Private Insurance: Good Ideas
From Families USA:
Understanding the Role of the "Exchange" or "Gateway" discusses the new health insurance marketplace, or exchange, that is being developed in national health reform proposals. This short piece looks at how an exchange would work and how it could help middle-class and low-income families find and keep the affordable, quality health care they deserve. (July 2009)
Health Care Must Be Affordable for All Families, Regardless of Income presents crucial arguments for why health reform must ensure that health care is truly affordable. It proposes placing reasonable limits on out-of-pocket costs and providing subsidies, especially for those with low and moderate incomes. (April 2009)
Protecting Unemployed Workers' Health Coverage: What States Can Do discusses how states can help unemployed workers keep or obtain health coverage during these turbulent economic times. (January 2009)
Appeals Court Rules that San Francisco's "Pay-or-Play" Law Is Permissible under ERISA provides an overview of the court ruling that clears the way for the city to implement its Health Access Program, which will be open to all of the city's uninsured residents. The piece also briefly discusses the federal ERISA law. (September 30, 2008)
Fighting Revocations and Limitations of Health Insurance Policies addresses the insurance company practice of revoking an individual's health insurance or suddenly eliminating coverage for health services long after the person has enrolled (known as "post-claims underwriting"). It also discusses what consumers and advocates can do about the practice. (July 2008)
The Facts about Prior Approval of Health Insurance Premium Rates discusses several insurance industry myths about the consequences of prior approval. The prior approval process is used by most states to make sure that insurance companies' proposed premium increases are not excessive. (June 2008)
Failing Grades: State Consumer Protections in the Individual Health Insurance Market. Laws protecting consumers purchasing health coverage in the individual market vary across the country. In many states, insurance companies can deny coverage, raise premiums significantly, refuse to cover treatment for certain conditions, and even revoke the coverage of policyholders who have been paying premiums for years. (June 2008)
Medical Loss Ratios: Evidence from the States presents the results of a 50-state survey we conducted in March and April 2008 that determined which states have laws or regulations that establish a minimum "medical loss ratio" (a percentage of premium dollars that must be spent on medical care). (June 2008)
Post-Claims Underwriting Survey presents the findings of a survey we conducted in April and May 2008 of all state insurance departments regarding laws in their states that prohibit insurers from limiting or rescinding health insurance policies after they have been issued. (June 2008)
Reinsurance: A Primer aims to help policymakers and advocates better understand what reinsurance is and how it can make coverage easier to obtain and more affordable. It also identifies some of the benefits of reinsurance to aid lawmakers as they design reinsurance programs to meet the needs of their states. (April 2008)
On January 9, 2008, the Ninth Circuit Court of Appeals allowed a San Francisco ordinance to go into effect that requires employers to pay for health care for their employees or pay the city to provide care. Click here for a summary of the ruling. The outcome of the full appeal is still pending. (January 9, 2008)
Affordable, High-Quality Health Coverage for All through Shared Responsibility is a Health Policy Memo laying out the responsibilities of each of the key stakeholders in America's health care system. These responsibilities, the Memo argues, are preconditions for achieving meaningful expansion of health coverage. (November 2007)
Maine's Dirigo Health Reform of 2003 is a thorough examination of the state's health care expansion. It discusses program eligibility, how much people pay for the different types of coverage, what benefits they receive, how the expansion is financed, how it reforms the state's insurance regulations, lessons learned so far, and the future of health reform in Maine. (November 2007)
Pennsylvania's 2007 Health Care Proposal: Prescription for Pennsylvania examines the governor's plan for comprehensive health reform. This report looks at who is eligible for new coverage, how much they'll pay, what benefits they'll get, and how the state will finance the expansion. It also discusses strengths of the plan, as well as areas of concern. (July 2007)
New Jersey's Path Toward Universal Coverage analyzes the state's blueprint for providing health coverage to all of its uninsured residents. (May 2007)
Illinois Covered Proposal examines the state's most recent coverage expansion effort, which focuses on adults between the ages of 19 and 64. (May 2007)
A Pound of Flesh: Hospital Billing, Debt Collection, and Patients' Rights provides an overview of some of the progressive reform measures that state policymakers have implemented to help families struggling with medical debt. (March 2007)
Vermont's Health Reform Laws discusses the basics of the state's two new laws, known as "Catamount Health." The piece also examines how Catamount Health will be financed, how the laws build on existing health coverage programs, and pros and cons of the laws. (December 2006)
Employers Should Pay Their Fair Share for Health Care explains what employer responsibility legislation is and discusses its benefits and potential drawbacks using examples of states that have implemented such legislation. (September 2006)
Testimony by Ron Pollack, Executive Director, Families USA, before the National Association of Insurance Commissioners, Health Insurance and Managed Care Committee, discusses state insurance reforms that will help consumers and those that won't. (June 12, 2006)
Making History: Maryland's Fair Share Health Care Law discusses how the law works, who it affects, and the key strategies advocates used to get the law passed. It also includes a timeline of critical events. (May 2006)
High-Risk Health Insurance Pools provides answers to key questions about high-risk pools, including who they help and how they are financed. The report also includes a list of questions consumers should ask if they are considering joining a high-risk pool, as well as a checklist for advocates. (May 2006)
Proposed Health Reform in Massachusetts: Net Gain for the Business Community examines the health reform bill passed by the Massachusetts House of Representatives, which is designed to expand coverage to the state's uninsured. It finds that, overall, the bill would result in a net benefit for the state's business community. | Press Release (January 2006)
Testimony before the Connecticut General Assembly in support of the Connecticut Employee Health Security Act Advocates in Connecticut are working to pass a law that would ensure that workers who work for large employers have access to health coverage. (March 17, 2005).
Testimony before the New York City Council in support of the New York Health Care Security Act Advocates in New York City are working to ensure that workers like janitors and construction workers have access to health coverage. (December 10, 2004)
Ideas that Work: Expanding Health Coverage for Workers, a Tool Kit for those who want to build a state-based health coverage initiative based on employer-provided insurance. Includes case studies of California and Hawaii, a "decision guide," and tables with state-by-state data about employment and insurance coverage. (October 2004)
The Illusion of Group Health Insurance: Discretionary Associations l Executive Summary | Discretionary associations enable insurance carriers to market individual health insurance policies under the guise of group insurance to consumers seeking low-cost insurance that appears to offer group protections. This Issue Brief identifies problems in the discretionary association marketplace and suggests a number of regulatory and legislative solutions. 18 pp. $3.00 (March 2004)
The Trade Act Health Insurance Subsidy: An Update from the States This Issue Brief analyzes the implementation of the new subsidy offered by the Trade Adjustment Assistance Reform Act of 2002 (TAARA) and suggests changes that might strengthen the existing program. (December 2003)
A Shelter in the Storm: How a Subsidy Could Help Unemployed Workers Get Health Insurance The rise in unemployment over the past three years has contributed to a substantial increase in the the number of uninsured Americans. This Issue Brief discusses the Trade Adjustment Assistance Reform Act of 2002 (TAARA) health insurance subsidy as one possible model for providing financial assistance to unemployed workers for the purchase of health coverage. (October 2003)
The Health Insurance Tax Credit in the Trade Adjustment Assistance Reform Act of 2002 This Issue Brief defines the TAARA tax credit and discusses who is eligible for it. It also provides answers to many other questions about how the tax credit will be administered, what kinds of insurance quality insurance will be provided, and the role states have in implementing the credit. Includes advocate suggestions for shaping the credit. (April 2003)
Protecting Consumers from Unfair Rate Hikes: The Need for Regulation of Health Insurance Renewal Premium Increases This Issue Brief examines the insurance industry practice of re-underwriting at renewal and discusses current efforts to regulate the practice at the federal and state levels. (February 2003)
Consumer Health Assistance Programs: Report on a National Survey Consumer health assistance programs come in many shapes and sizes. Some serve Medicare beneficiaries, for example; some serve people in long-term care facilities or those who are privately insured. Families conducted a nationwide survey of these programs, and the findings are summarized in this report. (July 2001)
Designing a Consumer Health Assistance Program As health care becomes more complex, many states and localities are developing consumer health assistance programs to meet the needs of consumers within their jurisdictions. This guide reviews some key considerations to keep in mind when designing such programs. (June 2001)
Health Care Consumer Assistance Fund Provision in the Patients' Bill of Rights Passed by the Senate (S. 1052).
Patients' Rights Get Boost by Jeffords Defection From the May-June 2001 asap! Update
Ron Pollack's Testimony in Support of a Strong Patients' Bill of Rights (March 15, 2001)
McCain and Kennedy Introduce a New Patients' Bill of Rights (February 8, 2001)
Families USA Executive Director Says HMO Decision Shows Need for Patients' Bill of Rights This statement by Ron Pollack, Executive Director of Families USA, was made in reaction to the Supreme Court's ruling in Pegram v. Herdrich--a decision holding that HMOs are shielded from litigation under the federal ERISA statute. (June 2000)
Ombudsman Programs: In this article published in the May/June issue of Healthplan Magazine, Ron Pollack, Executive Director of Families USA, outlines why health plans should embrace this strategy for helping America's health care consumers. (May 1999)
Patients' Bill of Rights Act Offers Comprehensive Managed Care Protections for Consumers: Other Leadership Bills Don't Pass Muster This press release reports on Families USA's analysis of the three leadership managed care bills and the finding that only the Patients' Bill of Rights Act (S.6/H.R. 358) will establish essential protections for America's consumers. (March 1999)
Consumer Group Applauds New Emergency Room Patient Protection Legislation is a press statement by Ron Pollack, Executive Director of Families USA, on the new, bipartisan Access to Emergency Care Bill. (March 1999)
New Bill Introduced to Implement Patients' Rights Legislation This press release comments on legislation introduced on March 1 that would establish managed care consumer assistance programs in each state. (March 1999)
An Updated Side-By-Side Chart on the federal Managed Care Bills And You Web site compares the newly introduced Leadership bills (in the 106th Congress) on consumer protections in managed care. (November 1999)
The Quality of Maryland and District of Columbia Medicaid Managed Care Plans: External Reviews
This report looks at the external quality review process for Medicaid HMOs and finds problems in how external reviews are administered. (December 1998)
Comments on Benefits Claims Regulation have been drafted in response to proposed revision of the internal appeals provision of ERISA, which applies to all employer health benefit plans. Groups are encouraged to sign onto these comments. (November 1998)
The Best from the States II: The Text of Key State HMO Consumer Protection Provisions offers the relevant text of state laws and regulations addressing important managed care consumer protections, including emergency room services, access to providers, liability, and more. (October 1998)
CBO Confirms Patients' Bill of Rights Cost Pennies is a press statement by Families USA Executive Director Ron Pollack. (July 1998)
Families USA Executive Director Ron Pollack testifies before the Senate Appropriations Committee on problems posed by ERISA to consumers enrolled in managed care plans. (May 1998)
Hit and Miss: State Managed Care Laws surveys state legislation addressing common problems with managed care. It analyzes state-by-state activity on 13 illustrative consumer protections and finds that many Americans are left unprotected. The spottiness of state consumer protections is compounded by ERISA, which preempts state laws for those in "self-insured" plans--one out of three people with employer-provided coverage. (July 1998)
HMO Consumers at Risk: States to the Rescue (Print only) An overview of 14 key HMO consumer protection issues addressed by a number of states through legislation or regulation during 1995 and the first half of 1996. (July 1996)
[Return to top]
From Academy Health and the National Academy for State Health Policy:
Maryland's Fair Share Act required large employers to spend up to 8 percent of their payroll on employee health benefits or pay the difference to fund the state's Medicaid program. ERISA Update: Federal Court of Appeals Agrees ERISA Preempts Maryland's "Fair Share Act" explains how other states may still enact employer assessments that fund health care expansions without being pre-empted by ERISA. It also summarizes both the majority and dissenting judges' opinions in the Maryland case, which may still be appealed. (February 2007)
From the Commonwealth Fund:
Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance, and How Health Care Reform Can Help examines why small businesses often have more difficulty offering their employees health insurance, as well as how the economic downturn has intensified the problem. The brief also outlines how measures in the health reform proposals, such as the creation of an exchange and tax credits for small businesses, could help small businesses and their employees gain access to affordable, comprehensive coverage. (September 2009)
Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, 2009 Update explains why young people ages 19-29 continue to be one of the largest and fastest-growing groups without health insurance and the possible repercussions of this trend. The brief also suggests policy reforms that could help young adults stay insured as they become more independent. (August 2009)
How Have Employers Responded to Health Reform in Massachusetts? Employees’ Views at the End of One Year reveals that employers have neither dropped coverage nor restricted eligibility for coverage in the state’s first year of health reform. Despite initial concern from critics, researchers have found that employers made no changes to the scope of benefits, range of provider choices, or quality of care available under their plans. (October 2008)
On the Road to Universal Coverage: Impacts of Reform in Massachusetts at One Year found that in the first year, the rate of the uninsured working-age adults in the state dropped by almost half, from 13 percent to 7 percent. In addition, the study found improvements in access to care, particularly among low-income adults, and fewer adults with high out-of-pocket costs and medical bill problems. (June 2008)
Americans between the ages of 19 and 29 represent the largest and fastest-growing segment of the population without health coverage. Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help argues that there are several ways to extend coverage to young adults—and prevent others from losing it. These include extending eligibility for Medicaid and SCHIP beyond age 18; extending eligibility for dependents beyond age 18 or 19 regardless of student status; and ensuring that colleges and universities require full- and part-time students to have insurance. (May 2006)
Insuring the Healthy or Insuring the Sick: The Dilemma of Regulating the Individual Insurance Market Short Case Studies of Six States Coverage in the individual insurance market is often expensive, limited in its benefits, and unattainable for anyone with pre-existing health conditions. In order to ameliorate this, several states have implemented consumer protections, such as requiring that health insurance providers offer coverage to people regardless of age or health status, limiting the premiums that insurers can charge, and mandating the benefits that must be covered. This report assess how well the range of consumer protections instituted in the six states promote access to coverage. (February 2005)
Insuring the Healthy or Insuring the Sick: The Dilemma of Regulating the Individual Insurance Market Findings from a Study of Seven States Coverage in the individual insurance market is often expensive, limited in its benefits, and unattainable for anyone with pre-existing health conditions. In order to ameliorate this, several states have implemented consumer protections, such as requiring that health insurance providers offer coverage to people regardless of age or health status, limiting the premiums that insurers can charge, and mandating the benefits that must be covered. This study evaluates the cost and availability of individual insurance coverage in seven states—four with weaker regulation and three with stronger regulation—and finds that coverage is more available and affordable in states with stronger regulation. (February 2005)
Stretching State Health Dollars: Building on Employer-Based Coverage Spurred on by tough financial times, many states have begun to develop creative ways to expand coverage by building on employer-sponsored health insurance. This report looks at the approaches that 14 states have taken in an attempt to expand coverage, including premium assistance, reinsurance, state subsidized health care programs for the low-income workers, small business expansions, and "pay-or-play" employer mandates. (October 2004)
From the Community Catalyst:
Massachusetts Health Reform: What It Does; How It Was Done; Challenges Ahead provides a comprehensive description of the Massachusetts health coverage plan, including an analysis of its strengths and weaknesses. (April 2006)
From the Economic and Social Research Institute and The Commonwealth Fund:
Early Implementation of the Health Coverage Tax Credit in Maryland, Michigan and North Carolina: A Case Study Summary Health Coverage Tax Credits (HCTCs) are refundable tax credits that fund 65 percent of beneficiaries' coverage. This report looks at implementation of the HCTC program and take-up rates in three states. (April 2005).
From Health Affairs:
Massachusetts Health Reform: Employer Coverage from Employees’ Perspective reveals that concerns about employers dropping coverage or scaling back benefits under Massachusetts’s 2006 health reform law have not been realized. In fact, the quality of and access to job-based coverage has actually increased. Now lawmakers are working to make premiums and out-of-pocket costs more affordable for smaller firms. (October 2009) Subscription Required
Where Does the Insurance Industry Stand on Health Reform Today? addresses the assumption that health plans will present a major source of opposition to expansions in coverage and other reforms. But a closer look reveals signs of change. Some plans continue their reflexive opposition to increasing government’s role in health care; other plans have stepped forward to advocate meaningful reform. Experiences in Massachusetts, California, Minnesota, and elsewhere suggest clear lessons for policymakers. (June 2008)
From The Health Assistance Partnership:
The Health Assistance Partnership (HAP) is the national organization for consumer health assistance (ombudsman) programs. The Private Insurance page of their Web site is designed for the staff of consumer health assistance programs that serve consumers insured by private health insurance. Health assistance programs serving such consumers operate in at least 22 states. These programs assist consumers in securing individual or group insurance and in resolving problems with access to care.
From HR Policy Association:
Pressure Building at State Level to Compel Employers to Provide Health Insurance Coverage According to this advocate for large employers, 30 states are considering bills that would require employers to either provide a basic level of health care coverage or contribute to a state fund to cover the uninsured. (April 2005)
From the Kaiser Family Foundation:
In Pursuit of Affordable Health Care: On the Ground Lessons from Families in Massachusetts details how the state’s health reform legislation has achieved near-universal coverage (94.7 percent) by combining a foundation of public coverage with greater access to private insurance through employers. While some budgetary challenges remain, the program has been largely successful, including a marked increase in job-based coverage. (September 2009)
Explaining Health Reform: What Are Health Insurance Subsidies? explains what insurance subsidies are and how they can help lower-income families and individuals afford health coverage. The brief also examines different ways of structuring subsidies and describes how each would affect the reform proposals that are currently under discussion in Congress. (August 2009)
Massachusetts has enacted a health care plan designed to offer virtually universal health coverage. Massachusetts Health Care Reform Plan summarizes the new plan and its implications for individuals, who must obtain insurance or face tax penalties, as well as employers, who must provide insurance or contribute to the government’s “Fair Share” program. (April 2006)
From the Lewin Group and Health Care for All California:
The Health Care for All Californians Act: Cost and Economic Impact Analysis l Summary The Health Care for All Californians Act (SB 291, introduced in February 2003) would have provided health insurance coverage for all Californians through a single health plan funded by the state. This report looks at what implementing the Act would have cost and the broader economic impact it would have had. In the first year of the plan alone, $8 billion would have been saved statewide. Businesses would have saved 16 percent over what they pay today, and families would have saved an average of $340 per year. (January 2005)
[Return to top]
From Maine Dirigo Health:
Dirigo Health Reform The Dirigo Health Reform Act was signed into law by Maine Governor John Baldacci in June 2003. The Act was designed to ensure that every Mainer has access to affordable, quality health care by 2009. The Dirigo Health Reform Web site provides an excellent resource of information on the Act and on DirigoChoice, Maine's new health care program for small business employees, the self-employed, and the uninsured.
From Mathematica Policy Research:
Using Section 125 Premium-Only Plans to Expand Health Coverage discusses how Section 125, or "cafeteria" plans, may be able to expand coverage, or at least make employer-based coverage more affordable for those who already have it, by allowing employees to pay their premiums with pre-tax dollars. This brief also examines policies that states are using to encourage greater adoption of cafeteria plans. (October 2008)
From the National Academy of State Health Policy and The Commonwealth Fund:
Designing Maine's DirigoChoice Benefit Plan DirigoChoice is Maine's innovative private-public partnership that offers health insurance to employees of small businesses, the self-employed, and the uninsured. This report discusses the process that Maine went through in developing a plan for DirigoChoice and outlining the health care benefit package that would be provided. (December 2004)
Dirigo Health Reform Act: Addressing Health Care Costs, Quality and Access in Maine In June 2003, Maine Governor John Baldacci signed the Dirigo Health Reform Act into law. The Act was designed to ensure that every Mainer has access to quality, affordable health care within five years. This report discusses the three major elements of the Dirigo Health Reform Act: cost, quality, and access. It also provides a bit of background on the development of the DirigoChoice Health plan. (June 2004)
From the National Conference of State Legislatures (NCSL)
Changing Definition of "Dependent": Who Is Insured and for How Long includes a table showing state legislation that extends the age under which young adults can be covered under their parents' health insurance policies. (September 28, 2006)
From the National Health Policy Forum:
Health Insurance Coverage for Small Employers examines the problems small firms and their employees face in obtaining affordable health insurance coverage. This report reviews these challenges, as well as some of the efforts made through state and federal reforms to address them. These efforts include rules regarding guaranteed issue and guaranteed renewability and some of the more recent initiatives designed to help small employers, including AHPs and HSAs. (April 2005)
Fundamentals of Underwriting in the Nongroup Health Insurance Market: Access to Coverage and Options for Reform Although the majority of Americans with health insurance obtain coverage through their employers, many individuals must negotiate the nongroup insurance market alone. Insurers use a process called medical underwriting to identify applicants with current or recent medical problems. Because these applicants are likely to cost the insurer more in claims than a healthier person, insurers may charge them higher premiums or restrict or deny coverage. This report reviews the practice of underwriting, state and federal regulation of insurers that offer nongroup health coverage, and several proposed options for improving access to coverage for applicants who are in poor health. (April 2005)
[Return to top]
From The New York Health Security Act Campaign:
The New York Health Security Act would require employers in the grocery, hotel, building services, construction, and industrial laundry sectors to either offer their workers their industry's prevailing level of health care or to contribute to a citywide fund to provide uncovered workers with family health coverage. The law would help responsible businesses to continue offering health care and expand access to health care for tens of thousands of working New Yorkers and their families, while indirectly saving tax-payers money.
From the Robert Wood Johnson Foundation
Health Reform in Massachusetts: An Update on Insurance Coverage and Support for Reform as of Fall 2008 provides an update of the impact on working-age adults, the primary target of reform policies, as well as an update on public support for health reform. The state has achieved its goal of near universal health coverage, and residents continue to show strong support for health reform, despite the rising costs of the program. (September 2009)
From State Coverage Initiatives
The Role of Reinsurance in State Efforts to Expand Coverage In order to spread the risk of health insurance, many states have implemented various models of reinsurance—in which the state takes over a portion of high-cost claims. This report discusses how six states have used models of reinsurance to assist in the expansion of coverage. (October 2004)
Reinsurance is when a state opts to cover a portion of private insurer's claims. This "stop-loss" mechanism may cover catastrophic claims above a certain dollar amount, or it may cover claims within a designated corridor. It is an indirect way of reducing premium prices, thereby providing a more affordable option for uninsured workers, and it remains a popular strategy for states that wish to maintain or increase health coverage. More Answers on Reinsurance is designed to serve as a technical guide for states that are interested in building a reinsurance program. (June 2004)
From the Urban Institute:
Roadmap to Coverage: Synthesis of Findings combines all of the research and analytic work done on the Massachusetts health coverage initiative, describes three policy approaches that would achieve universal coverage in the Commonwealth, and discusses the issues that would need to be addressed in order to implement the Roadmap options. (May 2006)
From the Wake-Up Wal-Mart Campaign:
The Wake-Up Wal-Mart campaign is a grassroots movement of Americans who believe that, by joining together in common purpose, they can change Wal-Mart and build a better America. Wal-Mart is the largest private employer in the world, with over $10 billion in profits, yet a large number of their employees are uninsured because they are not eligible for Wal-Mart's health benefits or cannot afford them.
[Return to top]
