Nearly two decades ago, progressives fought to include a so-called public option — a government-run health plan — in the broad health care overhaul known as Obamacare. That effort failed, defeated by heavy lobbying from the insurance industry and opponents who decried it as a government takeover of health care.

But the final Affordable Care Act, which President Barack Obama signed in 2010, didn’t bar states from adding a public option plan to their state-run insurance marketplaces. In recent years, several states have done so — and others might follow as rising health care costs, the expiration of federal subsidies and Medicaid cuts make coverage less affordable and available for millions of Americans.

This year Nevada became the third state, after Colorado in 2023 and Washington in 2021, to add a public option plan to its marketplace. So far, 10,762 people have signed up, according to figures provided by the Nevada Health Authority.

The goal of such efforts, said Christine Monahan, an assistant research professor at the McCourt School of Public Policy at Georgetown University, is to provide an alternative to profit-driven private insurance companies, “and to give people an option that doesn’t have that kind of capitalistic incentive in place.”

The results so far have been mixed, however. It’s still too early to say whether the states’ public option plans, which are public-private partnerships rather than purely government-run, will significantly lower costs for consumers or pay enough to providers to ensure their continued participation.

Meanwhile, other states’ efforts to create public options have stalled. In 2024, Minnesota delayed the creation of a public option amid concerns about the lack of a dedicated funding source. Efforts in Maine and New Mexico also have faltered.

“It’s really too early to see what the right combination of design of a public option is,” said Andrew Shermeyer, a doctoral candidate in health policy at the University of Minnesota and the author of a study on the Colorado plan. “We don’t know what works and what doesn’t. So that’s a real challenge for policy makers.”

Different approaches

As public-private partnerships, the public option plans in Washington, Colorado and Nevada rely on the participation of private insurers as well as health care providers. And they have to compete for customers with the purely private plans offered on the exchanges.

“We all know health insurance is extremely, extremely unaffordable and expensive. So the challenge behind it is you have to find something that’s attractive to consumers,” Shermeyer said. “You have to find something that insurers will comply with, and you have to find something that providers will feel adequately compensated for.”

States have used a combination of carrots and sticks to make sure those things happen.

In Washington state, private insurers that sell plans on the state marketplace can choose to offer the public option plan, which is called Cascade Select, but they don’t have to. To keep costs down and premiums low, the state mandates that participating insurers pay providers within a certain range.

In the first two years that Cascade Select plans were available, many providers were unwilling to participate. So in 2023, Washington began requiring that hospitals contract with at least one public option plan. The change has expanded the availability of Cascade Select plans — as of last year, they were available in every county — and boosted enrollment: Last year, about 30% of Washingtonians who purchased coverage on the marketplace enrolled in a Cascade Select plan, up from 1% in 2021.

Laura Kate Zaichkin, director of market competition and affordability at the Washington Health Benefit Exchange, said that figure is up to 40% this year. In 2021, Zaichkin said, Cascade Select premiums were a bit higher than for many other plans on the exchange. This year, they are about $100 per month cheaper, she said.

Zaichkin said the public option is more important than ever, because of the recent expiration of federal tax credits that had dramatically lowered the costs of purchasing marketplace coverage, as well as looming Medicaid cuts.

“I would say that it is a really important lever,” she said. “It always has been, and it is even more so right now, when individual market coverage is under threat and when customers cannot afford their premiums.”

Unlike in Washington, every private insurer that participates in Colorado’s marketplace must offer versions of the state’s public option plan, which is called the Colorado Option, in every county where it sells its own plans. Colorado Option plans all offer the same benefits across insurance carriers, so companies compete based on premiums, their networks of providers and customer service.

To keep premiums relatively low, participating health insurers are required to negotiate with providers to keep costs down. If state regulators think premiums are getting too high, they can take charge of the negotiations and mandate that hospitals or providers lower their reimbursement rates.

About 14% of marketplace enrollees chose the Colorado Option in 2023 when the plan launched. In 2025, the public option accounted for nearly half of the roughly 282,500 enrollees on the exchange, the state said.

But Julie Lonborg, senior vice president and chief of staff of the Colorado Hospital Association, said limiting payments to providers could end up reducing services and access to care for patients.

“Overall, enrollment continues to grow in the program, so it is having some success from the purchasers,” Lonborg said in an email. “But it is built on a fundamentally flawed policy of rate setting on hospitals that will result in consequences. Hospitals have felt pressured into rate reductions at a time when threats to health care funding are escalating.”

One of the arguments for a public option is that it introduces competition that pushes down premiums for all marketplace enrollees, no matter what plan they choose. But in his study of the Colorado marketplace, researcher Shermeyer said the Colorado Option only lowered premiums for people who were receiving the federal subsidies; unsubsidized enrollees saw higher prices compared with people living in other states.

Kyla Hoskins, a deputy commissioner who oversees the Colorado Option program at the state’s division of insurance, disputes that finding. Hoskins cited other research that found premiums across the state, even for private plans, declined by more than $100 after the Colorado Option was introduced.

She said more people are buying the Colorado Option plan because it’s more affordable and because of its simplicity.

“Your deductibles, your maximum out-of-pocket costs, the amount you pay when you see your primary care [provider] or fill a prescription — that cost sharing is the same no matter which health insurance company is offering the plan,” Hoskins said.

“And I think that clarity that standardization provides, has been a value to consumers,” Hoskins said.

Slow start in Nevada

Like in Washington, insurers in Nevada don’t have to offer a public option plan, called Battle Born State Plans (after the state’s nickname). However, the state has given them a strong incentive to do so by tying it to Medicaid.

Around 75% of Nevada’s Medicaid enrollees receive coverage through managed care. In order to remain eligible for Medicaid managed care contracts, insurers have to submit a bid to offer a public option plan that meets certain requirements.

Those Medicaid contracts are worth “millions if not billions to carriers,” said Stacie Weeks, director of the Nevada Health Authority, which oversees the state’s Medicaid program and its insurance marketplace. “Essentially, this new contractual arrangement leverages the state’s purchasing power with its Medicaid carriers to get a better deal for consumers in the private market.”

To ensure the participation of providers, Nevada’s law requires them to be in-network with at least one public option plan to remain eligible for Medicaid, public employee and workers’ compensation payments, according to the Century Foundation, a liberal-leaning think tank. Instead of regulating reimbursement rates, Nevada hopes to keep premiums low by mandating that they be at least 5% below those of private plans.

Nevertheless, enrollment has been slower than expected.

State officials predicted that around 35,000 people would sign up in the first enrollment period. The actual number is less than a third of that. And so far, only three out of the state’s eight health insurance companies on the state’s exchange have picked up the plan.

“We expect to see this number grow over time as public awareness increases and as Nevadans continue to seek quality coverage options that help reduce their monthly costs, regardless of their income,” Weeks said. She added that many Nevadans automatically reenrolled in their previous health plans, and may not know about the public option yet.

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

Former U.S. Sen. Pat Roberts fondly recalls personal relationships with U.S. Rep. Kika de la Garza and U.S. Sen. Debbie Stabenow that moved beyond party labels to shape bipartisan agriculture and food legislation.

Roberts said during an October interview at the U.S. Capitol that the get-the-work-done approach he admired, which brought a stalwart Republican like himself together with dedicated Democrats such as De La Garza and Stabenow, should serve as a salve for partisan wounds inflicted by political champions of division.

Raw partisanship placing Republicans and Democrats in uncompromising conflict has been a feature of the latest government shutdown.

“Somehow we’ve got to get control of this ideology,” Roberts said during an interview for the Kansas Oral History Project. “If you’re talking to somebody who’s an ideologist, they’re going to be right, and you’re wrong, regardless. You just can’t really talk to them, and we have far too much of that. We’re getting to the point of almost a meltdown in what the Senate used to be and the House used to be. That’s a real concern to me. That’s very sad.”

“The first thing you’ve got to learn in politics is to listen, and the second thing is there’s no ‘I’ in politics. It’s a ‘we’ thing,” he said.

Roberts said quality people were exiting Congress because they tired of clashes that inhibited the functioning of government. Some replacements didn’t have benefit of guidance from old-guard lawmakers who understood the value of collaboration, he said.

“I would hope that we could get back to a more bipartisan situation where you got things done,” Roberts said.

He was interviewed for the Kansas Oral History Project by Jackie Cottrell, who was chief of staff to Roberts for 18 years while he was in the Senate, and Mike Seyfert, who was Roberts’ staff director on the Senate Agriculture Committee.

‘Always want to listen’

Roberts, the first person to chair both the U.S. House and U.S. Senate agriculture committees, represented the 1st District of Kansas for eight terms in the U.S. House, from 1981 to 1997. When GOP U.S. Sen. Nancy Kassebaum declined to seek reelection in 1996, Roberts was elected to her seat. He served in the U.S. Senate from 1997 to 2021.

The interviewers asked Roberts about his dedication to regular listening tours that involved visits to every county in the Big First of western Kansas while he was a U.S. representative and subsequently each of the state’s 105 counties while serving as a U.S. senator.

In response, Roberts remembered advice given to him by Frank Carlson, who was elected to the Kansas House, became Kansas governor and then served in U.S. House and U.S. Senate.

“First thing you learn, Sen. Carlson told me, ‘You never get hurt by what you don’t say.’ He said, ‘You always want to listen.’ And, that’s what we did,” Roberts said.

Roberts said he was routine for him to stop in the county seat and run into acquaintances. He encountered critics who “would always show up and give me a hard time,” but that came with the job. It helped to hold onto a sense of humor at the public gatherings, he said, even when his views were at odds with recommendations from Kansas.

Roberts was born in Topeka, grew up in Holton, graduated from Kansas State University and served in the U.S. Marine Corps. He worked as a journalist but eventually followed a political career path, first as a congressional staffer and then as an elected official.

Ike, Dole connections

His father, Wesley Roberts, was deeply involved with Kansas GOP politics and served as chairman of the Republican National Committee.

While still a teenager, due to his father’s role in the Republican Party, Roberts met Dwight Eisenhower, the war hero who was elected president in 1952.

“Obviously, I was very familiar with politics. Perhaps that gave me the impetus to keep going with it,” Roberts said.

In the interview, Roberts looked back on the difficult process of completing the Eisenhower Memorial on Independence Avenue in Washington, D.C. He was chair of the memorial commission for the final six years. There was a protracted family dispute over the design. The monument features an open-air plaza with statues of Eisenhower as president, general and a child. The backdrop is a steel tapestry depicting the Normandy cliffs in France.

“I am sad that it took so long because we lost a lot of World War II veterans, and they couldn’t come up after looking at the World War II Memorial, which Bob Dole did, and then come up and salute their commander. That was my hope,” he said.

Roberts said he remembered speaking with Dole, the GOP’s unsuccessful nominee for president in 1996 and a retired US. Senator, twice a week when Dole was in his 90s. Dole was a disabled veteran from World War II and died in 2021 at age 98. Roberts recalled an especially poignant conversation with Dole.

“It’s fair for elderly men to say this, but all of a sudden he said, ‘Pat, there’s one thing I want you to understand.’ I said, ‘What’s that, Bob?’ He said, ‘I love you.’ And I said, ‘I love you, too, Bob.’ I teared up the whole day. He was a great man.”

The hard parts

Roberts said that in his first campaign for the U.S. House in 1980 he told Kansas voters he would not support a federal tax increase. President Ronald Reagan, however, reached an agreement with Democrats to cut $3 in federal spending for every $1 of federal taxes increased. The Reagan administration pressed Roberts to vote for the agreement.

In a White House meeting, Roberts told Reagan of his campaign promise. He also said some elderly people, including his mother, were concerned about a banking provision in the legislation. He recalled that other Republicans in the meeting looked at Roberts as if he was a leper.

“The president says, ‘Well, Pat, you’re following your convictions and I understand that, but I hope we can change your mind,'” Roberts said. “I arrived back to the office and the staff says, ‘Congressman, you’re invited to go to the White House with your mother at 10:00 in the morning.’ So, I had to call my mom. She (Ruth) says, ‘What kind of trouble have you got me into?'”

Reagan put on a charm offensive despite Ruth Roberts’ confession that she wasn’t an early supporter of Reagan. She had favored George H.W. Bush in the presidential primary. Roberts left the White House that day after affirming to the president he wouldn’t vote for the tax increase.

The White House had former U.S. Rep. Keith Sebelius, who was Roberts’ predecessor, call from a hospital bed to urge Roberts to back Reagan on the bill. In the end, Roberts relented.

In 2003, Roberts served as chairman of the Senate Intelligence Committee. His role was significant because the United States launched an invasion of Iraq in March 2003 based, in part, on a premise Iraq President Saddam Hussein was in control of weapons of mass destruction.

He said leadership at the Department of Defense and CIA were convinced Hussein had WMDs, but the Senate Intelligence Committee concluded in a 2004 report that pre-war assessments were unsupported by evidence. The committee’s bipartisan conclusion undercut assertions made by President George Bush and Vice President Dick Cheney to justify war with Iraq.

“That was probably the toughest responsibility that I had was to go to the White House and tell President Bush and Vice President Cheney, ‘Do not endorse your national intelligence estimate. It is flawed. Saddam Hussein did not have weapons of mass destruction.’ That was a tough deal,” Roberts said.

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