Washington, Colorado and Nevada rolled out public health plan options in 2021, 2023 and 2026, respectively. Over the years, seven other states have weighed introducing marketplace-based plans led, at least in part, by the state government.
Becker’s connected with leaders from Washington, Colorado and Nevada to better understand where their public options stand today.
Growth
While none of three states have “true” public options that are entirely run by the government, each has a slightly different structure. For example, carriers can volunteer to participate in Washington’s program — with a competitive selection process — but there is a hospital participation requirement. Colorado, on the other hand, mandates ACA carrier participation and uses a public hearing process when insurers miss their premium reduction target, bringing healthcare industry players to the negotiating table. In Nevada, managed Medicaid carriers must offer a “good faith proposal” for a Battle Born State Plan and undergo a competitive bidding process. Generally, providers participating in the Public Employees’ Benefits Program or Medicaid must join at least one public option network, according to Nevada law.
Colorado saw growth at a relatively fast pace. In 2023, 15% of Colorado marketplace enrollment was through a public option, but in 2026, 1 in 2 enrollees are in a public option, said Kyla Hoskins, deputy commissioner of the Colorado Division of Insurance.
Colorado started with a public option that leaned more on the government, but the program ultimately evolved with industry feedback.
“In Colorado, we started off at the state House with a true public option bill that was introduced,” she said. “Where we landed is the Colorado Option, which is a public option-like program, essentially kind of a public-private partnership.”
While effectuated enrollment was not yet finalized, as of the end of the 2026 open enrollment period, 40% of Washington’s market — roughly 115,000 of exchange customers — is enrolled in public option plans. That’s up significantly from 2021 and 2022, said Laura Kate Zaichkin, director of market competition and affordability at the Washington Health Benefit Exchange.
Challenges and pushback
In Washington, the one carrier with a public option in San Juan County — which is made up of islands and has one main hospital system — was unable to meet premium affordability and reference price target requirements, Ms. Zaichkin said.
“There are market conditions that make that a challenging area,” she said. “Statutory authority is a pretty blunt instrument, and what we’re learning is that it needs a more nuanced approach … particularly recognizing that hospitals are different in Washington state, and that it might be appropriate to have different treatment of different hospitals: rural hospitals versus some of the larger, more urban systems.”
While Colorado insurers that fail to meet their premium reduction targets face a public hearing, Ms. Hoskins said these hearings have not progressed far.
“All of those public hearings, the scheduled hearings, were dismissed,” Ms. Hoskins said. “They didn’t happen because the industry did come together and negotiate lower prices.”
At the same time, the Colorado Hospital Association is concerned with rate reduction pressure and administrative burden.
“Hospitals have felt pressured into rate reductions at a point when threats to healthcare funding are escalating,” said Julie Lonborg, CHA senior vice president and chief of staff. “Additionally, this program is administratively very burdensome on the payers, the hospitals and the state at a time when we need to be reducing administrative burden.”
While Providence, R.I.-based Brown University researchers pointed to premium reductions across plans compared to other states, Colorado’s Health Care Future — a product of the hospital, pharmaceutical and insurance group Partnership for America’s Health Care Future Action — challenged affordability. An April 10 news release said, in 2026, Colorado Option plans are more expensive than alternatives in the state for 85% of residents in the individual market.
What’s next
“Public option plans are meaningfully lower, and they’re meaningfully lower in a way where they’re driving significant healthy market competition and pulling down other nonpublic option plans, and we’re seeing sort of mixed results from that,” Ms. Zaichkin said of Washington. “That’s where we’re continuing to focus and strengthen.”
Colorado is seeing new entrants to the state’s ACA marketplace. With mandatory public option participation, that equates to more plans becoming available.
“Colorado Access is entering our market for plan year 2027, and we also had Select Health into our market in 2024,” Ms. Hoskins said. “The option was implemented in 2023, we got a new carrier in the individual market the next year, and we now have another one coming in.”
The public option is relatively new to Nevada. A spokesperson for the Nevada Hospital Association said they had not yet seen a major impact from the rollout. These plans have only about 10,700 enrollees, and insurers just started requesting discounts from hospitals, the spokesperson said.
Becker’s contacted health plan associations across Washington, Nevada and Colorado, as well as the Washington State Hospital Association and Nevada Health Authority, and will update this story if more information becomes available.
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