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1 NYSHealth Special Report Expanding Health Insurance Coverage for Sole Proprietors And Employees of Small Business: July 2011

2 Contents Background 1 Grant Activities 4 Results 7 Lessons Learned 8 The Future 9

3 Background In 2007, NYSHealth a brand new foundation began to address the issue of the uninsured in New York State. After investigating a number of potential strategies through research and interviews with stakeholders across the State, the Foundation s board and staff agreed to a three-pronged strategy for addressing the issue: 1) support projects and policy analysis to streamline enrollment and retention procedures for public insurance programs; 2) support projects and policy analysis to restructure or strengthen the individual and small-group insurance market; and 3) support projects and policy analysis to develop cost containment strategies for the health care market place. This report assesses a group of early Foundation investments related to the second strategy of supporting projects and policy analysis to restructure or strengthen the individual and small-group insurance market. Small businesses and sole proprietors are essential to New York State s economy. They bring new ideas and innovative services to residents, and employ more than half of New York State s non-farm private workers. Yet, workers in these firms are more likely to lack health insurance than their counterparts who work for larger firms half of the State s uninsured workers are either self-employed or work in businesses with fewer than 25 employees. According to David Sandman, Ph.D., Senior Vice President, When we looked at the coverage data, it was clear that self-employed workers and workers in small businesses were a significant proportion of the uninsured. We wanted to target that sector. These workers lack coverage because: Their employers are less likely to offer it. Only approximately 67% of companies with fewer than 50 workers offer insurance, while almost all companies with 50 or more employees offer coverage. 1 They are subject to higher premium increases. Employers with fewer than 50 workers experienced an 8.2% annual increase in premiums in 2009, whereas firms with employees and more than 200 employees experienced annual increases of 7.4% and 5.7%, respectively. 2 Their premiums are more expensive: $4,794 annually for employers with fewer than 50 workers, compared with $4035 for firms with 50 or more workers. 3 1 Jon Gabel, Whitmore H., and Pickreign, J. Decade of Decline: A Survey of Employer Health Insurance Coverage in New York State. New York State Health Foundation. November Ibid. 3 New York State Health Foundation Request for Proposals, Expanding Coverage Options in the Small Group and Individual Market in New York State. January

4 Background (continued) During its first year of operation, the Foundation s staff sensed that there were excellent opportunities to advance insurance coverage in the small-group and individual coverage markets through existing programs like Healthy NY, Brooklyn HealthWorks, and Working Today. In fact, the State was considering allowing an employers buy-in to its public insurance option, Family Health Plus. Thus, expanding coverage for low-income workers could be achieved without dramatic State legislation and, if successful, NYSHealth would have a direct, positive impact on thousands of New Yorkers. At the time, Governor Spitzer was new to office and was planning an ambitious strategy to strengthen health insurance coverage in the State. It seemed inevitable that the Spitzer administration could get drawn into considerations of State-led insurance expansion as momentum on the issue was spreading from Massachusetts, California, Pennsylvania, and even Louisiana. If the Foundation helped the State make progress in working with small employers to expand coverage voluntarily, the lessons learned from these efforts would be important to shaping any ambitious, State policy-oriented approaches to expanding coverage. The 2008 NYSHealth RFP Expanding Coverage Options in the Small Group and Individual Market in New York State grew directly out of the Foundation s desire to generate ideas for expanding health insurance options for small businesses and sole proprietors. The program s request for proposals (RFP) solicited ideas for one-year planning projects, to be followed by multi-year implementation projects based on the outcomes of planning. Five organizations received planning grants: Fidelis Care, HealthPass, Manufacturers Association of the Southern Tier, Plattsburgh-North Country Chamber of Commerce, and S2AY Rural Health Network. Grantees examined options, including extending the State-subsidized Healthy NY and Family Health Plus programs to small employers, aggregating small employers into larger units that could purchase insurance at lower cost, and launching marketing programs targeted to small employers. None of the projects moved on to the demonstration phase. Results of the planning activities undertaken by HealthPass, the Association, and S2AY found the original ideas to be unfeasible. Plattsburgh s proposed implementation projects were inconsistent with the Foundation s strategies. Funds granted to Fidelis Care were ultimately returned to the Foundation, but that project itself generated positive results in other ways. The unforeseen advent of Federal health care reform also introduced new circumstances. Although no projects were pursued, the initiative did yield benefits. Grantees gained a better understanding of factors that drive health insurance, and the Foundation used its capacity as a convener to forge partnerships among community organizations, insurers, and policymakers. 2

5 Background (continued) Expected Outcomes The Foundation expected that the Small-Group Market Coverage planning phase would yield entrepreneurial ideas for expanding coverage to small businesses and sole proprietors. It anticipated that these ideas would be backed with sound analyses of what it would take to increase coverage options and enrollment. The Foundation intended that some of the ideas developed during planning would warrant further testing in the form of demonstration programs. Its RFP notes, At the end of the planning grant, a panel of State and national technical experts will review the business plans. NYSHealth plans to make demonstration grant awards ranging from $200,000 to $1,000,000. According to Kelly Hunt, senior program director when the initiative started, As we looked across the State, we saw several small, local attempts to increase coverage among this group, but none of them was at the scale required to make a significant dent in the problem. We wondered whether any of these initiatives held promise for expansion, and wanted to see what business plans different groups would come up with if they had time and resources to plan carefully. Funding Initiative All grants funded under this initiative addressed the Foundation s goal of expanding health insurance options in New York State. Four organizations were funded under the Foundation s Small Group Coverage RFP. One organization, S2AY Rural Health Network, was funded apart from the RFP for a project that also directly addressed the Foundation s goal of expanding health insurance options in New York State. 3

6 Grant Activities The Foundation was hoping to receive ideas for planning projects that could ultimately: develop or enhance health insurance options such that they include a wider choice of health plans and benefits for small businesses, low-income workers, independent contractors, and sole proprietors; address the administrative complexity of offering health insurance; leverage funding resources to supplement health insurance options or subsidize premiums for employees in small businesses and consumers in the individual market; encourage brokers to market affordable coverage options for the small-group and individual markets, and increase the number of insurance carriers selling these options; or replicate or expand upon existing successful initiatives. The Small Group Coverage initiative allowed chambers of commerce, health insurers and others a year to systematically analyze options, such as the ideas listed above, for increasing access to health insurance. If the planning proposals yielded something feasible, NYSHealth was willing to consider funding the initial grantees with a much larger demonstration grant. Foundation funds supported activities such as surveys, focus groups, and actuarial analyses conducted by grantee staff and consultants. In all, the Foundation allocated nearly $500,000 for the planning phase. These funds supported the work of five organizations: New York State Catholic Health Plan, Inc., (Fidelis Care New York) examined the feasibility of opening the State-funded Family Health Plus insurance program to small employers. State legislation enacted in 2007 allows small employers to purchase Family Health Plus for workers and potentially receive State subsidies to reduce the cost of premiums. Under this provision, coverage was first extended to Section 1199 Benefit Fund members, and Fidelis Care served as the insurer for this new group. Given its early experience in offering coverage under the Family Health Plus Employer Buy-in program, NYSHealth awarded planning funds to Fidelis Care to analyze the implications of expanding coverage to a broader group of small businesses. After the State Department of Health released details of the Family Health Plus Employer Buy-In program in 2009, however, Fidelis Care concluded that the program was not a feasible option for small businesses. Fidelis Care returned planning funds to the Foundation, but continued to play an important role in helping the Foundation and another grantee, Community Service Society, further explore the potential of the Family Health Plus Employer Buy-In program. Fidelis involvement contributed to the successful restructuring of the program. 4

7 Grant Activities (continued) New York Health Purchasing Alliance, Inc., (HealthPass) analyzed the feasibility of incorporating Healthy NY into HealthPass menu of insurance plans. Healthy NY is a State subsidized insurance program for small businesses. HealthPass is a nonprofit agency offering an array of insurance plans from which small businesses can choose. Healthy NY is not one of those plans. With NYSHealth planning monies, HealthPass examined regulatory requirements, initiated discussions with an insurance carrier, developed business and marketing plans, estimated sales, and ascertained willingness of brokers to market Healthy NY. Due to risks associated with the integration especially incompatibility of Healthy NY with the HealthPass business model that relies on brokers and general agents NYSHealth and HealthPass mutually decided not to pursue a second phase project. In addition, the passage of the Affordable Care Act introduced new circumstances related to insurance coverage and the future of the Healthy NY program. Manufacturers Association of the Southern Tier examined Multiple Employer Welfare Arrangements (MEWAs) and Professional Employer Organizations (PEOs) as vehicles to reduce premiums by combining Chautauqua County s small employers into larger units based on demographic characteristics of the insured (called experience rating ). MEWAs are not subject to the same State insurance reserve, contribution, and other requirements applicable to insurance companies and can presumably offer insurance coverage rates below those of regulated insurance companies. A PEO combines the employees of several companies into one large pool and can offer business owners better rates on health insurance, workers compensation, and other costly benefits. Neither MEWAs nor PEOs proved viable, and the national focus on Federal reform added uncertainty regarding the need for alternative approaches under consideration. Ultimately, the, Association did not pursue a demonstration proposal with the Foundation. Yet, according to Sandman, Manufacturers Association of the Southern Tier did what it set out to do and did it well. The Association concluded that its ideas would not work, but we didn t consider that a failure. That is what planning grants are for. Plattsburgh-North Country Chamber of Commerce conducted market research to determine the insurance perceptions, preferences, and needs of small businesses. The research included an exploratory phase in which focus group participants discussed their opinions about insurance; a creative phase in which individuals reacted to six slogans designed to interest businesses in securing coverage; and a quantitative phase in which focus group participants responded to proposed advertisements. There is an information access and use problem in the predominantly rural Tri-Lakes area, the market research consultants concluded. The Chamber of Commerce submitted an Action Plan to the Foundation proposing next steps, but the Foundation decided not to fund the Plan because it focused on marketing existing options rather than on expanding the number of options. 5

8 Grant Activities (continued) The S 2 AY Rural Health Network, serving the Finger Lakes region of the State, explored ways to increase the number of employers offering the State-funded Healthy NY insurance program to its employees. S2AY began with the assumption that Healthy NY might be modified to better serve small rural employers. Interviews and focus groups with employers identified a different set of barriers; however, employers were confused about their options, distrusted insurance companies and government-sponsored programs, and were frustrated with burdensome State policies. Project coordinator Andrea Haradon commented, We thought the biggest obstacle was the cost of insurance, but it really wasn t. It was the difficulty and complexity of just accessing health insurance and navigating the different options. The growing debate about national health care reform created uncertainty about the future of programs, such as Healthy NY. Therefore, the Foundation did not fund a demonstration program when the planning period ended. 6

9 Results The Foundation funded these planning projects based on the assumption that at least some would result in subsequent implementation projects. For a variety of reasons, none did. From one perspective, therefore, the Small Group Coverage initiative did not produce results, and certainly not the results the Foundation expected at the outset. There was no single reason that planning projects did not move on to the demonstration phase the Foundation or the individual grantees made those decisions based on the outcomes from each project. From another perspective, however, the planning projects did produce some helpful results. Grantees systematically gathered information about the health insurance needs, preferences and priorities of small businesses in their communities. They gained a more complete understanding of factors that drive premiums and priorities of insurers, brokers, and agents. For example, Manufacturers Association of the Southern Tier reported, The work performed during the project was very helpful to further understanding the needs of small businesses... the project helped us better determine the needs of the business community. Importantly, as well, we were able to conduct research of the legislative barriers to implementing a new model. These and other insights will be useful to communities as they work with the State to implement Federal health care reform. Fidelis Care ultimately decided to return its grant funds to NYSHealth because it felt its existing efforts in and of themselves were informing the discussion on expanding Family Health Plus Employer Buy-in to small businesses. Through its own experience with the Section 1199 Benefit Fund members, Fidelis Care contributed great knowledge and the Foundation and another grantee Community Service Society seized upon these insights to foster additional discussions about the issue. The Foundation convened two meetings with policymakers in New York City and in Albany to discuss ways that the Family Health Plus Employer Buy-In legislation could be modified to make it more attractive and effective. According to Sandman, who moderated the meetings, The meetings we convened prompted further work and good partnerships. The Foundation gained a lot from this project and the relationship we forged with Fidelis. Though the sum of results was ultimately disappointing, the RFP allowed the Foundation to take a measured risk in trying to expand a difficult insurance market. Many of the stakeholders NYSHealth staff had spoken to prior to rolling out the initiative were supportive of the Foundation venturing into this area. We all knew the risks of rolling out this area, but most of the people we spoke to were supportive of this work. When the rubber hit the road, however, we were unable to get enough attention to our work from the government stakeholders who mattered. And, remember the RFP was released in January 2008 but by March 2008, we were already experiencing an unexpected transition in the governor s office, so it was hard to get the attention and support we sought at the State level, said Hunt. 7

10 Lessons Learned The Foundation and some grantees offered lessons from the Small Group Market initiative. In reflecting on why none of the planning projects moved forward to demonstration projects, Sandman noted, From my perspective, the overarching flaw is that we asked people to discover solutions within the existing structure of the small-group market in New York. What we needed were projects that focused on restructuring the market and fundamentally changing the rules of the game. Hunt added, The initial strategy in this area was intended to be much more actionoriented, but we were naïve in thinking that organizations could develop solutions within the current regulatory framework. The Foundation s strategy in this area evolved towards supporting policy analyses to help decisionmakers understand and potentially address the pros and cons of the regulatory environment. Sandman also observed that the initiative reminded him of the Foundation s capacity to bring stakeholders together. In this situation, the Foundation convened two helpful roundtables that grew out of planning activities conducted by Fidelis Care. Hunt noted, Sometimes the role of a Foundation is to create a partnership, and we did that. 8

11 The Future The future of health insurance coverage for small businesses will be guided by how the State implements provisions of Federal health care reform legislation. For example, Healthy NY, the focus of two of the five planning projects, faces an uncertain future. According to Melissa Seeley, the Foundation s program officer, In its current form it [Healthy NY] would not be eligible as a qualified health plan offered in the Exchange(s), namely because Healthy NY does not provide mental health benefits. These benefits could be added to an existing plan and the plan might be modified overall under Federal reform, which could then affect the price and also impact interest, explained Seeley. Healthy NY might also be replaced with other types of low-cost options, she said. Similarly, creative, regional approaches such as those explored by the Manufacturers Association will probably not be necessary as New York State establishes a health insurance exchange. 9

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