SJC grapples with single-insurer risk, pushes regional fix

San Juan County officials are sounding the alarm over the county's precarious position with a single health insurance carrier, warning that losing that carrier in a future bidding cycle could leave residents with no marketplace coverage at all.

The issue was raised during a County Council work session by Council Chair Justin Paulsen, who sits on a subcommittee examining insurance gaps. Paulsen distributed a memo from Trillium Swanson, who leads the county's community health network discussions.

A county with just one insurer — and no guarantee it stays

San Juan County moved to a single insurance provider, Ambetter, for the 2026 insurance season — a shift that Paulsen said "rocked the world," especially on Lopez and Orcas islands, because neither of the county's own clinics accepted the plan. UW Clinic agreed to temporarily accept Ambetter, and the Orcas clinic brought it on through Highland Hospital.

Officials fear losing Ambetter entirely in the next cycle, leaving zero carriers — something the state Office of the Insurance Commissioner maintains "can't happen." Paulsen pushed back, noting it has happened in two other Washington counties, both early in the exchange's history. "Why is he saying it can't happen when it has happened?" asked Council member Kari McVeigh. Paulsen explained insurers submit bids ahead of open enrollment, and it's in that window that carriers have sometimes withdrawn, forcing regulators to scramble for replacement coverage.

Paulsen pointed to San Juan County's high cost of care — particularly its reliance on medevac flights — as a deterrent to insurers. When Kaiser Permanente served the county, it "summarily dismissed 30 or some flights," refusing to pay for transport it deemed non-essential, and ultimately withdrew.

Compounding the uncertainty, Paulsen said subcommittee data showed exchange enrollment dropping from roughly 1,700 residents in 2025 to about 1,200 in 2026, with no clear explanation for the missing 500. He said he knows families who dropped coverage after premiums, driven up by lost federal subsidies, rose from about $100 a month to as much as $800 per individual — pushing a family of four's costs toward $1,600 to $1,700 monthly. "That's food, rent, and otherwise," Paulsen said.

Fixing a flawed definition of "adequate" coverage

Paulsen and Fuller both pointed to flaws in how the state defines network "adequacy." Paulsen said Ambetter was able to bid into San Juan County partly because regulators judge adequacy using a broad radius — by his estimate, around 50 miles — permissive enough that Ambetter's Whidbey Island clinics counted, even though they weren't practically accessible to county residents. Council member Jane Fuller, who represents Lopez Island and other smaller islands, raised a separate problem: self-insured constituents were forced onto Ambetter plans their Lopez clinic and hospital district couldn't accept, leaving the district, in her words, "powerless" to help them.

Fuller said she intervened directly with the CEO of UW Medicine to secure a six-month emergency contract for constituents who otherwise would have had to abandon long-established providers and start over in Island County. A senior policy advisor to the insurance commissioner acknowledged the standard was problematic, but suggested the fix may not be legislative — it could instead require an administrative change within the commissioner's own office.

Seeking a legislative fix — and a bigger ask still to come

Paulsen is proposing that the county add the issue to its legislative priorities, citing Senate Bill 6210, which already references San Juan County among counties that have faced only one insurance provider. In a follow-up interview during the Council meeting held on Aug. 25, Paulsen clarified that SB 6210 was not extended into law, and even had it passed, would not have tied San Juan County's market to other counties — only directed the insurance commissioner and governor's office to identify and intervene in counties facing zero or one bidder, the kind of gap that has already stranded two counties early in the exchange's history.

A separate, larger idea Paulsen has floated — tying the market to Whatcom County (three insurers) and/or Skagit County (four), rather than a "county by county whack-a-mole" approach — isn't addressed by SB 6210 or any existing bill. Pursuing it would require a new bill, or an amendment to a reintroduced SB 6210, in a future session.

Fuller and McVeigh both voiced support, with Fuller cautioning that the County's lobbyist may have limited bandwidth to dig into the issue and suggesting the work group — which includes Ellen Wilcox, San Juan County's health communities manager, along with local hospital districts — keep gathering data to strengthen the case.

Paulsen said the work group is also trying to bring hospital district leadership together in support of a unified message. "Something's got to change," he said. "All of this is just symptomatic of a huge health insurance problem."