The nation’s healthcare system has serious affordability and growing access problems. Few people are happy with the hybrid system the Affordable Care Act failed to fix. Trading one bad system for another, however, is not good reform. Still, that’s where things are headed in Washington state.
Washington state Insurance Commissioner Patty Kuderer is helping lead the way. In press conferences, podcasts and meetings of the Universal Health Care Commission, she has been talking about request legislation for the 2027 legislative session that would allow her office to study and design universal primary care with integrated behavioral health for Washingtonians.
Under one model being considered, existing primary-care spending from multiple payers would be pooled in a common fund used to pay providers. People would still need insurance or another way to pay for specialty, hospital and emergency services, and many would remain reliant on hospital charity care and taxpayer-supported programs.
Who would ultimately be charged more to make this universal system for primary care truly available to all? Those are among the questions the study and design process would have to answer. Rep. Lisa Parshley, D-Olympia, has agreed to sponsor the request legislation in the House.
The Office of the Insurance Commissioner (OIC) plans to use money from its regulatory account for this work, which gives the request legislation better legs than it otherwise might have, given the state’s projected budget deficit. That OIC account is financed by assessments on insurers, and insurers are allowed to recover those assessments from policyholders. So even if state General Fund money isn’t being used, the work is not cost-free. Policyholders will be paying for it.
Draft request legislation says it would require the agency to submit a report and proposed implementation plan to lawmakers by June 30, 2028. That could set up a legislative debate over implementation in 2029.
Blame the other guy
One of Kuderer’s latest pitches for the idea went like this: “We know we have a broken system. And we are continually reminded from the other Washington that they have no interest in really repairing it. … They want it to continue to be the way it is, which is, like I said, irretrievably broken.”
Kuderer’s framing puts blame on the Trump administration while giving considerably less attention to Washington state’s own policy and spending choices. Those include Medicaid payment rates that often fail to cover providers’ costs, contributing to the cost-shifting onto private payers and making it harder for Medicaid patients to find care.
The Democrat commissioner also has tried to ease the worries of advocates who want a comprehensive taxpayer-financed system and do not want the effort to stop at — or be wasted on — designing a system for primary care alone. She said she thinks primary care for all is a foundational building block for the comprehensive plan and reminded naysayers that she is a hard-core believer in a taxpayer-financed, universal system. “As long as I’m above ground, I’m working on this,” she said in the OIC Answers podcast.
Everyone wants healthcare for all, including me, but I’m hard-core against a taxpayer-financed system of healthcare. Why? Because rationing and wait lists in other taxpayer-financed systems demonstrate that "universal" is not "universal."
I think a free market is the only thing that can save us from the healthcare woes facing ail of us. If we want prices to decrease, good access, quality care and decisions made by doctors and patients, we need more competition and more payment arrangements, not fewer. We need more transparency and less dependence on third-party payment, which distorts normal market behavior and weakens the price discipline consumers exercise in other parts of the economy.
UHCC backs the study
The UHCC, on which the OIC is represented, voted at its Sept. 3 meeting to support the OIC’s design and study of a primary-care financing and payment model. It did so despite concerns that, even if one agrees primary care should be available to all through a shared financing system, the state's healthcare workforce might not be able to meet the additional demand.
Expanding coverage, eliminating cost-sharing or creating a new public financing system could increase demand for services. OIC staff members have acknowledged the workforce problem, noting Washington state’s serious and uneven shortage of primary-care providers. Workforce solutions are needed whether or not this plan moves forward.
Any plan to guarantee primary care to all requires sustainable funding, enough health care workers to meet increased demand and an honest examination of its potential effects on access, quality and patient choice. The OIC design process is supposed to answer unresolved questions, but funding, workforce capacity, access, quality and patient choice are fundamental issues that should have been framing the state's reform debate from the start. Instead, reformers have spent far more time emphasizing promised benefits than confronting potential costs and tradeoffs.
Trading one bad system for another is not a solution.
