—we’re already at about 40 percent—at that point, the WHT would become the only plan on the exchanges to receive cost assistance. The exchanges could still continue to operate, and private plans could still be sold on them, but that’s where the cost assistance should go.”
The WHT would encourage as much employer participation as possible, as employer-sponsored plans are where most people get their coverage, Stackhouse said. However, due to the Employee Retirement Income Security Act of 1974 (ERISA), employers could not be mandated to participate directly in the WHT.
“However, we can require employers to provide health coverage to all employees, including part-time, contract, and interns. We can create a required health expenditure, per employee, to make sure enough money is going toward the health coverage of those employees. We can define what kinds of spending can qualify towards that expenditure. And we can cover all children, which will allow employers to focus more on individual plans and less on family plans, which are much more expensive and much more complicated.”— Stackhouse
All premiums, copays, deductibles, and out-of-pocket expenses would be eliminated for WHT enrollees. Under the WHT public financing model, there would be an employer tax of 10.5 percent per employee, based on payroll. Employers could pass two percent of that tax on to employees.
“The beauty of this design is that every employer will have the option to simply pay 10.5 percent of employee compensation and have their entire workforce covered by the WHT,” Stackhouse said. “And because this expenditure is the same whether they’re doing it through private or public insurance, we believe many employers are going to choose to unburden themselves of the administrative work and cost that goes into providing private health insurance, and simply opt to pay the 10.5 percent to cover all their employees.”
The option would be available for all of a company’s employees or on a per-employee basis. So some could be on the WHT, and some could be on private insurance. And an employee could choose to enter themselves into the WHT even if their employer offers private health plans, Stackhouse said.
“Providers participate in this simply by accepting reimbursement,” he said. “All licensed providers are eligible to participate and receive reimbursement, and they cannot be denied reimbursement for any services they provide. And all they have to do is accept the fee-for-service rate set by the board.”
The WHT board would negotiate reimbursement rates with participating providers, Stackhouse said.
“This provides a very key incentive for providers to participate because if they want a seat at that negotiating table, if they want to be a part of rate setting, they will have to participate in the WHT. And we encourage the creative use of existing infrastructure like hospitals, the (Department of Motor Vehicles), public libraries, (and) voter registration [facilities]. There are many places where public outreach can be done. Where people can be informed about this and enrolled.”— Stackhouse
Warren George, who served on the Oregon Joint Task Force on Universal Health Care, spoke during the public comment portion of the meeting. He encouraged UHCC members to collaborate with Oregon universal healthcare representatives when considering whether to include residents from other states in eligibility requirements for any proposed universal healthcare plan in Washington.
“The Oregon task force faced this, and we wrestled with it for days,” George said. “And part of the answer is it could be really important for Oregon and Washington, in particular, to cooperate in their implementation plans.”
Washington and Oregon are both working to create universal healthcare systems, and representatives of those efforts shared their progress during a recent Washington Senate Health and Long Term Care Committee meeting.
Mike Benefiel, Democratic precinct committee officer for Washington Legislative District 23, also spoke during the UHCC meeting.
“We have a healthcare crisis in our state that sees thousands suffering needlessly (with) major medical debts, bankruptcies, (and) people losing their homes and lives,” Benefiel said. “On average, one person dies every day in Washington because of a lack of healthcare coverage. So why is a Democratically-led legislature moving so slowly? We have legislation available in SB 5335. Shame on all of us for not fixing this horrible system that impacts our friends, families, and children.”