State Public Option Act (S. 489 and H.R. 1277, 116th Congress): Potential Impact on Sexual and Reproductive Health and Rights

Adam Sonfield, Guttmacher Institute and Leah H. Keller, Guttmacher Institute

The Guttmacher Institute is evaluating how sexual and reproductive health and rights fit into U.S. health care reform efforts. Previous analyses have described people’s wide array of sexual and reproductive health needs and laid out a set of principles for how to address them within the health care system. This analysis applies those principles to one specific health care reform proposal. Evaluations of additional proposals can be found here.

Proposal name and bill number: State Public Option Act (S. 489 and H.R. 1277, 116th Congress)

Proposal sponsor/author: Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM)

Proposal version date: 2/14/2019

Summary of Proposal

An incremental approach to health reform that allows states to offer residents of all incomes the option of buying into Medicaid. This public option would compete with private plans in the Affordable Care Act’s (ACA) health insurance marketplaces. It would also expand the scope of reproductive health services and provider reimbursement rates for every state’s Medicaid program, regardless of whether the state implements the public option. Otherwise, the current package of Medicaid services and patient protection provisions would apply.

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: In states that choose to do so, provides a new public option on the ACA marketplaces for state residents who are not covered by any other plan, but does not attempt to guarantee coverage for all U.S. residents. Consistent with the existing ACA rules, blocks undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from coverage. Requires enrollees to pay monthly premiums, but limits out-of-pocket costs through ACA premium subsidies and premium caps for higher-income enrollees (whose premiums are not capped in other ACA marketplace plans). Also renews financial incentives for states to take up the ACA’s broader Medicaid expansion, if they have not yet done so, which could close coverage gaps in those states.

Cover the complete scope of sexual and reproductive health services without barriers: The Medicaid public option covers the same services that are covered for other Medicaid enrollees, but the state may impose higher copayments and deductibles than allowed for Medicaid generally. Requires coverage of "comprehensive reproductive health care services, including abortion services," for all Medicaid enrollees (not just the new public option enrollees), though the bill does not define what "comprehensive" means.

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Includes providers already in the Medicaid network and maintains Medicaid standards around patients’ freedom to visit the provider of their choice, including family planning providers. These standards have long been interpreted to protect providers who offer reproductive health services (like Planned Parenthood) from being excluded for reasons other than their ability to provide care.

Fully reimburse providers and invest in their education, facilities and technology: Increases reimbursement for primary care providers, including obstetrician-gynecologists, advanced practice clinicians, certified nurse-midwives and many publicly supported clinics (for all of Medicaid, including the new public option); this could expand the provider network.

Keep pace with emerging services and methods, such as telehealth: Not addressed.

Guarantee and Enforce Strong Patient Protections

Eliminate legal, cultural and safety-related barriers to care: Not addressed.

Respect patients’ privacy and autonomy and guard against coercion: Existing Medicaid and ACA protections would apply. For example, Medicaid requires that patients receive the contraceptive method of their choice "free from coercion or mental pressure." And the ACA prevents the federal government from interfering with the principle of informed consent, patient-provider communication and patients’ timely access to care.

Fight discrimination and promote equitable health care access and experiences: Existing Medicaid and ACA protections would apply, including the ACA’s strong antidiscrimination protections for patients.

Overall Assessment


  • Allows states to create a new public option to compete with private plans, making coverage more affordable for many U.S. residents.
  • Renews incentives for states to adopt the ACA’s broader Medicaid expansion, which could further expand coverage.
  • Requires comprehensive coverage of reproductive health care services, including those related to abortion, for all Medicaid enrollees.
  • Utilizes existing Medicaid administrative infrastructures, provider networks and patient protections.
  • Induces primary care providers to join the network via higher reimbursement rates, which would expand access for all Medicaid enrollees.


  • Because states are not required to implement the Medicaid public option, leaves U.S. residents in a potentially large number of states without any new coverage options.
  • Does not specify the procedures or care included in "comprehensive reproductive health care services, including abortion services," leaving that coverage vulnerable under hostile federal or state administrations.
  • Maintains the ACA’s existing restrictions that exclude undocumented immigrants and DACA recipients from buying coverage, with or without government subsidies.

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