Delivery of Care
On the precipice of enacting a RI public option
In the next few weeks, the RI Attorney General and his legal team will introduce a proposal to enact a public option health plan in RI
Photo by Richard Asinof/File photo
Adi Goldstein, RI Deputy Attorney General, is working with the Attorney General in preparation of a report of potential solutions to the current health care crisis in Rhode Island.
By Richard Asinof
Posted 5/11/26
In Part One, ConvergenceRI explores the backstory to the proposal by Attorney General Neronha and his legal team to create a public option health plan for Rhode Islanders
What kind of public opinion polling will be conducted to gauge public support for the creation of a public option health plan in Rhode Island? How will the proposed public option health plan become embroiled in the gubernatorial election? Will the new initiative funding independent journalism in Rhode Island be willing to invest in the need for better health care reporting? What role can OHIC play in promoting the concept of a public option health plan in RI? Will WPRI’s “Behind the Story” invite ConvergenceRI to appear on its show to talk about this series on creating a public option in Rhode Island?
Missing from the conversations around health care is the growing role that Brown Health is now playing as one of the largest aggregators of personal debt in Rhode Island. Without some kind of new regulation enacted, Brown Health will be positioned to determine what kinds of prepayments are necessary as copays for patients when they attempt to receive medical services. Further, as one of the largest private employers in state, Brown Health further controls potential reductions in employee benefits such as health insurance, creating a Kafka-esque scenario for nurses and doctors employed by Brown Health.
PART One
PROVIDENCE — It may not have the dramatic media currency of a house fire that forces families to abandon their now charred triple-decker.
It may not have yet emitted strong enough political pheromones to rouse the dulled senses of state’s top political reporters.
And, given the musical chairs now underway at the State House, with House Speaker Joseph Shekarchi departing to seek a seat on the RI State Supreme Court, it may be traveling well under the radar screen of many legislators and State House scribes. (Editor’s Note: Shekarchi, it appears, may be well aware of what is brewing with the public option proposal, even if reporters are not.)
But the promise of Rhode Island enacting a public option health plan is on the verge of changing the state’s health care delivery system for the better, breathing new life into the state’s motto: “Hope.”
What makes this public option plan somewhat different than a single-payer system is that it has been intentionally designed to require as little federal involvement or sign-off as possible, given the current federal dysfunction around public health care.
Here is the backstory of the effort to create a public health option in Rhode Island, featuring an interview with Adi Goldstein, Deputy Attorney General, and Lee Staley, the AG’s health project director. It was recently conducted by ConvergenceRI, with the full participation of Hannah Levintova, an editor with Mother Jones.
With all the distractions of an embattled President desperately trying to keep the Epstein files under wraps, as well as an ongoing war being fought in the Middle East, how important is the proposed public option health plan to the lives of everyday Rhode Islanders? It promises to change the trajectory of health care delivery for the next two decades — and provide a pathway for other states to follow on a road toward better public health, in ConvergenceRI’s opinion.
ConvergenceRI: Thank you for you doing this. I’m excited to have Hannah Levintova join the conversation. She is a financial whiz and can give the story a distinct flavor. Let’s jump in right away and say: Where are we in creating a single public option health plan for Rhode Islanders?
GOLDSTEIN: Hello. I'm Adi Goldstein, deputy attorney general. I'm joined by Lee Staley chief of the health care unit— who has been driving the ship and exploring the public option as a potential solution/proposal for our health care system.
He can do a lot of the talking and I can provide some high-level facts, as needed.
STALEY: My background is in core health care policy making. I was at federal HHS before starting at the AG’s office here. I was counsel to the Centers for Medicare and Medicaid Services.
I was in private practice with some health care regulatory work before that.
A lot of what we are going to be talking about today is really focused on health care financing, and looking at how the system is currently arrayed, versus what it needs to look like going forward. And so, maybe if it’s helpful, I can start with how we got here and what are we solving for, what are the problem looks like.
LEVINTOVA: Before we kind of get into the history, it would be helpful to know the ending. Are you pursuing single payer? Tell us the ending, and then the story.
STALEY: This is a good point of clarification. The proposal that we are talking about is a comprehensive public insurance option, a system whereby the state of Rhode Island would establish a state-run public health insurance option to compete with private insurance companies.
Individuals could enroll in it, and employers could move their employees into that public option.
Key decisions with respect to what the benefits would look like would be made by the state.
The way that we all think about it is as an initial step, potentially, towards a single payer system, and, setting up the type of infrastructure that the state would need down the road if it chose to go towards single payer.
And, just one other data point that has informed the way that we think about the benefits and trade offs of single-payer versus the public option. I think the most important challenge with the single payer system is it would require significant federal approval in order to operationalize it; the federal government would essentially need to sign off on a number of waivers for how the state would use funds and potentially even aggregate funds from Medicaid and Medicare in order to finance a state-run system.
And, because there are obvious challenges that we don’t need to go into with respect to getting that federal approval right now, we view the comprehensive public option as a more realistic near-term solution that would require some federal support, some federal backing, but less than the single-payer system.
GOLDSTEIN: We have to work within the world as it exists, not as we would like it to be.
And, there are certain things in place that we are not going to be able to change, right? Medicare, Medicaid.
We are working within a system where we have to assume that now, there will be little to no change in the federal context.
ConvergenceRI: What is the goal?
GOLDSTEIN: We are trying to create a proposed set of pathways and solutions that are probably more feasible.
And, one thing that we are can get into a little bit later is that while I think what we are looking at and exploring is pretty cutting edge, among different states, it is not entirely without precedent
So, there are some examples across the country that maybe don’t quite do everything that we want to accomplish in Rhode Island.
STALEY: Such as Washington and Colorado. Just to build off that a little bit, there are a number of states, I want to say, four or five, that have enacted or started to implement some version of a public option system.
For example, in Colorado, the way that system works at a very high level is that the state sets state-mandated requirements for what a public option would look like and then those actual plans are administered, effectually underwritten, by private insurance companies.
It is most analagous to Medicare Advantage, really. It is kind of how Medicare Advantage works, where you have the state coming up with a set of core benefits and (establishing) what are the main parameters, but then it is actually run and administered by private plans. There are a number of examples that have gone that route.
Of course, the discussion of a public option has been around for many years, going back to the Affordable Care Act.
This was part and parcel of what the ACA would have included — a publicly run insurance option that could compete with primary plans, that was narrowed down and ultimately was not included in the ACA (but there is a long history to that).
This project was initiated several years ago, actually, and the way that I’ve been thinking about it, the way we all have been thinking about it is: We recognize that our current health care financing system is structurally broken, essentially.
It involves a wide array of private payers, private intermediaries like PBMs that we’ve taken action on in other fronts, administering what are essentially life-saving benefits for citizens around the country and in Rhode Island. And, the cost of that fragmentation and disaggregation are massive. They amount to billions of dollars every year — money that is not spent on patient care.
And, we’ve seen that nationwide. Here in Rhode Island, we have major financial structural difficulties with health care facilities; there are hospitals operating on negative margins in the state. Some of them are heavily dependent upon Medicaid funding, which often reimburses less than private funding.
We have a primary care system, for example, that is deficient. Here in Rhode Island, we have reimbursement rates that are significantly below our neighboring states.
And, what we have seen is that when there are crisis moments, it is very difficult for the state to mobilize an effective response because the system is so fragmented.
And, right now, the current operating paradigm is that there are agencies here in Rhode Island that can nudge private insurers towards doing things, like funding primary care appropriately, but it really is only a nudge and it is very indirect -- and it is very slow moving and it takes a lot of time.
One goal that we think this proposal we’ve been considering addresses is putting more control in the hands of the state to be able to operate (more efficiently) and solve the challenges that it is dealing with from an active perspective.
