State-run public health insurance options are gaining real traction across the US. Washington, Colorado, and Nevada each launched their own programs — in 2021, 2023, and 2026, respectively. Together, they offer a close look at how public options work in practice, what enrollment growth looks like, and where friction with industry stakeholders remains.
How Each State Structures Its Public Option
No two state programs look exactly alike. None of the three operate a “true” public option, meaning a plan run entirely by the government. Instead, each state uses a hybrid approach that blends public goals with private participation.
Washington’s Competitive Carrier Model
In Washington, carriers volunteer to participate. However, the state runs a competitive selection process, and hospitals must meet a participation requirement. This setup gives the state leverage while keeping private insurers involved in plan delivery.
Colorado’s Mandatory ACA Carrier Participation
Colorado takes a firmer approach. The state mandates that ACA carriers participate in the Colorado Option. When insurers miss their premium reduction targets, a public hearing process kicks in, bringing healthcare industry players to the negotiating table. This model started as a push for a full government-run option. Over time, it evolved into what officials now call a public-private partnership.
Nevada’s Managed Medicaid Framework
Nevada requires its managed Medicaid carriers to submit a good-faith proposal for a Battle Born State Plan. These carriers then go through a competitive bidding process. Generally, providers participating in the Public Employees’ Benefits Program or Medicaid must join at least one public option network under Nevada law.
Enrollment Growth Across States
Colorado Sees Rapid Expansion
Colorado’s growth stands out clearly. In 2023, public option plans covered 15% of Colorado’s marketplace enrollment. By 2026, that figure rose to 1 in 2 enrollees. Kyla Hoskins, deputy commissioner of the Colorado Division of Insurance, credits the program’s flexibility and openness to industry feedback for this acceleration. Furthermore, new carriers have entered the market. Colorado Access joins for plan year 2027, following Select Health’s entry in 2024 — a sign that competition is increasing rather than shrinking.
Washington Crosses the 40% Mark
Washington has also seen strong uptake. As of the end of the 2026 open enrollment period, roughly 40% of the exchange market — about 115,000 customers — enrolled in public option plans. That marks a significant jump from 2021 and 2022. Laura Kate Zaichkin, director of market competition and affordability at the Washington Health Benefit Exchange, notes that public option plans are driving healthy competition, pulling down premiums on non-public option plans as well.
Nevada’s Early-Stage Rollout
Nevada’s program, by contrast, remains in early stages. Currently, only around 10,700 enrollees are in these plans. Insurers have just begun requesting discounts from hospitals. As a result, the Nevada Hospital Association reports no major impact from the rollout yet.
Challenges and Industry Pushback
Growth does not come without friction. Each state faces distinct obstacles from providers, insurers, or geographic realities.
Washington’s Rural and Island Market Problem
One carrier operating in San Juan County — a region made up of islands with a single main hospital — could not meet premium affordability and reference price targets. Zaichkin acknowledges this as a structural challenge. Statutory authority, she says, works as a blunt instrument in these cases. A more nuanced approach is necessary, particularly one that treats rural hospitals differently from large urban systems.
Colorado’s Public Hearings and Hospital Concerns
Colorado’s public hearing process, while available, has not yet been used effectively. All scheduled hearings were dismissed because industry players came together and negotiated lower prices beforehand. Still, the Colorado Hospital Association (CHA) raises serious concerns. According to CHA’s Julie Lonborg, hospitals feel pressure to cut rates at a time when threats to healthcare funding are rising. She also points to administrative burden as a growing problem for payers, hospitals, and the state alike. Additionally, a Colorado industry group challenges affordability claims, arguing that Colorado Option plans cost more than alternatives for 85% of individual market residents in 2026.
What Comes Next for Each State
Washington Focuses on Market Strengthening
Washington plans to continue refining its approach. Officials are studying mixed results from the competitive pressure public options exert and working to strengthen program performance in challenging markets.
Colorado Welcomes New Market Entrants
Colorado sees new carrier entries as a positive indicator. The state’s mandatory participation framework appears to be encouraging broader market involvement. Officials view growing plan availability as proof that the model is working.
Nevada Watches and Waits
Nevada’s program is too new to draw firm conclusions. Stakeholders and the state will monitor enrollment trends closely as the program matures and as hospital discount negotiations progress.
