Democrats are primed to experiment this year with ways to provide universal health-care coverage in hopes that a politically friendly Democratic administration might offer its blessing in 2021 to create statewide universal systems.

While some health-care experiments for state-level Democrats don’t require permission from the federal government, many roads to making health care more accessible would certainly be blocked by any Republican administration in the White House. One option Democratic lawmakers in Oregon will push in 2019: creating a Medicaid buy-in option outside the Affordable Care Act (ACA) marketplace, which has proven increasingly pricey thanks in part to the president’s determination to undercut the health-care law at every turn.

The buy-in option would allow anyone in Oregon to buy into Medicaid. But since Medicaid is a federally run program, redesigning it to include anyone would require the federal government to sign off, according to an analysis of Oregon’s options.

Oregon state Rep. Andrea Salinas (D-Lake Oswego), who recently led a workgroup examining ways to expand health-care coverage in the state, said implementation of a robust Medicaid buy-in program could happen “within two years” of federal approval if the legislature makes headway in 2019.

“We have to try to set ourselves up for the best case scenario in 2020,” Salinas told Rewire.News. “It’s about getting away from the idea that volume of services is the path to better health care. … A Medicaid buy-in is not the complete panacea, but we’re trying to set the stage so we’re ready to move to something like single payer when the time is right.”

Acknowledging political reality two years into the Trump presidency, Salinas said, is critical in creating a universal system that could be fully implemented with the federal government’s eventual green light. “We have to work with the system we have now,” she said. 

A Medicaid buy-in for people in Oregon “isn’t going to be super cheap,” Salinas acknowledged. Purchasing a Medicaid-like health-care plan would cost around $600 a month, she said. That would be about $200 more than the average ACA plan in 2017, though the Medicaid buy-in option, unlike the ACA plans, would cover more ancillary health costs like co-pays.

Oregon’s low uninsured rate—around 93 percent of the state has some form of health insurance—”doesn’t mean everyone can go to the doctor’s when they need to,” Salinas said.

‘This is a populist issue,” she said. “People just want fixes when it comes to health care … and that’s what we’re trying to give them.”

A host of states with Democratic trifectas controlling both legislative chambers and the governor’s office are preparing to test the viability of universal health-care systems that might not be fully implemented until a president supportive of these policies is elected. California Gov. Gavin Newsom (D) has asked the federal government for permission to create a statewide single-payer health system. In Washington state, which has one of the lowest uninsured rates in the United States, Gov. Jay Inslee (D) is pushing for a public health-care option, which would offer health-care plans on the insurance exchange that would reimburse health-care providers at Medicare rates.

The Trump administration’s efforts to undermine the ACA, or Obamacare, has resulted in 14 Washington counties having “only one option for coverage,” Inslee said in a statement. “This public option will ensure consumers in every part of the state will have an option for high-quality, affordable coverage.”

Lawmakers also have ways of expanding affordable health care without involving Medicaid or Medicare. State legislators could create a government-run health insurance company and use it to drive private health insurers from the ACA marketplace, making Obamacare essentially free for families earning less than $100,000 a year, according to a 2018 analysis by the People’s Policy Project.

In Colorado, where state-level Republicans lost their last vestige of political power when Democrats took back the state senate in the 2018 midterms, lawmakers are looking at policies that could lead to universal health-care coverage.

Colorado Gov. Jared Polis (D) made universal health-care coverage a centerpiece of his campaign for governor. This month he focused on the issue during his first address to the Colorado legislature, which is under Democratic control for the first time since 2014.

“Our ultimate objective is to bring universal, high-quality, affordable care to every Colorado family,” said Polis, who leads a state where roughly 7 percent of citizens lack health insurance, about half the uninsured rate when the ACA became law. “We know that won’t happen overnight, but the work we will do together in this legislative session will put us on the right path and bring us closer to our goal.”

Polis has yet to reveal the steps he’ll take this year, pointing in an email to a newly created “Office of Saving People Money on Health Care” that will lead the charge. The office would create a “statewide interagency collaborative effort to develop common policies and strategies to reduce the cost of health care” and develop “proposals for a new, lower cost health insurance” option, according to Polis’ office. The health-care office would look at the viability of a “reinsurance” program that would provide insurance for health insurance companies so the companies could bring down costs. 

Democratic legislators in Colorado, including House Speaker KC Becker (D-Boulder), have backed a public option pilot program that would allow people to buy in to the state’s Medicaid plan, Colorado Public Radio reports.

Momentum is building among Democrats toward passing two bills, introduced on the opening day of this year’s legislative session, that would lay the groundwork in creating a government-run insurance program, sometimes called a “public option,” that would be offered, along with private insurance options, on the state health insurance market.

The first bill would require the state develop a proposal to create and implement a public option, called a “state option” in the legislation. To use federal funds, such a program would require the Trump administration’s approval, as stipulated by the ACA. In justifying the state option, the bill states that residents in 14 Colorado counties have only one health insurance plan to choose from on the state exchange and “the number of uninsured Coloradans in those counties is rising.”

The second bill would skirt the permission process by creating a modified public option as a pilot program, “if feasible,” for residents of two counties in Colorado’s central mountains. It would allow middle-income residents to buy the private insurance plans available to state workers, essentially joining the state insurance pool. The available plans would include ACA-mandated coverage of preconditions, contraception, and other consumer protections.