The Legislative Task Force on Health Insurance Options for Small Businesses and the Working Uninsured summarized their work in a report in February 2004. The committee consisted of Representative Pat Gardner, Chair; Representative David Graves; Representative William Hembree; Representative Howard Mosby; Representative Don Parsons; and Representative Pam Stephenson and four hearings were held in 2003.

The task force was created because Georgia has the sixth highest number of uninsured in the nation, with over one million Georgians without any type of health insurance, two-thirds of whom are chronically uninsured. Of the one million uninsured in Georgia, over two-thirds work or are dependents of workers. Those working in small businesses comprise a disproportionate share of the working uninsured, while small employers offering health insurance benefits to their employees face higher costs and are able to offer fewer options than large private and public employers.

The task force was charged with exploring options for expanding health insurance coverage among the working uninsured and employees in small businesses. In order to fulfill that charge, the task force explored the results from The Georgia Healthcare Coverage Project to learn about the number and characteristics of workers without coverage, the distinctions between businesses offering and those not offering coverage, and attitudes of employers about health insurance. It heard from a wide variety of interested stakeholders including small business owners, providers, insurance industry experts and state agencies and reviewed the findings of The Health Care Access Forum that brought together county commissioners, state legislators and community health care leaders and concluded that coverage for the working uninsured and for children should be the top priorities in the state. Presenters were asked to provide information about what state legislators might do to help our small businesses find affordable healthcare for their employees. The presentations and dialogue focused on what good public policy might be if we moved from “special” interests to “common” interests. Information presented to the group included:

• Over 90 percent of all privately insured Georgians obtain coverage through the employment-based market.
• Rural Georgians and those living in low to moderate income families are most likely to be uninsured.
• 80 percent who are offered coverage enroll in that coverage.
• 16 percent of employers currently not offering coverage previously offered a plan.
• 57 percent of the working uninsured and their dependents are employed by small employers (employers with less than 25 employees).
• For those employers not offering coverage, cost was the most prominent deterrent, followed by employee turnover and the hassle of administering insurance plans
  

During Session 4, all attendees were given an opportunity to make recommendations to the task force and these included:

• Expanding Medicaid for children
• Creating public-private programs to bridge gaps in coverage
• Expanding coordination of care in Medicaid, especially for high cost enrollees
• Establishing high risk pools
• Focusing on cost control and
• Improving efficiency in the current disorganized system
• Implementing a sliding scale premiums for low-income state employees
• Evaluating individual mandates
• Creating universal access through a consolidated system.
• Mandating that every Georgian have an insurance card for health
• Facilitating expansion of federally qualified community health centers to draw down more federal money
• Improving patient understanding of the cost of care
  

The task force learned that there is a broad consensus supporting action to expand health insurance coverage in Georgia because of the burden on:

• Hospital emergency rooms, which have an unfunded mandate to provide emergency care resulting in high levels of uncompensated care
• Individuals, who are sicker because of poor access to medical care
• Providers, who are called on to care for uninsured individuals at later stages of illness, with the potential for worse outcomes at higher cost, and
• All participants in the system who bear the costs of caring for uninsured individuals because of cost shifting. Employers who provide health insurance for their employees pay more, in part, because other employers do not provide health insurance.

Expansion of coverage can be achieved through one of two approaches:

1. A complete transformation of the health care financing system in Georgia with a consolidated payer system that would cover all residents of the state.

Develop a proposal for a consolidated-payer approach to achieving universal coverage by replacing the myriad of employer, private, and public health plans with coverage for all Georgians regardless of age, employment, health status or other characteristics. Risk would be spread broadly, services would be comprehensive, and the service delivery system would remain as it is, but without restrictions on choice of providers. Current public spending on health care programs would be consolidated and tax-based funding sources paid by all employers and residents would replace all premiums, deductibles, and out-of-pocket payments. Aggregate health spending would be expected to decline and stabilize and administrative savings from directing all funding through one payer would be sufficient to cover all the uninsured and underinsured.

2. An incremental approach which identifies cohorts of the uninsured in Georgia and targets coordinated policies to expand coverage to each cohort.

In recognition of lack of public will to move to a consolidated payer at this time, the taskforce can support incremental change. Since, within the voluntary system as it now exists, there will always be some uninsured individuals, coverage expansions need to be designed based to identify the major cohorts of individuals who are uninsured and create programs and policies to “plug the holes” in the system. This strategy implies a process of reforming the health care system with multiple, but cohesive interventions implemented over time. It includes support for community efforts to provide comprehensive care for the residually uninsured in a comprehensive and cost effective manner. This approach requires an identification of short- and long-term steps that can be taken to move toward more comprehensive coverage in Georgia within the context of the current public/private partnerships.

Cohorts of the Uninsured

The task force identified five major cohorts of uninsured individuals whose needs must be addressed to move towards comprehensive health care coverage in Georgia:

1. Children
2. Working individuals and their dependents with incomes over 300 percent of FPL
3. Working individuals and their dependents with incomes above poverty but below 300 percent of FPL
4. Working poor and the indigent
5. Medically uninsurable individuals
   

Proposals

Although the committee focused on identifying strategies for groups 2-4, policies must be developed for each. Therefore, the short term (2004 legislative session) proposals from this task force could include:

1. Facilitate the implementation of a high-risk pool in Georgia to provide coverage for medically uninsurable individuals who are unable to obtain health-care coverage due to pre-existing medical conditions. This facilitation role includes legislative support and support for collaboration between the Georgia Health Policy Center, leaders in the health insurance industry and the appropriate administrative body for obtaining all existing federal support to develop and fund a high-risk pool.
2. Support communities with public resources that might be matched by private funds specifically designated for sharing information about existing Community Health System programs. Effective existing programs could be replicated to coordinate providers at the local level, increasing access to primary care for the uninsured and reducing the individual and institutional burden of the uninsured.
3. Engage researchers in formal modeling of specific proposals for insurance market reforms, purchasing cooperatives, and subsidies to identify the best next steps and prepare the task force and the legislature for action in future sessions.
4. Provide operating support enabling counties seeking to provide health care to specific populations to contract with multiple providers directly.
5. Introduce legislation to improve patient understanding of the cost of care, particularly the cost of prescription drugs.
6. Explore ways to manage the cost and delivery of medications.
7. Finally, the task force could seek to expand its mandate to develop strategies to address all of the cohorts of uninsured Georgians in a coordinated manner that would move the state toward comprehensive health insurance.