WASHINGTON — Jay Inslee fought to get two key — and contentious — provisions into the health-care law that Rob McKenna believes is fundamentally unconstitutional, adding a dose of personal friction to an ideological contrast between the two gubernatorial hopefuls.

Inslee, who resigned from the U.S. House last Tuesday, was one of the more ardent advocates for the Patient Protection and Affordable Care Act. He argued for a government-funded public option to compete against private health plans and takes credit for rallying his Democratic House colleagues at a pivotal point in early 2010 when they appeared to be losing their resolve for change.

McKenna, the Republican state attorney general, contends that while parts of the health law benefit consumers, it is "built on an unconstitutional foundation" because it requires all Americans to buy coverage. Inslee, by contrast, believes achieving universal coverage for 50 million uninsured Americans is "not only a policy issue, but an issue of morality."

The complicated health-care law has dozens of authors. But Inslee was a crucial force in shepherding a pair of measures with keen support in the Puget Sound region.

One provision rejiggers Medicare reimbursement formulas so cost-effective doctors, such as those in Washington state, would get paid more.

Medicare spending varies tremendously by region. Medicare spent an average of $11,000 for an enrollee in Louisiana in 2008, 70 percent more than on a typical senior in Alaska, according to The Dartmouth Atlas Project, which tracks patterns in health-care delivery.

This geographic disparity stems from lower Medicare payments in certain areas and providers performing fewer or less intensive services. As one of the lead negotiators for the congressional Quality Care Coalition, Inslee tackled the problem by requiring Medicare to shift to paying providers based on quality and value, not just volume.

That is a significant change that should particularly benefit providers in Washington, said Madeline Otto, director of federal government relations for Group Health Cooperative in Seattle. Medicare spends $6,423 per member in the state, on average, ranking it in the bottom 20th percentile nationally, according to a 2011 report by the Institute of Medicine, an independent health-care group.

Inslee's work on a second provision in the health-care law was more controversial.

Inslee had attempted for several years to forge a balance between fostering competition and innovation in biotechnology drugs, which are made with living cells, unlike conventional chemical-based pharmaceuticals.

But these biologics, many of which are used to treat patients with cancer, rheumatoid arthritis and other debilitating conditions, can cost tens or even hundreds of thousands of dollars a year. The hope is that bringing cheaper generics, or more accurately, biosimilars, into the market would lower the tab.

Inslee, with the urging of biotech firms, twice introduced bills to grant 12 years of monopoly after a biologic drug goes on sale. A competing bill backed by Rep. Henry Waxman, D-Calif., called for five years of protection, the same as for chemical drugs.

The pharmaceutical and health-products industry was the top donor by industry to Inslee's 2010 congressional campaign, giving nearly $120,000, according to the Center for Responsive Politics, a campaign-finance watchdog group.

Patents for biologic and conventional drugs last 20 years, but much of that time can pass before the Food and Drug Administration approves a product for sale. Biotech companies lobbied for extended exclusivity, saying it was crucial to recouping their massive investment in research and development. Health insurers joined patients advocates in backing shorter protection.

Biologics accounted for $67 billion, or 22 percent, of total spending on medicine in the United States in 2010, and is growing fast, according to IMS Health.

In 2007, 43 percent of drug spending under Medicare Part B, which covers drugs given by infusion, went to just six biologics. Three of those are manufactured by Amgen, of Thousand Oaks, Calif., which operates the former Immunex plant in Inslee's former district in Bothell.

Amgen's political-action committee and employees were big givers to Inslee's 2010 congressional race, according to the Center for Responsive Politics.

During a June 2009 subcommittee hearing of the House Energy and Commerce Committee, Inslee questioned a conclusion by the Federal Trade Commission that biotech companies didn't need additional incentives to continue developing new drugs.

Giving companies 12 years of exclusive sales may keep costs higher, Inslee acknowledged. But if a biologic drug existed that could treat a child's leukemia, he asked, what might the patient's family fear more, "the risk that they'd have a 10 to 30 percent higher cost of the drug, or the risk that this drug that could cure their child would never be created?"

The Affordable Care Act bars biosimilar drugs for 12 years.

Kyung Song: 202-662-7455 or ksong@seattletimes.com