Three political realities in expanding coverage for the working poor: one state's experience.

Abstract

In recent years, states have experimented with innovative approaches to expand coverage for underserved persons. Yet lack of health insurance among low income workers remains a problem. A 1997 survey reported that more than half of adults in low income, working families have been uninsured sometime in the previous two years. This group is likely to increase in the future as states implement time-limited welfare benefits and if employer-sponsored health coverage continues to decrease as in recent years. This paper describes the bipartisan effort of the Indiana Commission on Health Care for the Working Poor to design coverage expansions for uninsured, low income workers and families in Indiana. Initially, legislators challenged the state's insurance industry to develop a private health insurance plan that the state might subsidize to make it affordable to low income workers and/or their employers. However, based on findings from Indiana focus groups of working poor that the Commission conducted, the Commission recommended strategies to mobilize existing safety net providers into networks to provide comprehensive and coordinated care to low income workers and families in designated service areas. Specifically, the state would pay direct subsidies for primary and preventive care to community health centers that participate in networks with safety net hospitals. Also, the state would establish a state-sponsored stop loss fund to protect network hospitals against expenses incurred in the care of catastrophically ill network clients. These strategies reflect three realities that face states as they craft health coverage expansions for uninsured low income workers and families in today's health policy environment. First, in a conservative state, policy makers are unwilling to pay the cost of even limited coverage for low income workers and families. Second, the uninsured poor already obtain care from safety net providers that are programmatically constituted and ideologically committed to serve them. Third, this lack of demand for health coverage with minimum benefits threatens voluntary participation in a subsidized private program. The findings of the focus groups confirmed that, unless heavily subsidized, it is unlikely that low income workers are going to purchase even heavily subsidized health insurance to finance their health care. Given the constraints of the day, addressing the need for health coverage for the remaining uninsured calls for innovative thinking beyond conventional paradigms. Direct subsidies for community health centers and subsidized stop loss protection for safety net hospitals to facilitate the development of networks are promising strategies for extending coverage to uninsured, low income workers and families. While not a substitute for enrollment in a fully-paid health plan, these strategies do promise real improvement in access to high quality health care services for this group of vulnerable Americans.