On this page we provide additional background on some of our main project areas.
Coverage By and For All
- Informing the Design of Effective and Affordable Required-Coverage Approaches. An IHPS-led team began a project in July 2005 to inform the design of a cost-effective and workable approach to cover all Californians. The project is developing and analyzing alternative state coverage approaches that involve varying combinations of individual, employer and state responsibility. These range from an individual mandate with sliding-scale subsidies towards coverage in a health insurance pool, to a required-employer-contribution construct with all workers and dependants having access to an exchange offering choice of health plans. Hybrid alternatives involve individual participation requirements and minimum required employer roles, along with a purchasing pool and sliding-scale subsidies to assure access and affordability.
The IHPS-led team undertaking this California HealthCare Foundation-supported project includes RAND and the Actuarial Research Corporation. The project report will provide estimates of coverage effects and on-budget state costs, as well as costs to individuals, employers, federal matching funds, and tax expenditures. While the role of employer contributions is generally recognized, a lesser-known determinant of the costs to state residents is how a given coverage approach affects federal tax subsidies available for worker contributions to coverage. IHPS is working with key, knowledgeable policy officials in California to identify and estimate specified approaches that can receive serious consideration.
Expanding Job-Based Coverage for Low-Income Workers and Families
- IHPS assisted the Institute of Medicine Committee on Rapid Advance Demonstration projects in developing its recommendations to cover the uninsured, through the participation of IHPS President, Rick Curtis, as an expert consultant with the committee. Assistance included summarizing previous state coverage initiatives and identifying possible recommended approaches to federal demonstration constructs and related objectives and specifications. (The Committee's recommendations on state health insurance demonstration are included in its 2003 IOM Report "Fostering Rapid Advance in Health Care.")
- In Montana, IHPS is providing expert consultation regarding the design and implementation of a small employer purchasing pool and associated premium incentives and subsidies for low-income workers and dependents. (2005)
- In Oregon the Institute is assisting the development and design of an affordable contribution option (i.e., the Health@Work contruct) for uninsured small firms with low-income workers who would receive subsidies from the State's Family Health Insurance Assistance Program.
- In Connecticut, IHPS is providing assistance to the State Office of Health Care Access (OHCA) in developing options to expand health insurance coverage of uninsured working families. Specific policy development and analysis work focuses on the design of an employer-based subsidy option for the HUSKY plan in Connecticut, with previous work towards a potential initiative to reach uninsured small employers and their workers. The Institute has also worked closely with the State Department of Social Services to identify the characteristics of target employers and workers. This work is funded by a grant tp OHCA from the U.S. Health Resources and Services Administration (HRSA). (2001-2005)
- Under contract to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, IHPS developed a draft "guidebook," "Using Premium Assistance to Expand Coverage through Small Firms," that is currently under review by ASPE staff. The guidebook summarizes the important statutory, regulatory, policy and operational issues that a State must think about when considering a premium assistance program that encourages coverage expansions of low-income people through their small employers. (2003-2004)
- Expanding Healthy Families to Cover Parents: Issues & Analyses Related to Employer Coverage. To assist policy makers in California and elsewhere in designing programs to expand health insurance coverage for working families, IHPS prepared a report analyzing the relationship between existing employer coverage and proposed expansions of public programs like S-CHIP to include parents as well as children. By helping policy makers understand when private employment-based coverage is and is not likely to be available to low-income parents, the report aimed to help them design policies that reinforce, rather than undermine, job-based coverage for low-income workers, and to target public subsidies appropriately and efficiently. For this report, IHPS analyzed data from two national surveys (CPS and MEPS) in order to provide policy makers with a better understanding of questions such as: how access to existing employment-based coverage, and how workers' decisions to accept or decline that coverage, vary across wage levels, family income and percent of poverty; what kinds of workers are and are not likely to have access to employment-based insurance (EBI) and characteristics of businesses workers with and without access to EBI tend to be concentrated in; and how often (insured and uninsured) low-wage workers have access to EBI through a working spouse. The project was funded by a grant from the California HealthCare Foundation and resulted in a major report and several issue briefs. (2000-2001)
- Assisting California Counties in Designing an Approach to Cover the Working Uninsured: Under a June 2003 grant from the California HealthCare Foundation, the Institute provided technical assistance to a group of interested California counties. The objective of this project was to plan and develop a local premium assistance approach, in which a consortium of local coverage expansion efforts would cover adults and children through small firms not previously offering health insurance by blending local subsidy funds with federal matching funds and employer and employee contributions. The Institute helped the counties to determine what the local premium assistance approach would look like and how it could best be implemented. This involved assistance with detailed program design and development and with investigating the potential for engaging a joint administrative vendor to work with participating employers on behalf of all participating counties. (2003)
- IHPS provided technical assistance to the Winter Park Health Foundation in Orange County, Florida, to help develop and flesh out the concept for a project involving premium subsidies for employment-based health coverage for low-income workers and families. The work included developing and refining a conceptual model and program design for the project, including applicable federal waiver approaches; and developing preliminary estimates of the population that could potentially be reached at various funding levels, based on suggested subsidy schedules. (2003-2004)
- Under contract with the Colorado Department of Health Care Policy and Financing, IHPS identified feasible options for coordinating financing for public health insurance for children and families through Medicaid and the Child Health Plan Plus (SCHIP) programs with employer-sponsored coverage. (2003-2004)
- Extension of Health Insurance to Working Uninsured and Their Families in Orange County, CA: The Institute provided assistance to CalOPTIMA-a Medi-Cal and Healthy Families health plan that consists of multiple integrated provider-based systems-in the design of a pilot program approach under a grant CalOPTIMA received from the U.S. Health Resources and Services Administration. The purpose of the pilot program would be to provide subsidized insurance coverage for workers in non-offering small employers. Under this project, the Institute collected information through employer and employee focus groups and subsequent interviews, summarized and interpreted the results, and designed the proposed structure and operational features of the pilot program, including subsidy structure, benefit plans, eligibility guidelines, enrollment/marketing approach, and administrative structure. Specific topics addressed included participation considerations for non-citizen workers, design considerations for a lower-cost benefit plan, potential administrative capacities and relationships, and availability and workability of tax subsidies. With respect to tax subsidies, the Institute researched existing State and federal tax savings available to low-income workers and recommended a program structure aimed at maximizing such savings for low-income workers who enroll in subsidized health insurance offered through their employers. In addition, the Institute developed a model state-county policy and program framework so that "pilot" county programs aimed at expanding health coverage through the workplace, such as the program envisioned by CalOPTIMA, can access federal matching funds. (2000-2003)
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- In Wisconsin, the Institute assessed and developed recommendations for revising the policy framework within which the State operates a "premium assistance" program to help uninsured families pay otherwise unaffordable contributions towards employer coverage. This work was funded under a HRSA "State Planning Grant." (2001)
Other Uninsured Worker Coverage Approaches
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An Assessment of Taft-Hartley Plans to Reach Uninsured Workers in California: Under a grant from the California Healthcare Foundation, the Institute researched and analyzed Taft-Hartley plans, since their structure and operation are similar to purchasing pools, to assess their potential to provide coverage to uninsured workers and their families. The Institute concluded that the potential for Taft-Hartley plans to independently engage in coverage expansions without the assistance or cooperation of government is very limited due to a range of potential political, economic, legal, and philosophical obstacles. However, the Institute concluded that there is the potential to leverage characteristics of Taft-Hartley plans for reaching the uninsured, in particular part-time workers and their families. (1999-2000)
Expanding Coverage for Low-Income Children
Under multi-year grants from the David and Lucile Packard Foundation, the Institute's California office operates a technical assistance center to provide policy expertise and strategic assistance to counties and the State to achieve coverage of all children. Initially, the projects focused on the Santa Clara Children's Health Initiative (CHI) to cover all children residing in Santa Clara County. In 2002-2003, the project expanded to several counties in the Greater Bay Area and is now the state's leading technical assistance provider in creating health coverage for all children. The Institute provides direct and contracted technical assistance in the areas of health policy analysis and options development, strategic planning, financing, applied research, and evaluation. The Institute disseminates information through publications and convenes workshops and/or symposia to analyze issues and develop program options. (2001-ongoing)
- IHPS-California also participates in a multi-organization consortium of technical assistance providers to counties and regions engaged in Children's Health Initiatives (CHIs). Funded by a grant from The California Endowment's Children's Coverage Program, the Technical Assistance consortium provides coordinated technical assistance to counties and regions, with a focus on advancing solutions that support statewide health coverage for all children.
- Sacramento Sierra Valley Regional Children's Health Coverage Initiative: IHPS was contracted by five First 5 Commissions in the Sacramento Sierra Valley region (Sacramento, El Dorado, Yolo, Colusa and Yolo counties) to provide policy and technical expertise in designing and implementing the first regional children's health initiative model in California. Under the auspices of this contract, IHPS is conducting a quantitative analysis of the cost and provision of uncompensated care for children in both hospital and clinic settings. (2004-ongoing)
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- Central Valley Children's Health Initiatives: IHPS has been funded by the Tulare, Kern and Fresno First 5 Commissions to provide policy and strategic expertise in the creation of their children's coverage expansions. The Institute is working with the Commissions and their partners in the following areas:
- identifying the potential target populations;
- governance and infrastructure development;
- program design issues such as benefits, cost-sharing and eligibility criteria;
- system re-engineering and program integration;
enrollment and retention of the target population in available coverage sources; and
- the cost, financing and pricing issues regarding health plan and administrative vendor options. (2003-ongoing)
- Coordinating Public and Private Financing Sources Toward Continuous Coverage Structures For Uninsured Kids: Under a now concluded grant from the David and Lucile Packard Foundation, the Institute's national office developed a resource center to assist expansion and continuity of health insurance coverage of children in low- and modest-income working families by developing ways to coordinate with job-based family coverage on their behalf. A major activity under this project was to explore coordination issues in depth in a series of papers and focused roundtable discussions with interested policy makers and identified experts. In addition, the Institute served as a national resource and technical assistance center for States (and their private-sector partners) who are seeking to coordinate public funding with job-based family coverage on behalf of uninsured children. The provision of direct technical assistance including dissemination of analyses of national survey data by the Institute focused on sites with the greatest potential for beneficial action that addressed both continuity as well as expansion of coverage. (1997-2003)
Building on its extensive experience, the Institute has continued to assist States interested in using private small-employer purchasing pools to cover uninsured workers. Often, these approaches overlap with the Institute's general coverage-expansion work, because purchasing pools can serve as an excellent venue for combining employer and employee contributions with State and federal subsidies and meeting benefit plan and participation guidelines. Projects under this topic include:
- In California, the Institute authored a report for State policy makers, "What Health Insurance Pools Can and Can't Do." The report assesses key factors, characteristics and examples to illuminate what approaches do and don't work. The California HealthCare Foundation asked IHPS to develop this report, because many policy maker and legislative proposals incorporated various pool approaches to address cost and access concerns. (2005)
- In Montana, IHPS is providing expert consultation in the design and implementation of a small employer pool and related subsidies. Authorized by legislation enacted in May 2005, the pool is on track to begin coverage in January 2006. While subsidy funds are earmarked for the target populations, the amount will necessarily constrain initial enrollment to a very limited number.
- In Hawaii, the Institute was asked to provide insights and advice regarding the potential for a
purchasing pool for small employers, and to provide insights regarding the potential structure for associated subsidies or tax credits for low-wage small firm workers. The Institute's assistance included Rick Curtis' presentation at the October, 2005 "3rd Annual Health Policy Forum" of the Hawaii Uninsured Project and subsequent recommendations for promising approaches.
- In Wisconsin, the Institute assisted State officials in assessing the feasibility of implementing a voluntary small group purchasing pool within legislatively authorized parameters, and conducted interview and focus group work with small employers and uninsured low-wage employees regarding different coverage proposals involving individual and employer tax credits and purchasing pools. This work was funded by the Department of Health and Family Services under a HRSA "State Planning Grant." (2001) In early 2003, under a separate contract from the Department of Employee Trust Funds, the Institute completed an assessment of barriers to, and alternative scenarios and associated statutory changes for, the successful creation and operation of a small employer group health purchasing coalition in Wisconsin.
- In Kansas, the Institute assisted with the development of a policy framework and a request for proposals to select an entity to operate as a small employer purchasing pool. The Institute's work included the development of a subsidy structure for premiums for low-wage employees of qualifying small employers who purchase insurance through the purchasing pool. The latter included consideration of the interaction of the subsidy structure with the pool's (premium) rating structure and related operational policies. This work was funded by the Kansas Insurance Department under a HRSA "State Planning Grant." (2001-2002)
Analysis of Alternative Proposed Structures for Small Employer Group Purchasing Arrangements: In order to assist the Department of Labor's (then) Pension and Welfare Benefits Administration (now the Employee Benefits Security Administration) in analyzing alternative proposed structures for small employer group purchasing arrangements, IHPS developed a set of Principles for Group (or Cooperative) Purchasing Organizations, illustrated the need for those principles by summarizing lessons learned from experience with pooled purchasing, and briefed Department officials on the results of the analysis. (1999-2000)
- Small Employer Worker-Choice Purchasing Pools: Under a multi-year grant from the John A. Hartford Foundation (1992-1999), the Institute provided technical assistance across the nation to develop employee-choice purchasing groups for small employers. Through this grant, the Institute provided a broad range of technical assistance to public entities and private coalitions or associations containing both small and large employers. This assistance included market research, design of participation rules, development of benefit plans, development of rating and underwriting structures and policies, and assistance with requests for information and proposals from and contracting with health plans. In addition, the Institute developed and evaluated requests for proposals for administrative service vendors and health plans and developed training and educational materials for agents, employers, and employees. Also, Institute staff assisted State officials who sought to design market rules that were complementary to small group purchasing activity.
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- Montana Association of Health Care Purchasers (MAHCP): The Institute has assisted the MAHCP for over eight years in its effort to reform the delivery and financing of health care in Montana. The MAHCP consists of many of the largest public and private employers in the State that were interested in the development an employee-choice of competing plans program for small and large employers. The MAHCP is now concentrating on more directly facilitating provider competition and cost-effective delivery of care through employer self-funded and other arrangements. The Institute has assisted the MAHCP with the development of these new strategies and with the evaluation of risk adjustment methodologies and potential HMO self-funded risk-sharing arrangements. (1995-2003)
Other Small-Employer Insurance Issues
- Small-Employer-Market Rating Reform: Through various projects, Institute staff have extensive knowledge about small group health insurance market practices, small group and individual market reforms, and the Employee Retirement Income Security Act (ERISA). In particular, under a multi-year subcontract with The RAND Corporation, the Institute collected, analyzed, and categorized State small group reform laws from 1990-97 for all 50 States under funding from the Robert Wood Johnson Foundation and individual market reform laws from 1996-97 under funding from the U.S. Health Care Financing Administration. (1998) The Institute has occasionally updated this knowledge base, particularly for States that have enacted more extensive reforms.
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- Small Employer Attitudes Regarding Health Insurance: Under a grant from the Commonwealth Fund, the Institute interviewed insured and uninsured small employers in several areas across the country. The employers discussed their rationales for or for not offering coverage, the ability of their employees to get coverage, and what they considered the best source of coverage for their employees. In addition, the employers provided their input on the potential of various proposals-individual or employer tax credits, expansion of public programs, etc.-to cover the working uninsured.
Tax Credit Analyses
- Policy Brief on Tax Credits for the Uninsured and Maternity Care. The March of Dimes engaged IHPS to prepare a policy brief on this topic. The brief provides background on maternity coverage in group and individual health insurance plans, presents an overview of the general types of tax credit approaches currently being proposed to subsidize private coverage, and their implications for availability of maternity benefits, and examines possible strategies for maximizing access to maternity benefits under various tax credit approaches. To refine the final product, IHPS facilitated a roundtable discussion of the first draft with approximately a dozen experts with a range of perspectives. (2003)
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- Tax Credits for Individual Insurance and Effects on Employer Coverage. For the Economic and Social Research Institute's "Covering America" project (funded by the Robert Wood Johnson Foundation), IHPS prepared an occasional paper discussing the potential effects on employment-based coverage of offering federal tax credits (solely) for individual health insurance, and discussing how tax-credit proposals might be refined to improve their impact on overall coverage rates. (2002)