When President Joe Biden outlined his legislative priorities during his first address to Congress last month, notably absent was a major campaign promise: a public health insurance option. Instead, his current health reform proposal will funnel $200 billion more to private insurance companies to subsidize premiums, without any requirement that they cap out-of-pocket costs or eliminate them altogether.

As a result of Biden’s approach, states have been left to introduce public option legislation themselves, in the process taking on some of the nation’s largest and most politically organized businesses. From coast to coast, health insurance companies, hospitals, and pharmaceutical companies are using every tactic at their disposal to block states from passing public option legislation.

Such efforts show how determined the industry is to block any sort of reform that threatens its massive profits.