Billy Wynne, the founder of Wynne Health Group consulting firm, created the Public Option Institute to study the implementation of public insurance options in Washington and Colorado. Wynne established himself as a presence in the public option debate with two series in Health Affairs after Republicans' efforts to repeal and replace the Affordable Care Act failed. The new institute is formed with funding from the billionaire couple John and Laura Arnold, who have taken an interest in advancing policy to lower healthcare costs. Wynne is based in Denver and has advised on Colorado's public option plan in a personal capacity, separate from his work with the institute.
Modern Healthcare's political reporter, Rachel Cohrs, sat down with Wynne to discuss the public option debate.
MH: Can you tell me how this partnership with Arnold Ventures to form the Public Option Institute came about?
Wynne: I wanted to pay very close attention to and parse out the real issues involved in states implementing these types of programs and begin to consider what federal options there would be to support programs like this, if you had an administration that was so inclined. I started a framework that was called Medicare Direct, for a federal waiver to support and facilitate states and moving forward with public option programs that the states themselves design. That to some degree built my interest, and my presence in the debate around these issues. It was about that time that the second Health Affairs series was being published that I approached Arnold Ventures to seek out a grant to try to really take a deeper dive into what especially Colorado and Washington are doing, with the goal of being an informative and evidence-based resource for this debate and for policymakers.
MH: Why do you think the analysis of implementation in these early states is important?
Wynne: First of all, I think people are curious. It's an interesting issue, it's a controversial issue, and so for folks to see in a relatively clear and helpful way what these states are doing, these choices that they are making and why they are making these choices, is interesting and hopefully helpful when informing the debate as it moves forward. We don't pretend that people in general are going to take a keen interest in these policies, but policymakers, state and federal lawmakers, state and federal policy staff and think tanks are paying attention to this. There are going to be other entities and people making excellent contributions to this, so we are not pretending to be the only one, but we would like to be a helpful asset in the discussion.
MH: Which states do you think could be the next frontier for this type of policy?
Wynne: There are a number of states that are contemplating public option-style programs, and that term is used broadly and differently in different contexts. But for example, Oregon and New Mexico passed bills last session to look at different programs, whether it be Medicaid buy-in or other varieties, and just recently I saw reporting on Connecticut re-examining the idea. All told, I think there are as many as 10 states having active discussions about public option-style programs. I think if you had a Democratic president who was more philosophically aligned with that trend, you would assuredly see more states actively considering it. Many of them rightfully see the Trump administration as not necessarily a barrier, but that they won't make it any easier for them to do things like this.
MH: You worked at the national level in Congress. Do you think your analysis on these early states could in the future inform national conversation?
Wynne: I certainly would like to think so. Beyond our analysis, what's happening in these states should inform the national conversation because they are real-life testimony to the viability of different types of approaches to a public option program, and not the least of which will be the political reality of pursuing these types of programs. Colorado's plan to require health plans to participate, and to assign state-established reimbursement rates for hospitals, that is a very,very politically sensitive issue. And as that sort of debate, and really battle, is going to play out here in a very robust way, it would be unwise to ignore that at the federal level because the politics are comparable.
MH: There are some contrasts between the models so far in Colorado in Washington. What are the big questions you are looking at as you examine these two models?
Wynne: They are in different phases, so what Colorado does is a longer time horizon and more subject to change. But right now, Washington is not requiring hospitals or plans to participate and Colorado is. That to me is a real stark contrast and important consideration, and a big difference, and we will see what kind of participation Washington is able to obtain through this voluntary basis, and if Colorado moves forth with this path, the participation and impact you see in that program.
Another important factor is that Colorado intends to have a public option available statewide, in all areas and all counties in the first year, where as Washington has not set that as a mandatory component. It does have that goal, but the legislation says that if you have one plan with a public option in one county, that's a sufficient start to adhere to the legislature's directive, so basically a much lower bar in the first year to get things off the ground.
MH: One of the big points of conversation is how the policy would impact rural hospitals. How are you planning to evaluate those impacts?
Wynne: We will most definitely be paying close attention to, for now, the commentary and input that rural hospitals have in the debate, and I think it has been fairly robust, especially in Colorado where they are planning to set hospital-specific rates. We hope to see more detail on what that formula looks like soon, and what that would mean for different hospitals.
Colorado and Washington have articulated an intent to protect and preserve rural hospitals with how they implement the programs, and in Washington rural hospitals that view the public option as adverse to them could just opt out. Colorado they might not have that choice, so it's a little more acute here in terms of how this is going to play out for them. The predominant consideration for them will be how will the formula account for the financial reality of a rural hospital.
MH: Do you have any words for the providers who are watching Colorado with concern over what it could mean for their bottom lines?
Wynne: It's not our charge to do deep-dive financial analysis of individual hospitals or the hospital sector, but all of us who care about access to affordable healthcare have an interest in access to hospital services. All other things aside, we share that goal. I am not afraid to say that's my goal, that broad goal is contingent on high-quality hospital services. So if these programs end up limiting access to quality, affordable hospital services, then that would raise some questions and that would be one important thing to consider.
