Research Report 

Access to 

Affordable Health Coverage 

for Women-Owned Businesses: 

A Summary of Key Issues and 

Policy Options
 

 April 2003 
FOREWORD 

The inability to secure affordable health care for employees is a critical and 

growing concern of many women business owners. It is estimated that 60% of 

the 41 million uninsured Americans reside in families with members employed by 

small businesses. Thus, an estimated 7.3 million of the uninsured are employees 

or families of employees of the 9.1 million women-owned firms in the U.S. 

The National Women’s Business Council (NWBC) believes that a review of 

current research and other information can provide critical information to finding a 

solution to this critical problem. This review explores the ability or inability of 

women business owners and other small business owners to secure affordable 

health care. Also examined are associated costs and the extent of existing health 

care coverage for employees. In addition to reviewing the existing state of health 

care, this report analyzes alternative strategies and proposals that have been put 

forth to deal with the issues of health care cost and access. 

The National Women’s Business Council is a bi-partisan Federal government 

council created to serve as an independent source of advice and counsel to the 

President, Congress, and the U.S. Small Business Administration on economic 

issues of importance to women business owners. Members of the Council are 

prominent women business owners and leaders of women’s business 

organizations. 

The National Women’s Business Council is committed to: 

• conducting research on issues of importance to women business owners and 

their organizations; 

• communicating these findings widely; 

• connecting the women’s business community to public policy makers; and 

i 
• providing a platform for change in order to expand and improve opportunities 

for women business owners and their enterprises. 

This research was prepared under contract for the National Women’s Business 

Council by Westover Consultants, Inc., a woman-owned business headquartered 

in Silver Spring, MD. For more information about the Council, its mission and 

activities, contact: National Women’s Business Council, 409 3rd Street, SW, 

Suite 210, Washington, DC 20024; phone: 202-205-3850; fax: 202-205-6825, email: nwbc@sba.gov 

ii 
 

INTRODUCTION 

There are a significant number of Americans without health insurance. According to 

the U.S. Census Bureau, an estimated 41 million Americans in 2001—14.6% of the 

population—did not have health coverage. Reducing the number of uninsured 

represents a far-reaching, national issue that the Executive Office, Congress, state 

legislators, health care researchers, public policy analysts, and others have struggled 

with, especially over the last decade. Most disconcerting is the irony that the majority 

of the uninsured are working people who contribute daily to the health of the Nation's 

economy. These unprotected individuals tend to work for small businesses with fewer 

than 20 employees, a sector of the economy that accounts for 90% of all U.S. 

companies. Considering that small firms are about half as likely as larger ones to 

provide health insurance coverage to their workers and their families, the health care 

crisis becomes even more apparent. Women-owned businesses, one of the fastestgrowing sectors of the small business community, are impacted significantly by this 

critical issue, which bears directly on their ability to survive, thrive, and grow. 

Although most people would agree that no American should go without health 

insurance or needed medical care, there is less agreement on the best way to reach 

this goal. A number of possible solutions have emerged, some of which will be 

addressed through legislation in the 108th Congress. Other strategies are already 

available to both small and large companies to boost access to affordable health 

coverage and increase choice. This report reviews selected Internet research and 

other documents that explore both proposed and existing health coverage options for 

the small business community, including women entrepreneurs. In sum, this 

assembled information should prove to be a useful guide for those confronting one of 

the most formidable challenges to successful small business ownership in the 21st 

century. 

iii 
 

 

EXECUTIVE SUMMARY 

The Problem for America 

• The Lack of Access to Health Insurance is an Ongoing Concern in the United 

States. In 2001, an estimated 41 million Americans – 14.6% of the population – did 

not have health insurance coverage.1 The uninsured are less likely to seek 

adequate medical care and preventative services, placing the healthy development 

of themselves and their families at risk.2 

• The Majority of Americans Who Lack Health Insurance Are Working for Small 

Companies. Americans who work for firms with fewer than 25 workers were half as 

likely to have health insurance as those who work for companies with 1,000 or more 

workers. This poses a major problem for America since 90% of U.S. companies are 

small businesses that employ fewer than 20 workers. The percentage of small firms 

offering health insurance to employees was estimated at 61% in 2002 – a decline 

from an estimated 67% in 2000. These declines came almost exclusively from the 

smallest of the firms – those with fewer than 25 employees. In comparison, 99% of 

firms with 200 or more employees offered health benefits in both 2000 and 2002.3

 In 

a recent study by the National Association of the Self Employed, 70% of 

respondents did not have health insurance themselves or provide it for their 

employees.4 

• The Cost of Health Coverage Is Rising. In 2002, monthly premiums for employersponsored health insurance increased by 12.7% – the largest increase in 12 years – 

with small firms seeing an increase of 13.2% and large firms an increase of 12.5%. 

On average, annual premiums are $3,060 for single coverage and $7,954 for family 

coverage. Workers’ share of these premiums has also risen substantially, with single 

coverage averaging $454 per year (a 27% increase since 2001) and family coverage 

averaging $2,084 per year (a 16% increase since 2001). Similarly, deductibles for 

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PPO in-network providers jumped 37% to $276, up from $201 last year.3 With health 

care costs rising and a downturn in the economy, workers can expect to pay more 

for coverage but get less for their money, as benefits erode. 

The Problem for Women-Owned Businesses and Other Small Firms 

• Most Small Employers Are Not Offering Health Insurance Coverage Because it 

is Too Costly. Eight in ten small employers (84%) who did not offer health benefits 

cite the high cost of premiums as a very important factor in reaching that decision. 

Other important reasons include not being able to qualify for group rates (57%) and 

administrative burdens (30%).3 Health coverage is generally more expensive on a 

per capita basis for smaller companies. In 2002, small firms with 3 to 9 employees 

paid $285 monthly for single coverage compared to $269 monthly for firms with 10 to 

24 employees and $239 monthly for firms with 25 to 49 employees.3

 Administrative 

expenses for insurers of small group health plans are also higher– ranging from 33 

to 37% of claims for insurers of small group health plans, versus 5 to 11% of claims 

for large companies’ self-insured plans.5 

• Many Major Small Business Associations Name Health Care as Major Concern 

for Their Membership. The National Association for the Self-Employed (NASE), 

the National Association of Women Business Owners (NAWBO), the National 

Federation of Independent Business (NFIB), the U.S. Chamber of Commerce and 

other small business organizations include access to and/or cost of health care 

among their 2003 legislative priorities. In a recent membership survey conducted for 

NAWBO, members were most likely to name association health plans among the 

public policy issues on which they want NAWBO to focus. Fifty-eight percent (58%) 

of NAWBO members who own employer firms offer health benefits to their 

employees.6 

 v 
 

 

• When Small Firms Do Offer Health Benefits, There Is Typically a Narrow Range 

of Choices. Among small businesses that offer health insurance, few provide their 

workers with a choice of health plans. Seven in ten (71%) firms that provide health 

benefits offer their workers only one plan option. The most prevalent reason cited for 

offering just one option is that the company gets a better deal from insurers by 

requiring all or most employees to be in the same plan. 3 

• Women-owned Businesses Are Affected Significantly by the Lack of 

Affordable Health Coverage. With an estimated 9.1 million women-owned firms in 

the U.S., employing 27.5 million workers, 7 public policy regarding access to 

affordable health coverage is a major concern for women-owned businesses as well 

as other small employers. The inability of many women-owned businesses to offer 

health insurance could mean that an estimated 7.3 million of the uninsured are 

employees of women-owned firms. 8 

Proposed Solutions 

A number of strategies and proposals, some of which will be addressed in the 108th 

Congress, have been put forth to deal with the issues of health care cost and access: 

• Association Health Plans (AHPs). Under the President’s health care proposal, 

AHPs can help reduce the number of uninsured by giving small businesses the 

same purchasing clout, federal regulatory structure, accessibility, affordability, and 

choice in the health care market place that large company experience. By allowing 

small businesses to band together across state lines through their membership in a 

bona fide trade association, small business owners would be able to offer affordable 

health benefits to employees and their families resulting from greater bargaining 

power, economies of scale, and administrative efficiencies.9 Under proposed 

legislation, AHPs would not be required to conform to state health insurance 

coverage mandates and insurance regulations—one of the major factors, many 

 vi 
 

contend, that contribute to the rising cost of health coverage. Currently, labor unions, 

medium-sized businesses, and large companies are able to offer health benefits to 

their employees under one uniform federal statute known as ERISA—the 

Employment Retirement Security Act of 1974. This advantage saves these 

organizations from having to comply with different rules, regulations, and benefit 

mandates that exist in each of the 50 states.9 If the ability to offer AHPs is 

strengthened through legislation, small business owners could purchase health 

coverage through federally regulated, self-funded AHPs, thereby expanding the 

small group market. An estimated 300,000 to 8.5 million American workers and their 

families could gain health insurance coverage from AHP legislation.10 In June 2001, 

the Senate passed the Kennedy-McCain version of the Patient’s Bill of Rights (S. 

1052) which did not contain AHP provisions. In August 2001, the House passed H.R. 

2562, a different version of patient’s rights legislation, which contained AHP 

provisions (rolled in from H.R. 2315/H.R. 1774 in June). Just recently, H.R. 660, the 

Small Business Health Fairness Act, was introduced with more than 70 co-sponsors 

and bi-partisan support. This bill re-introduces many of the elements of previous 

AHP-focused legislation. 

• Medical Savings Accounts (MSAs). Under a four-year pilot project authorized by 

the Health Insurance Portability and Accountability Act (HIPAA) of 1996, MSAs were 

enacted although with a number of restrictions. MSAs, which are available only to 

self-employed persons or businesses with 50 or fewer employees, are tax-exempt 

personal savings accounts to be used for qualified, out-of-pocket medical expenses. 

To be eligible for an MSA, an individual must maintain a high deductible health plan 

(i.e., $1,500 to $2,250 for individuals and $3,000 to $4,500 for families). There are 

two health-plan options—individual and family. The allowable contribution to the 

MSA depends on the size of the health plan deductible chosen, and funds not spent 

by the end of the year may be rolled over into the next year. Many support the 

permanent authorization of tax-qualified MSAs with certain modifications to make 

them more flexible, such as varying the deductible depending on the type of 

 vii 
 

expenditure and extending eligibility to all businesses. These HIPAA MSAs are often 

referred to as Archer MSAs, named for Rep. Bill Archer (R-Texas) who championed 

the MSA legislation. The Archer MSA demonstration project will end on December 

31, 2003, unless it is extended or made permanent by law. The Medical Savings 

Account Availability Act of 2001(S 1067/HR 1524), introduced by Senators Grassley 

(R-IA) and Toricelli (D-NJ) and Representatives Thomas (R-CA) and Lipinski (D-IL) 

would improve MSAs and make them permanent.11,12,13 

• Refundable Tax Credits. President Bush has proposed a refundable tax credit to 

help the uninsured purchase private health insurance coverage. In this manner, 

individuals could purchase health insurance that they can own and keep, even if 

they change jobs or their employers change plans. The credit would vary by family 

income and size, and provide a subsidy of up to 90% of the cost of health insurance 

premiums, with a maximum credit of $1,000 per adult and $500 per child (for up to 

two children) for a maximum family credit of $3,000. The health tax credit would be 

refundable, such that even those who owe no income tax would receive credit by 

filing an income tax return and claiming a refund against their health insurance 

expenses. The credit would also be advanceable, based on the individual’s prioryear income, making it available whenever the individual or family seeks health 

insurance, and before filing an income-tax return for that year, in order to reduce the 

amount of the monthly health insurance premium. This proposal would also permit 

certain low-income individuals to purchase private insurance for themselves and 

their families through state-sponsored health insurance groups or high-risk 

pools.14,15 

• Flexible Spending Accounts (FSAs). FSAs were first authorized by Congress in 

1978 and are allowed under Section 125 of the Internal Revenue Code. They enable 

workers to allow up to $4,000 (pre-tax) tax-free money to spend on health care 

expenses—such as co-payments, deductibles, and services—not otherwise covered 

by their insurance, or to pay for health insurance premiums. FSAs function exactly 

 viii 
 

like MSAs, except those funds not used by the end of the year are returned and 

cannot be carried over for future expenses. In order for workers to be allowed to take 

control of their health care costs, such limitations would need to be changed.9 

• Health Marts. Spearheaded by Rep. Tom Bliley (R-VA), Health Marts are 

administrative entities or cooperatives of workers, employers, insurers, and 

consumers that are formed to offer more choice in employer-based health coverage. 

Instead of selecting a health insurance carrier for all of a company’s employees, the 

employer would sign up with a Health Mart which, in turn, would offer workers a wide 

range of health coverage options (e.g., HMOs, PPO plans, MSAs, and other 

vehicles). Employees would then select the health insurance coverage that they 

prefer. Health Marts would offer multiple health plans, accept all small employers, 

and conform to state laws governing differences in premiums among small firms, but 

would be free of state mandates that require coverage of certain benefits and 

providers. In theory, this would allow them to offer a less costly benefit package. 

Health Marts are similar in many respects to Health Purchasing Cooperatives 

(HPCs) which have been initiated in several states, offering collective purchasing 

arrangements for small employers.16, 17 

• Cafeteria Plans. As its name suggests, cafeteria plans (also referred to as “Flexible 

Spending Plans” or “Section 125 Plans”) allow each employee to choose from 

among a menu of predetermined options in deciding where their benefit dollars will 

be spent—including medical, accident, disability, vision, dental, and group term life 

insurance—and the amount of the benefit. Funded through “tomorrow’s earnings”, 

employees must estimate the anticipated cost of such expenses for the upcoming 

year and request to have the estimated amount redirected from wages into the plan. 

Benefits are paid through payroll withholding with pre-tax dollars. Such plans allow 

small firms to offer benefits that would otherwise be unaffordable with real tax 

savings to employees.18 

 ix 
 

• Consumer-Choice Health Purchasing Groups (CHPGs). CHPGs bring employers 

and consumer together for the purpose of collectively purchasing health coverage 

form health plans. Governed by an employer-consumer board, CHPGs provide 

employees of participating firms with information to compare the price, 

characteristics, and performance of each plan. Employees then choose a plan that 

best fits their needs and preferences, and the CHPG enrolls employees in the plan 

of their choice.19 

• Defined Contribution Health Insurance. This strategy allows employees to select 

from any health plan being offered, at a cost that he or she chooses to pay, using 

both their employer contributions and the personal contributions that they make, 

instead of having the employer select plan options for their workers, as is 

customarily done in employer-sponsored health coverage. If the employer’s 

contribution does not cover the full cost, the worker would supplement it with their 

own funds or choose a less generous plan and pay less out-of-pocket.20,21 

• Health Reimbursement Arrangement (HRA). An innovative and flexible health 

plan design approved last year by the U.S. Treasury and IRS (Rev. Rul. 2002-41 

and Notice 2002-45), an HRA is a type of defined contribution account that may be 

used to pay both out-of-pocket health care expenses and health coverage premiums 

for employee and dependant health care, including long-term care coverage. 

Amounts credited to an HRA must be provided solely by the employer and cannot be 

financed through employee salary reductions, and any unused balances may be 

rolled over from year to year. These flexible plans may be provided by an employer 

in conjunction with a cafeteria plan as well as another health plan that would be 

ordinarily financed through employee salary reduction.22 

• High Risk Pools (HRPs). The Trade Act legislation (H.R. 3009) passed in the 107th 

Congress and signed by the President in August 2002 provides up to $100 million in 

federal funding for states to create high-risk pools or to fund existing ones. The Act 

 x 
 

enables offering uninsured people with pre-existing conditions access to affordable 

health insurance coverage. State risk pools first appeared 25 years ago and cover 

about 153,000 people. Currently, 30 states have enacted legislation establishing 

HRPs. States with well-functioning high-risk pools have virtually solved the problem 

of health insurance access for their medically uninsurable residents.23 

 xi 
 

 

 

 

REFERENCES 

1 “Health Insurance Coverage 2001,” Current Population Reports, U.S. Census Bureau, 

September 2002. www.census.gov 

2 “Expanding Health Insurance: The AMA Proposal for Reform,” American Medical 

Association, 2002. www.ama-assn.org 

3 “Employer Health Benefits: 2002 Annual Survey,” The Kaiser Family Foundation and 

Health Research and Educational Trust, 2002. www.kff.org 

4 “Affordability in Health Care: Trends in American Micro-Business,” the National 

Association for the Self Employed, 2002. www.nase.org 

5 “Study of the Administrative Costs and Actuarial Values of Small Health Plans,” by 

Rose C. Chu and Gordon R. Trapnell, SBA Office of Advocacy, January 2003. 

www.sba.gov/advo 

6 “2002 Membership Survey of the National Association of Women Business Owners,” 

NAWBO, 2002. www.nawbo.org 

7 Center for Women’s Business Research. www.womensbusinessresearch.org 

8 National Women’s Business Council estimate based on the employment distribution of 

women-owned firms and the previously cited statistic that only 61% of small firms 

offered health insurance to their employees in 2002. www.nwbc.gov 

9 “National Agenda: Health Care,” National Federation of Independent Business, 

November 11, 2002. www.nfib.org 

 xii 
 

 

 

10“Association Health Plans: Improving Access to Affordable Quality Health Care for 

Small Businesses,” U.S. Department of Labor, December 2002. www.dol.gov 

11 “MSAs Can Be a Windfall for All,” by Greg Scandlen, Policy Backgrounder No. 157, 

November 2, 2001. www.ncpa.org 

12 “Medical Savings Accounts,” National Association of Health Underwriters. 

www.nahu.org 

13 “Archer MSAs: A Good Beginning—A Better Future,” (Issues and Answers No.105), 

Council on Affordable Health Insurance, July 2002. www.cahi.org 

14 “White House Renews Call for Health Insurance Tax Credits,” by Amy Snow Landa, 

AMNews, American Medical Association, February 18, 2002. www.ama-assn.org 

15 “The Bush Health Agenda—Part II: Tax Credits for the Uninsured,” by Mark 

McClellan, National Center for Policy Analysis (Brief Analysis No. 415), August 20, 

2002. www.ncpa.org 

16 “Small Employer Health Insurance Purchasing Arrangements: Can They Expand 

Coverage?” by Elliot K. Wicks and Jack A. Meyer, National Coalition on Health Care, 

May 1999. www.nchc.org 

17 “Health Marts, A Free Market Health Care Solution,” by Peter J. Ferrara, Policy Brief, 

Americans for Tax Reform, October 4, 1999. www.atr.org 

18 “Implementing a Cafeteria Health Plan,” by T. Michael Regan, Physicians News, 

March 1998. www.physiciansnews.org 

 xiii 
 

 

19 “Consumer-Choice Health Purchasing Groups,” Institute for Health Policy Solutions, 

1999. www.ihps.org 

20 “Health Insurance: Letting Employees Choose,” by Greg Scandlen, Brief Analysis 

No. 325, National Center for Policy Analysis, July 6, 2000. www.ncpa.org 

21“Defined Contribution Health Insurance,” by Greg Scandlen, National Center for 

Policy Analysis, (Policy Backgrounder No. 154), October 26, 2000. www.ncpa.org 

22“Defined Contribution Health Plans: A Greenlight for HRAs,” Kilpatrick Stockton, July 

2002. www.kilstock.com 

23 “Getting Started: A State Checklist for Creating High-Risk Pools,” (Issues and 

Answers No. 111), Council on Affordable Health Insurance, December 2002. 

www.cahi.org 

 xiv 
 

 

SECTION 1.0: THE PROBLEM FOR AMERICA 

This section describes the high number of uninsured adults in the Nation who 

work for small companies and examines their characteristics, reasons for lacking 

coverage, and some consequences of being uninsured. The surging cost of 

health insurance is also addressed. 

1.1 The High Number Of Uninsured Americans 

The number of Americans without health insurance in this country is significant. 

According to the Census Bureaus' 2001 Current Population Survey, an estimated 

14.1% of the population, or 41 million Americans, lacked health coverage.1 The 

number of uninsured Americans steadily increased from the late 1980s to the 

end of the 1990s. In 1999, the Census Bureau reported a decline in the share of 

Americans without health coverage for the first time in 12 years. At that time, an 

estimated 15.5% of the population was uninsured during the year, compared with 

12.9% in 1987 and 16.3% in 1998.1 Despite expansion of existing Government 

health care programs, especially Medicaid, and the creation of new programs, 

like the State Children's Health Insurance Program (SCHIP), the number of 

uninsured has remained stubbornly high. The problem has persisted through 

periods of both economic prosperity and recession.2 

Data from the National Center for Health Statistics (NCHS) corroborate Census 

statistics on the high number of uninsured. In the initial quarter of 2002, the 

proportion of uninsured persons was 14.3%, a slight increase from 14.1% in 

2001. NCHS reports that the proportion of Americans without health insurance 

decreased over the period 1997-2001, from 15.4% in 1997 to 14.1% in 2001.3 

The number of persons without health coverage tends to grow as unemployment 

increases, which—considering the recent upturn in unemployment—is bound to 

exacerbate the current health care crisis. Reflecting the economic downturn that 

1-1 
 

began early in 2001, the annual average unemployment rate climbed from 4.0% 

in 2000 to 4.7% in 2001 to 5.8% in 2002. 4 

1.2 The High Number Of Uninsured Workers 

Working Uninsured in Small Firms. Most insured Americans obtain their health 

insurance coverage through the work place. In 1997, over three-quarters (75.9%) 

of the employed population received health insurance coverage through their 

own employer or another person's employer, as reported in the Census Bureau's 

Survey of Income and Program Participation (SIPP).5 Among the unemployed in 

1997 and those not in the work force, 33.2% and 45.2% respectively, received 

employment-based coverage through a spouse or former employer.5 

Although employers are the Nation’s portals for employee health coverage, most 

of the uninsured are working adults who contribute daily to America’s growth and 

prosperity. The Census Bureau reports that in 1997 small businesses were less 

likely than larger businesses to offer health insurance benefits to their workers 

and cover them. About one-half (52.1%) of workers in firms with fewer than 25 

employees were offered health coverage through their current employer, with 

only one-third (33.8%) choosing to receive such coverage. These rates increased 

with firm size to the point that over three-fourths (78.2%) of employees in firms 

with 25-99 workers were offered health insurance, with over half (53.3%) 

accepting it. Nearly all (91.6%) workers in companies with 500 to 999 employers 

were offered health insurance benefits, with two-thirds (66.3%) accepting 

coverage.5 

Small companies are not only less likely than large companies to offer health 

insurance coverage to their employees and cover them; when they do, health 

insurance choices can be quite limited. “Larger companies were more likely to 

offer a choice of several health insurance plans, to cover part-time workers, and 

to offer long-term care" than smaller companies.5 

1-2 
The Kaiser Family Foundation, in its 2001 National Survey of Small Businesses, 

queried a random sample of 805 business owners and other executives with 

three to 24 employees regarding their health insurance benefits and practices. 

The study found that only 60% of these offered health insurance coverage. The 

availability of coverage varied substantially by firm size and other characteristics. 

Generally, the smaller the firm, the less likely it was to offer health insurance, 

with only 56% of small businesses with three to nine employees offering 

coverage, compared with 72% of small businesses with 10-24 employees.6 

In a sample survey of 300 small businesses nationwide, the National Association 

of Health Underwriters (NAHU) found that nearly three-fourths (72%) of small 

businesses in America currently offer some type of health insurance coverage to 

their workers. The businesses that make coverage available have significantly 

higher average sales volumes ($2.2 million) and more benefits-eligible 

employees than those that do not offer coverage ($1.2 million).7 

Characteristics of the Uninsured. An analysis by the Institute of Medicine 

(IOM) of the National Academies provides insight into the characteristics of 

persons who lack health coverage. IOM conducted an extensive review of 130 

research studies that examined the health insurance status of non-elderly adults 

and its effect on health-related outcomes. Although the uninsured are found in all 

segments of the U.S. population, the IOM identified three personal characteristics 

that are closely related to having coverage: health status, race and ethnicity, and 

socioeconomic status. Non-Hispanic workers are more likely to be covered than 

either African Americans or Hispanics, and men are more likely to be covered 

than women. The IOM suggests that some racial and ethnic disparities in the use 

of appropriate health care services and in rates of morbidity and mortality would 

likely be reduced with increased minority access to health insurance coverage.8 

As for reasons for lack of coverage, The Commonwealth Fund cites three 

primary reasons. First, health insurance premiums are so costly and the income 

1-3 
of most uninsured people is so low that they cannot afford to purchase health 

coverage.9 In 2000, the worker’s share of the average health insurance premium 

for a single employee under age 65 was $2,424 and a family policy cost 

$6,348.99 This means that for nearly one-half of the uninsured population, the 

cost of health coverage exceeded 25% of family income. 

Second, over 90% of people with private health insurance obtain it through their 

place of employment.9 However, the majority of uninsured workers do not have 

the option of securing employment-based health coverage either directly or 

through a family member, mainly because the business does not offer it.9 

Third, working adults often cannot qualify for public insurance programs because 

eligibility criteria are stringent, especially if the worker has no children. For 

example, although children in families with incomes below 100 percent of the 

Federal poverty guidelines are eligible for Medicaid in all states, an adult who 

earns $4,000 annually would not even qualify for Medicaid in most states.9

 Thus, 

in broad terms, the majority of the uninsured are low-income people without 

access to employment-based coverage or public coverage. 

Employee Access to Coverage. Not all employees are offered coverage 

equally, and many do not accept coverage that is available to them. Offers of 

company health insurance and take-up rates by workers vary by industry and 

occupation. "Workers in the educational service industry and the manufacturing 

industry were the most likely to be offered health insurance—92% and 90.7%, 

respectively,” as were workers in the transportation, communication, and public 

utilities industries (89%) and in the public relations and administration industry 

(88.7%). In contrast, employees in the agriculture, mining, and construction 

industries (57.3%) and the repair and recreational service industries (58.3%) 

were the least likely to be offered health insurance.5 

In terms of occupations, persons who worked as architects, technicians, 

scientists, and medical workers were the most likely to be offered health 

1-4 
 

insurance (92.8%), "followed by managers and administrators (89.5%). Farm, 

construction, and mining workers were the least likely to be offered (55.5%) 

health insurance".5 Similarly, the likelihood of accepting the option of health 

insurance varied by occupation. "For example, mechanics, repairers, and 

precision workers were not the most likely to be offered health insurance, but 

they were one of the most likely to be covered if health insurance was offered." 5 

Although employers provide opportunities for many workers to become insured, 

in 1997 nearly one-half (46.4%) of workers who were eligible to participate in 

their employer's health insurance plan elected not to do so. Either coverage was 

too expensive or they received it through another source.5 Nearly one in ten 

(9.3%) employed persons had public, privately purchased, or military-related 

health insurance. The General Accounting Office (GAO) reports similar findings: 

About one in three employers (36%) with fewer than 10 employees offered health 

insurance coverage to their workforce, although these businesses represented 

about 61% of small firms.10 

The National Association of Health Underwriters has found that about one-half of 

the small employers that offer health insurance report that "all of their eligible 

employees take the company's health insurance." If employees do not, it is 

because the majority (79%) have coverage elsewhere. Nonetheless, there are 

still others (18%) who for cost or financial reasons do not accept coverage.7 

Additionally, the less an employee earns, the less likely she or he is offered 

health insurance coverage. Workers receive offers of coverage in 48% of 

businesses with an average employee wage of under $2,200 per month, 

compared with a 72% offer rate among businesses with an average employee 

wage exceeding this amount. Similarly, businesses that employ workers in 

positions that primarily require a college degree are more likely to offer coverage 

than businesses with jobs that usually require a high school diploma or less.8 

1-5 
 

 

1.3 The High And Rising Cost Of Health Care 

In a national sample survey of more than 2,000 employers of all sizes, the Kaiser 

Family Foundation and the Health Research and Educational Trust 

(Kaiser/HRET) extensively explored the cost of health coverage. In 2002, health 

insurance premiums for employment-based coverage increased by 12.7%, the 

largest increase since 1990. This was the sixth consecutive year that the rate of 

increase grew faster than the prior year’s. In fact, “premium increases in 2002 

exceeded the overall rate of inflation by 11 percentage points.”11 The 

researchers attribute the high rate of premium growth for job-based coverage 

primarily to increasing medical claims expenses.11 

Double-digit increases in health premiums were noted for all types of health 

plans. Premiums rose for health maintenance organizations (HMOs) (13.3%), 

indemnity plans (12.7%), preferred provider organization (PPOs) plans (12.7%), 

and point-of-service (POS) plans (11.9%). Firms with three to 199 workers 

witnessed premium increases of 13.2%. This figure slightly exceeded that of 

firms with 200 or more workers, which experienced premium increases of 12.5%. 

The largest premium increases (14.9%) were found among firms with 10-24 

employees. For all firms, there was slight geographic variation in premium 

increases across the country, ranging from 12.5% in the South and Northeast to 

13.2% in the Midwest.11 

In 2002, the average monthly cost for health premiums for single and family 

coverage was $255 and $663, respectively, for the combined employer and 

worker share. The annual cost of premiums that year reached $3,060 for single 

coverage and $7,954 for family coverage. For firms with three to 199 workers, 

these annual costs were higher for single coverage ($3,100) but lower for family 

coverage ($7,737). The smallest of these firms paid higher premiums for single 

coverage than did any other firm size group. Employers of three to nine workers 

paid $3,419 annually for single coverage, while employers of 10-24 workers paid 

1-6 
$3,233.11 Thus, small business owners who may be among those least able to 

afford health coverage are facing the highest premiums. 

1.4 The Human Costs Of Being Uninsured 

National figures on the number of uninsured do not reveal the real consequences 

to America of so many citizens living without health insurance. According to the 

American Medical Association (AMA), the uninsured are less likely to seek 

adequate medical attention and preventive services, which inevitably places the 

healthy development of themselves and their families at risk.12 Similarly, the 

Institute of Medicine (IOM) reports that individuals without health insurance are 

more likely to have poorer health and die prematurely than those who are 

insured.8 

Furthermore, the IOM reports a number of other adverse health consequences 

for uninsured persons. For example, uninsured adults do not receive the care 

recommended for the prevention and treatment of chronic diseases, such as 

timely eye examinations to avert blindness or foot examinations to prevent 

amputations in diabetics. They also lack access to medications critical to the 

management of life-threatening conditions such as hypertension or HIV disease. 

They receive fewer diagnostic and treatment services after a severe injury or 

heart attack, increasing the risk of death.8 Similarly, uninsured adults are more 

likely to forego recommended cancer screening tests (e.g., mammograms, 

clinical breast examinations, Pap tests, and colorectal screenings), delaying 

diagnosis and increasing chances of premature death. Notably, uninsured 

women with breast cancer have a 30%-50% higher risk of dying from this 

condition and are less likely to receive breast-conserving surgery than are 

women with private health coverage.8 

Going without health insurance has different consequences depending on a 

person’s age, general health status, and the length of time uninsured. Individuals 

between 55 to 65 years old and low-income adults are especially susceptible to 

1-7 
deteriorating health without health coverage. Population-based studies that 

monitored non-elderly adults over an extended period found that individuals who 

were uninsured when the study began had a 25% higher risk of dying than 

persons with private health insurance. This pattern held true for deaths from 

heart attack, cancer, traumatic injury, and HIV infection.8

 The long-term effects of 

these and similar findings can only be staggering, given that an estimated 40% of 

the uninsured are without health insurance coverage for a period of 18 months or 

more.13 Besides increased morbidity and mortality, treatment in hospital settings 

often depends upon insurance status, IOM research shows. For example, 

uninsured patients with traumatic injury are less likely to be admitted to a 

hospital, to undergo needed surgical procedures, and to receive physical 

therapy.8 

1-8 
REFERENCES 

1 “Health Insurance Coverage 2001,” Current Population Reports, U.S. Census 

Bureau, September 2002. www.census.gov 

2 “Transforming our Health Sector by Empowering Consumers,” Grace-Marie 

Turner, Galen Institute, December 10, 2002. www.galen.org 

3 “NCHS, Family Core Component of the 1997-2002 National Health Interview 

Surveys.” www.nchs.gov 

4 “Labor Force Statistics from the Current Population Survey: 1948-2002.” U.S. 

Department of Labor, Bureau of Labor Statistics. www.bls.gov 

5 “1997 Survey of Income and Program Participation,” U.S. Bureau of Census. 

www.census.gov 

6 “2001 Kaiser Foundation Survey of Small Business,” Kaiser Family 

Foundation, 2001. www.kff.org 

7 “Small Employer Health Insurance Attitudes and Purchasing Trends,” 

Association of Health Underwriters. www.nahu.org 

8 "Care Without Coverage: Too Little, Too Late,” The National Academies, 

Institute of Medicine, Board on Health Care Services, Committee on the 

Consequences of Uninsurance, National Academies Press, May 2002. 

www.nap.edu 

9 "Challenges and Options for Increasing the Number of Americans With Health 

Insurance,” Sherry Glied, The Commonwealth Fund, January 2001. 

www.cmwf.org 

1-9 
10 “Health Insurance: Characteristics and Trends in the Uninsured Population,” 

Government Accounting Office, (GA0-01-507T), March 13, 2001. 

www.gao.gov 

11 “Employer Health Benefits 2002 Annual Survey,” The Kaiser Family 

Foundation and Health Research and Educational Trust, 2002. www.kff.org 

12 “Expanding Health Insurance: The AMA Proposal for Reform,” American 

Medical Association, 2002. www.ama-assn.org 

13 "Targeting Long- and Short-term Gaps in Health Insurance,” P.F. Short and J. 

Klerman, The Commonwealth Fund, June 1998. www.cmwf.org 

1-10 
 

 

SECTION 2.0: THE PROBLEM FOR WOMEN-OWNED BUSINESSES AND 

OTHER SMALL FIRMS 

This section examines the role of small companies in the economy and the 

response of the small business community, including women entrepreneurs, to 

the lack of affordable health coverage. It also explores reasons why small firms 

are generally not providing coverage and how those who do offer it are struggling 

to maintain it. 

2.1 The Importance Of Small Business To The Economy 

The crucial role that small businesses play in the American economy cannot be 

overstated. In 2001, there were an estimated 22.4 million small businesses in the 

country, accounting for virtually all (99%) of America's employers and employing 

just over one-half (53%) of the private work force. President Bush makes clear 

the importance of the small business sector: “Small businesses have always 

been the backbone of our economy. They perennially account for most 

innovation and job creation, and not just when our economy is robust and 

growing. Small businesses have sustained the economy in weaker times as well, 

and put us back on the track to long-term growth. It is vital that we work together 

to give small businesses the climate they need to thrive.”1 

Without access to affordable health insurance by a much greater proportion of 

small firms, the gap between the uninsured and the insured is likely to widen as 

the small business sector continues to grow. In the period 1998-1999, the 

number of small firms—inclusive of those both with and without employees— 

continued to rise, with a large share of the total and growth stemming from an 

increase in sole proprietorships. The number of small businesses with paid 

employees rose from 5.5 million in 1997 to 5.8 million in 1999, an increase of 5 

percent.1 Non-employer businesses, too, played a key role in small business 

growth. This category of firms includes, for example, businesses that are 

operated by one or more individuals and can range from home-based enterprises 

2-1 
 

 

 

to mom-and-pop stores to independent contractors. According to the Census 

Bureau, non-employer firms increased by 2.3% between 1999 and 2000, from 

16.2 million to 16.5 million. Non-employer enterprises accounted for 70% of all 

businesses, although they contributed a relatively small but growing share of the 

overall sales and receipts generated by the small business sector.2 

2.2 Barriers To Small-Firm Health Coverage 

High health insurance costs and limited choice of health plans pose a formidable 

challenge to small business owners. Most small business owners surveyed who 

do not offer health insurance coverage cite cost as the primary barrier. In the 

Kaiser Family Foundation survey, nearly three-fourths (72%) of small firms 

surveyed did not offer coverage for this reason. Other reasons, although less 

important, for not taking up coverage included the availability of health insurance 

from a spouse or other family member (43%), administrative burden (34%), and 

the ability to attract high-quality employees without it (32%).3 

The majority (67%) of small business owners surveyed are dissatisfied with the 

high and increasing expense of health insurance coverage, with many 

suggesting that rising costs could cause them eventually to shift more of the 

premiums cost to the employee or to pursue other alternatives. Among small 

firms that offer coverage, about 28% indicate that they have changed health 

insurance plans in the last two years, mostly for cost reasons. Finding and 

keeping affordable health insurance poses such a challenge for many small 

businesses that about one-third (35%) of those that offer it say that they will 

probably have to increase the share of costs that is borne by their employees if 

health insurance premiums continue to rise. About 37% of firms indicated that 

they will likely switch to a defined contribution approach in the next five years.3 

Despite the importance of cost as a deciding factor in whether to offer health 

insurance coverage, not all employers are as aware as one might expect of the 

2-2 
 

actual price of coverage. In the Kaiser survey, nearly one-third (29%) of small 

business owners who did not offer health insurance benefits overestimated how 

much it would cost them, projecting that that an average monthly premium for a 

single employee would cost $264, compared with the actual average cost of 

$227. In any event, most of these business owners felt that the most they could 

pay would be about $110 monthly toward the premium and their employees 

would be able to contribute only about $89 monthly.3 

In a 2001 survey conducted by the National Association of Health Underwriters 

(NAHU), most small employers (59%) that offered health insurance benefits were 

satisfied with their company's health plan and felt that their workers were 

satisfied with it too. Employers were not as satisfied, however, with the limited 

range of health insurance plans available to them.4 

Surveys conducted at regional and state levels support many of the findings of 

national surveys and studies. The Plattsburgh-North Country Chamber of 

Commerce, which represents about 2,000 businesses in upstate New York, 

released data in 2001 from its third annual small business survey. Health 

insurance cost and access were among the top three concerns of the 

overwhelming majority (68%) of surveyed small business owners with 10 or 

fewer employers. More than one-half (54%) of the respondents represented 

family-owned businesses; 19% were women-owned firms; and 4% were minorityowned businesses.5 

The Ohio-based Council of Smaller Enterprises (COSE), the Nation’s largest 

local small business association, found that nearly 70% of its members believed 

health care costs to be "the most important short-term issue they face.”6 COSE 

warns that "premiums can become so expensive that they threaten some 

employers' ability to offer health care benefits at all, resulting in an increased 

number of uninsured.”6 The organization has been recognized by both the Bush 

and Clinton administrations for its pioneering work in health care group 

2-3 
 

purchasing models, which has resulted in coverage to 13,000 small firms in the 

northeast Ohio area.6 

2.3 Small-Firm Commitment To Its Work Force 

Many small firms offer health insurance to their workers, despite the high cost, 

because they feel it is the right thing to do. According to the Census Bureau, the 

smaller the business that offers coverage, the higher the proportion of covered 

employees whose health care premiums are paid entirely by the firm. 

Approximately 44% of covered employees in businesses with fewer than 25 

workers had their entire premium paid by their employer, compared with just 

29.4% of covered employees in large firms with 1,000 or more workers.7 

In the NAHU study, nearly one-half (45%) of small employers that offered health 

insurance required that their employees pay part of the premium, which averaged 

about 42% of the total cost, or approximately $44 monthly. Most employees 

(64%) paid an additional amount to include a family member, which averaged 

around $168 monthly for a spouse and $249 monthly for a spouse and children.4 

Despite the tendency of smaller firms who offer health coverage to pay a higher 

proportion of the premium than larger firms do, this trend could be slowed in the 

future given the weakened national economy. In evaluating the response of 

business owners to surging health coverage costs, market and health policy 

experts at a 2001 Wall Street Roundtable forecast that premium cost-sharing 

with employees is inevitable and will increase. Higher deductibles and copayments are also likely to occur. In addition, there may be an increased 

application of coinsurance in which patients pay a percentage of their medical bill 

instead of a predictable fixed-dollar amount.8 

Premium cost-sharing is already a reality for many employers, as shown in the 

2002 Employer Health Benefits Survey conducted by the Kaiser Family 

2-4 
 

 

Foundation and the Health Research and Educational Trust (Kaiser/HRET). “In 

2002, employee contributions for single and family coverage increased 

substantially in nominal dollars—contributions for single coverage grew almost 

27% while contributions for family coverage grew by 16%. The fact that worker 

contributions have increased in 2002 after remaining stable or declining in prior 

years is likely due to employer’s greater willingness to pass along cost increases 

given the weaker economy and lower demand for labor.”9

 Researchers warn that 

this pattern could affect employees in several ways. “Workers may seek less 

expensive options, or, if the employee’s share of the premium is high enough, 

may choose not to accept health insurance coverage.”9 

Higher premium cost-sharing can also affect a company’s talent pool. “Of the 

firms that increased the amount employees pay for coverage this year, 41% 

report that it was somewhat harder to attract and retain workers compared to 

23% of firms who did not increase the amount employees pay.”9 

In addition to paying a greater share of health care premiums, employees are 

experiencing higher cost-sharing for health plan deductible and copayments. “In 

PPOs, deductibles increased from $201 in 2001 to $276 in 2002. Deductibles for 

single coverage in conventional plans also increased significantly—from $195 to 

$270 this year.” 9 In addition, the percentage of workers enrolled in HMOs with a 

$5 copayment decreased from 11% in 2001 to 5% in 2002, as the share of 

workers with a $20 copayment jumped from 2% to 11%. Although higher copayments and deductibles save costs, researchers point out that they may also 

discourage use of needed services, particularly among lower income persons.9 

2.4 Access To Health Insurance In Women-Owned Companies 

A Visible and Growing Presence. With an estimated 9.1 million womenowned firms in the U.S., employing 27.5 million workers, public policy regarding 

access to affordable health coverage is a major concern for women-owned 

2-5 
 

businesses as well as other small employers.10 The inability of many womenowned businesses to offer health insurance could mean that an estimated 7.3 

million of the uninsured are employees of women-owned firms.11 

In 1999, women represented just under one-half (46%) of the American labor 

force, the highest labor participation rate in the world. Women also played a 

significant role in the decision-making process in the work place. Of the 20.7 

million people in 1999 who occupied executive, administrative, and managerial 

positions, 46%, or 9.4 million, were women. Of these women, about 6% were 

under the age of 25, about 30% were between 35 and 44, and only 2.6% were 

age 65 or older.7 

Large Representation in Service Industries. Although women-owned 

businesses operated in all industrial categories in 2002, fully half (53%) were in 

the service sector. Approximately 16% of these firms were in retail trade; 9% 

were in finance, insurance, and real estate; 3% were in construction; and 12% 

fell into an unclassified category. The wholesale trade, retail trade and service 

industries accounted for 65.9% of total revenues.10 Almost two-thirds (64.3%) of 

the total revenues generated by women-owned businesses were derived from 

the wholesale and retail trade and service industries. In the 2002 Kaiser/HRET 

survey, the highest increases in health insurance premiums (13.9%) were 

experienced by businesses in the service sector and by state and local 

governments. Businesses in the retail industry encountered the second highest 

rate increase in premiums that year (12.2%).9 

The experiences of women business owners in accessing affordable health 

coverage support many of the research findings of national small business 

surveys described earlier. This was apparent at the Roundtable on Affordable 

Health Care for women business owners, hosted by NWBC in February, 2003. 

During that meeting, a diverse panel of women entrepreneurs, business 

association executives, and other stakeholders raised awareness of how the lack 

2-6 
 

 

 

of access to affordable health coverage is affecting their companies, employees, 

and constituents. Women business owners expressed a sincere commitment and 

willingness to provide health insurance coverage despite its high cost because of 

a moral obligation to their work force. Some of the businesses represented at the 

Roundtable paid anywhere from 80%-100% of employee coverage.12 

Upon starting a business, many women entrepreneurs cannot afford to provide 

health insurance coverage at all, although they tend to offer this benefit as their 

business grows. In a recent survey of the 8,000-member National Association of 

Women Business Owners, over one-half (58%) of employer firms offered health 

insurance coverage.13 

Even companies that are able to purchase insurance are hit routinely with the 

high cost of coverage year after year. As a result, many women entrepreneurs for 

the first time are considering increasing premium cost-sharing with employees, 

paring down coverage, or dropping benefits altogether. The lack of access to 

affordable health coverage is also considered to be a key factor in creating an 

uneven playing field for women entrepreneurs in attracting and maintaining 

employee talent.12 

2-7 
 

 

REFERENCES 

1 “The State of Small Business: A Report of the President 1999-2000—The 

Annual Report on Small Business and Competition,” U.S. Small Business 

Administration, Office of Advocacy. www.sba.gov 

2 “Nonemployer Statistics: 2000,” U.S. Census Bureau, October 2002. 

www.census.gov 

3 “2001 Kaiser Foundation Survey of Small Business,” Kaiser Family 

Foundation, 2002. www.kff.org 

4 ”Small Employer Health Insurance Attitudes and Purchasing Trends,” National 

Association of Health Underwriters, March 2001. www.nahu.org 

5 “Small Business Survey,” Plattsburgh-North Country Chamber of Commerce, 

2001. www.northcountrychamber.com 

6 “2002-2006 Public Policy Agenda for Northeast Ohio,” Greater Cleveland 

Growth Association, COSE, 2002. www.clevelandgrowth.com or www.cose.org 

7 “Annual Demographic Survey, Supplement,” Bureau of Census, March 2000. 

www.census.gov 

8 “Wall Street Comes to Washington: Market Watchers and Policy Analysts 

Evaluate the Health Care System,” Center for Health Systems Change, Issue 

Brief No. 43, September 2001. www.hschange.org 

9 “Employer Health Benefits: 2002 Annual Survey,” The Kaiser Family 

Foundation and Health Research and Educational Trust, 2002. www.kff.org 

2-8 
 

 

10 “Center for Women’s Business Research. 

www.womensbusinessresearch.org 

11 National Women’s Business Council estimate based on the employment 

distribution of women-owned firms and the previously cited statistic that only 

61% of small firms offered health insurance to their employees in 2002. 

www.nwbc.gov 

12 “Roundtable Report on Access to Affordable Health Coverage by WomenOwned Businesses and Other Small Firms,” National Women’s Business 

Council, March 2003. www.nwbc.gov 

13 “2002 Membership Survey of the National Association of Women Business 

Owners,” NAWBO, 2002. www.nawbo.org 

2-9 
SECTION 3.0: PROPOSED SOLUTIONS FOR BUSINESS OWNERS 

In this section we discuss a variety of approaches for increasing access to 

affordable health coverage by small business owners. 

3.1 Strategies For Accessing Affordable Health Coverage 

Concern in the past decade about the high number of uninsured has prompted 

policymakers and other stakeholders to explore ways to improve access to 

affordable health coverage by the self-employed and other small businesses. 

After facing multiple years of double-digit increases in health insurance premiums, 

business owners are especially motivated to identify alternative ways to manage 

surging health care costs for themselves and their work force. Employees, too, in 

response to the effects of this prolonged crisis (e.g., increased cost-sharing, 

pared-down coverage, higher deductibles, or even loss of coverage altogether), 

have awakened to a new era in the management of their own health care. 

Consumers everywhere are discovering the need to be more aware and savvy 

about how to spend their health care dollars. They are searching for products that 

permit more consumer choice in what they will buy, from whom they will buy it, 

and how much they will spend. 

As the small business community awaits the outcome of pending national 

legislation, there are a number of health coverage programs already available that 

offer small business owners flexibility, options, and control in their health care 

spending. Accordingly, this section reviews association health plans, medical 

savings accounts, refundable tax credits, state high-risk pools, defined 

contribution accounts, cafeteria plans, flexible spending accounts, health 

reimbursement accounts, small group purchasing cooperatives, and health marts. 

For each program, we provide a general description, discuss recent legislative 

activity (if any), and highlight other key information of interest to small firms. 

(Additional details on each approach can be obtained by referring to the Topical 

Resource List in the Appendix.) 

3-1 
3.2 Association Health Plans 

Description. One of the most significant pieces of health-related small business 

legislation before the 108th Congress is the expansion of association health plans 

(AHPs) beyond the state level. An AHP is a group health plan that is sponsored 

by a business, professional, and/or trade association offering medical benefits to 

all its members.1

 Many view AHPs as a major part of the solution to the current 

health care crisis in America. Under the President’s health care proposal, AHPs 

would help decrease the high number of uninsured by giving small businesses the 

same advantages enjoyed by large companies. These enhancements include 

purchasing clout, economies of scale, Federal regulatory structure, accessibility, 

affordability, and choice in the health care market. 

By banding together across state lines through a bona fide association, AHPs 

may help level the playing field for small firms by allowing them to exploit lowered 

administrative costs that should result in less expensive health insurance 

premiums. The interstate operations of AHPs would exempt them from state 

health insurance coverage mandates and, instead, subject them to Federal law.2 

Some contend that state mandates are one of the principal cost-drivers in the 

rising price of health coverage. Currently, labor unions, medium-sized businesses, 

and large companies can offer health benefits to their employees under one 

uniform Federal statute known as ERISA, the Employment Retirement Security 

Act of 1974. This law exempts such organizations from having to comply with 

different rules, regulations, and benefit mandates in each of the 50 states.2

 As 

proposed, AHPs could either purchase coverage directly from insurance 

companies or could self-insure (i.e., pay claims from association funds), if they 

cover sufficient numbers of participants. AHPs that self-insure would be subject to 

solvency requirements so that sufficient monies would be available to pay claims 

when presented. 

3-2 
 

 

The U.S. Department of Labor (DOL) would be the Federal agency responsible for 

oversight of AHPs if the legislation is passed by Congress and signed into law. 

The agency would certify AHPs, confirming that sponsoring associations are bona 

fide and not formed solely for the purpose of marketing insurance. AHPs would 

have to meet strict requirements designed to protect participants and foster 

financial solvency. The DOL would establish a separate fund to guarantee that 

outstanding participant claims would be paid if, for some reason, the AHP became 

insolvent.2 

Some AHPs currently exist at the state level, and a number of small businesses 

now offer health coverage through programs sponsored by trade and professional 

associations. These health programs are considered multiple employer welfare 

associations (MEWAs) that, under current Federal law, are subject to state 

insurance laws and regulations.2 If the ability to offer AHPs is strengthened 

through pending legislation, business owners could purchase health insurance at 

more affordable rates, thereby expanding the small-group market. 

Legislative Activity. AHP legislation has been introduced a number of times in 

the Congress. While the White House and the House of Representatives have 

generally supported AHPs, the Senate has primarily opposed them. Many 

Senators have been unwilling to alienate state insurance commissioners, who 

would have to relinquish some authority if AHPs become subject to a Federal 

regulatory structure and DOL oversight.3 In June 2001, the Senate passed the 

Kennedy-McCain version of the Patient’s Bill of Rights (S. 1052), which did not 

contain AHP provisions. In August 2001, the House passed H.R. 2562, a different 

version of patient’s rights legislation, which included provisions for AHPs (rolled in 

from H.R. 2315/H.R. 1774 in June), as well as medical savings accounts.4 

In May 2001, Representatives Ernie Fletcher, M.D. (R-KY), and Cal Dooley 

(D-CA) introduced the Small Business Health Fairness Act (H.R. 1774). The same 

bill was introduced in the Senate (S. 858) by Senator Tim Hutchinson (R-AR) and 

was cosponsored by Senator Christopher Bond (R-MO), the ranking member of 

3-3 
 

the Senate Small Business Committee. In February 2003, Rep. Ernie Fletcher and 

96 cosponsors proposed the Small Business Health Fairness Act of 2003 (H.R. 

660), which would give AHPs an ERISA preemption.3,5 A month later in the 

Senate, incoming Small Business Committee Chairperson Olympia J. Snowe 

(R-ME) introduced the same bill (S. 545) with six cosponsors.5 

Other Considerations. One of the most favorable arguments in support of AHPs 

is that small firms would experience lower health insurance premiums because of 

savings from lower health plan administrative costs. This would, in turn, enable 

more small firms to offer health insurance to their work force. In a study released 

in 2003 by the Actuarial Research Corporation for the SBA, the high 

administrative costs of health plans designed for small businesses were explored. 

Researchers found that the administrative costs for insurers of small business 

group health plans ranged from 33% to 37%, in contrast to 5% to11% of claims for 

larger companies. Furthermore, sales, underwriting, and operating expenses were 

all higher for the small health plans.6 A Congressional Budget Office study of 

potential AHP impacts on small-group premiums and coverage found that small 

firms would pay premiums that were, on average, about 13% lower than what they 

otherwise would have paid. The reduction stems partly from exemption from state 

health coverage mandates and partly from “a net shift to the new plans of firms 

with relatively low expected health costs.”7 

AHPs have the overwhelming support of most major business associations for 

small firms, including those that primarily serve women- and minority-business 

owners.8

 Micro-businesses (i.e., firms with 0-10 employees) face an especially 

difficult challenge gaining access to affordable health coverage in terms of 

premiums and plan choice. For these, the smallest of small businesses, AHPs are 

especially attractive. In 2002, the National Association for the Self-Employed 

(NASE)—the nation’s leading business association and resource for the selfemployed and micro-businesses—conducted a random survey of 2,000 small 

business owners. This study explored different parameters relative to owners’ 

3-4 
 

 

current health care insurance and their views on AHPs, MSAs, and health care 

tax credits.1 

Reported findings were based on data received from 600 of these businesses. 

Approximately three out of four of the small business owners surveyed indicated 

that they would be “very” or “somewhat likely” to participate in an AHP if doing so 

would result in less expensive insurance (78%) coverage, greater choice in health 

care benefits for themselves and their workers (75.1%), and less administrative 

burden (72.7%). Thus, if AHP legislation currently pending in Congress becomes 

law, it should reduce the extraordinarily high proportion of self-employed and 

micro-businesses that currently do not offer health insurance coverage (70.3%) 

and have never offered it (88.3%). About three in seven (42.3%) of the survey 

respondents belong to a business, professional, and/or trade association. Over 

half (50.5%) of the businesses that were not members of an association indicated 

that they would be “very” or “somewhat likely” to join an association in order to 

receive AHP benefits. Respondents in the 2002 NASE survey are wellestablished firms, having been in business for an average of 17.2 years, with an 

average of three employees and average gross revenues in 2001 of $341,000.1 

The chief opponents of AHP legislation are the Nation’s health plans, led by Blue 

Cross/Blue Shield organizations nationwide—the largest insurers in the smallgroup market—and some labor unions and consumer groups.9,10 Opponents cite 

insurance fraud as an area of major concern. However at the recent Roundtable 

on Affordable Health Care, Secretary of Labor Elaine Chao provided reassurance 

that the DOL, as the lead Federal agency fighting insurance fraud, will tightly 

regulate insurance fraud through its newly named Employee Benefit Security 

Administration (EBSA). EBSA recovered nearly $9 million last year attributed to 

health plan fraud.8 

The other key argument against AHPs is that they would foster “cherry picking,” or 

selection of only the healthiest persons for plan participation. The legislation, 

3-5 
however, contains numerous provisions intended to prevent this practice. AHPs 

must comply with the Health Insurance Portability and Accountability Act (HIPAA), 

which prohibits group health plans from excluding high-risk individuals or 

businesses with a history of high claims. The legislation also limits the ability of 

AHPs to alter the premiums of lower and higher cost employers or direct 

potentially higher cost participants to the individual insurance market.11 

3.3 Medical Savings Accounts 

Description. Medical savings accounts (MSAs) are tax-exempt arrangements 

that were established for the self-employed and businesses with 50 or fewer 

workers. This strategy allows individuals to set aside monies for routine, out-ofpocket health care expenses and to build up savings for future medical 

expenses.1

 Currently, MSAs are available as part of a congressionally approved 

four-year demonstration project (authorized by HIPAA) that ends on December 

31, 2003, unless extended or made permanent by law. If not, only individuals who 

previously had MSAs and employees of previously participating employers will be 

allowed to continue to make contributions to an MSA. These HIPAA MSAs are 

often referred to as Archer MSAs, named for Rep. Bill Archer (R-TX) who 

championed the bill.12,13,14 

There are two health plan options—individual and family—and the allowable 

contribution to the MSA depends on the size of the health plan deductible chosen. 

To be eligible for an MSA, an individual must maintain a high-deductible health 

insurance policy (i.e., $1,500 to $2,250 for individuals and $3,000 to $4,500 for 

families). Monies can be contributed to an MSA throughout the year, or the 

participant can elect to make a lump sum payment at the beginning of the year. All 

MSA contributions are 100% deductible, and any unused funds can be carried 

forward to the next year, earning interest all the while.12,13,14 By expanding and 

making MSAs permanent, as well as by removing enrollment limits, new 

3-6 
 

legislation could allow many individuals with a high-deductible health plan to 

participate.15 

Legislative Activity. As with AHPs, legislation on MSAs has been introduced in 

Congress on several occasions. In 2001, as noted above, House-approved 

patients’ rights legislation (H.R. 2562) contained provisions for MSAs.4 The 

Medical Savings Account Availability Act of 2001 (S. 1067/H.R. 1524) introduced 

by Senators Charles Grassley (R-IA) and Robert Toricelli (D-NJ) and 

Representatives Bill Thomas (R-CA) and Bill Lipinski (D-IL) proposed to improve 

MSAs and make them permanent.12,13,14 In February 2003, Rep. Ron Paul (R-TX), 

along with cosponsor Rep. Ginny Brown-Waite (R-FL), introduced the Medicare 

Medical Savings Account Expansion Act of 2003. In its present form, the 

legislation would make MSAs permanent and eliminate the ceiling for the number 

of enrolled businesses.5 

Other Considerations. The small business community generally views MSAs 

favorably. In NASE’s 2002 small business survey, information on MSAs was 

collected from self-employed persons and micro-businesses. Only two in seven 

(28.3%) of the survey respondents were aware of MSAs prior to the survey, and 

practically none of these business owners (only 1.8%) currently had an MSA for 

themselves or their employees. However, after learning about MSAs through the 

survey questionnaire, nearly half (42.6%) were open to the idea, with 6.8% 

indicating they were “very interested” and 35.8% noting they were “somewhat 

interested”. In fact, about one quarter of surveyed entrepreneurs (26.8%) said 

they were “very” or “somewhat likely” to establish an MSA policy for their work 

force, and over one-third (33.6%) indicated that they would personally contribute 

to an MSA if the business offered one to its employees. An overwhelming majority 

(79.2%) of business owners felt that MSAs should be made available to all 

individuals and employers and not limited to the self-employed and small firms 

with 50 or fewer workers.1 

3-7 
 

3.4 Refundable Tax Credits 

Description. In 2002, President Bush proposed a refundable tax credit to those 

persons lacking access to employer-based coverage so that they could purchase 

private health insurance. Individuals could obtain coverage that they can own and 

keep, even if they lose or change jobs. The size of the credit would vary by family 

income and size, and provide a subsidy of up to 90 percent of the cost of health 

insurance premiums. There would be a maximum credit of $1,000 per adult and 

$500 per child (for up to two children) for a maximum family credit of $3,000. The 

credit would be refundable even for taxpayers who owe no income tax. Such 

persons would file an income tax return and claim a refund against their health 

insurance expenses. The credit would also be advanceable on the basis of the 

individual’s prior-year income. This feature would enable persons who, for 

example, may not have enough cash readily available to meet monthly premiums 

to receive an advance through the tax credit system. In addition, certain lowincome persons could purchase private coverage for themselves and their 

families through state-sponsored health insurance groups or high-risk pools.16,17 

Refundable tax credits would have special appeal to the individual insurance 

market. As it is currently structured, this market provides coverage to a broad mix 

of people with different life circumstances. These include the self-employed, 

workers in businesses where health coverage is not offered, individuals outside 

the labor force, persons who have exhausted their COBRA coverage after leaving 

an employer, and early retirees who are too young to qualify for Medicare.18 

Legislative Activity. The 108th Congress is currently considering legislation that 

would extend a tax credit to individuals to purchase health insurance. In February 

2003, Rep. Mark Kennedy (R-MN) introduced a bill (H.R. 583) in the House along 

with 107 cosponsors that would allow individuals a refundable credit against 

income tax for this purpose. The bill would also establish state health insurance 

safety nets.5 

3-8 
Other Considerations. The business community generally supports refundable 

tax credits as an important component of a viable solution to the health coverage 

crisis. In a Kaiser Foundation survey the overwhelming majority (89%) of small 

employers favored tax credits to help purchase private health insurance for their 

workers. Three in four small employers supported tax credits or other financial 

assistance to help employees purchase health insurance on their own.19 

Under President Bush’s health care tax credit proposal, an individual would 

receive a maximum $1,000 tax credit per adult to purchase health insurance. It is 

important to know whether there are low-cost health insurance policies available 

that can be purchased with the credit. Research conducted by the Health 

Research and Educational Trust suggests that there are a number of low-cost 

plans available for younger and healthier adults, although older adults would have 

great difficulty finding high-quality health coverage at this price. About onequarter of the plans on the market for a healthy 27-year old male cost $816 

annually. In contrast, only one-quarter of healthy 55-year old males can get a 

policy for under $2,184 per year.20 Researchers at the Center for Studying Health 

Systems Change raise similar concerns based on their national Community 

Tracking Survey. Their data show that health insurance premiums for older 

persons and for those in declining health are more costly than for other groups.21 

3.5 State High-Risk Pools 

Description. For many individuals who lack employer-based health coverage but 

have extensive medical expenses, obtaining coverage in the individual insurance 

market is not an affordable option. In most states, insurers can refuse coverage to 

“high risks” because of a current or preexisting medical condition. State high-risk 

pools, which first appeared 25 years ago, help insure those who have been 

denied private coverage in the individual market. In 2001, 29 states maintained 

high-risk pools, although enrollment was limited and covered only an estimated 

113,000 individuals.22 Such pools now operate in 30 states and cover about 

3-9 
153,000 persons. Most of the states also use their pools to comply with HIPAA 

provisions relating to individuals leaving employer group coverage. Some enroll 

Medicare-eligible persons in their high-risk pool for supplemental coverage. 

Legislative Activity. The Trade Act legislation (H.R. 3009) signed into law in 

August 2002 provides up to $100 million in Federal funding for states to create 

high-risk pools or to fund existing ones. In March 2003, Representative Edolphus 

Towns (D-NY) and 17 cosponsors introduced the State High Risk Pool Funding 

Extension Act of 2003 (H.R. 1110) to continue the current funding of high-risk 

pools at the state level. Also in March, Representative Mark Udall (D-CO) 

introduced an amendment to the Public Health Service Act that would enable 

high-risk pools to receive reductions in prices charged for prescription drugs.5 

Other Considerations. Some research shows that high-risk pools have had a 

limited impact on making heath coverage more available and affordable to 

otherwise uninsurable persons. Often, state risk pools have long waiting lists, 

exclude new participants, and charge higher health insurance premiums relative 

to income. They also require large deductibles and copayments, restrict annual 

and lifetime benefits, and may impose preexisting-condition exclusions to reduce 

adverse selection.22 State high-risk pools operate at a loss because the amount 

of medical claims paid is typically higher than the amount of insurance premiums 

collected. Nonetheless, some states (e.g., Kentucky, Oregon, Washington, and 

Wisconsin) have found innovative ways to finance their high-risk pools by 

broadening their revenue bases.22 States with well-functioning high-risk pools 

have made major strides in increasing access to health insurance for their 

medically uninsurable residents.23 

3.6 Defined Contribution Accounts 

Description. A defined contribution account (DCA) is an account that an 

employer establishes on behalf of an employee to pay health care expenses. The 

3-10 
employer credits the account a certain amount that the employee can use to pay 

for medical expenses. DCAs may also be used to pay for health-related expenses 

that are typically not covered in traditional health plans, such as some vision 

correction procedures. When utilized in combination with an existing health plan, a 

DCA arrangement can provide funds to cover out-of-pocket expenses and 

deductibles.24,25 

Legislative Activity. Legislation pertaining to DCAs has been particularly active 

in the past two years. In the 107th Congress alone, one bill in the House (H.R. 

3657) and three in the Senate (S. 1919, S. 1992, and S. 2032) were introduced to 

permit improved disclosure, diversification, access, and accountability for DCAs. 

In January 2003, Senator Thomas Daschle (D-SD) proposed legislation (S. 9) 

advancing further improvements to DCAs in the 108th Congress.5 

Other Considerations. DCAs present some uncertainty that should be carefully 

considered. “Under current law, there is some risk that DCAs will be treated like 

flexible spending accounts, including the use-it-or-lose-it rule. This effectively 

prevents amounts from being carried over from year to year.” 24,25 

3.7 Cafeteria Plans 

Description. As its name suggests, a cafeteria plan (also referred to as a “flexible 

spending plan,” “flexible benefits plan,” or “Section 125 plan”) allows employees to 

design their own benefits package. Workers can select different types and levels 

of benefits that are funded with nontaxable employer dollars. Employees are 

allotted a certain predetermined number of credits, dollars, or points that they can 

use to purchase benefits. Individuals can pick from a menu of predetermined 

benefit options to best meet their needs and those of their families.26 

The types of benefits that can be carried by a cafeteria plan are typically those 

that would not result in taxable income to employees if they were provided outside 

such a plan. Examples include health insurance, dental insurance, life insurance, 

3-11 
accidental death and dismemberment coverage, disability coverage, and vacation 

leave. The only exception to this rule of thumb is group life insurance exceeding 

$50,000: although it can also be included in a cafeteria plan, this benefit continues 

to be taxable.26 Also, retirement benefits cannot be included, except for a 401(k) 

plan. Many employers, however, opt not to include a 401(k) plan as part of their 

cafeteria plan because the regulations governing 401(k) plans are complex, 

especially when combined with Section 125 regulations.26 

Legislative Activity. Since their inception, numerous bills have been introduced 

in the House and the Senate to improve the operation of cafeteria plans. In 

January 2003, Representative Jim DeMint (R-SC) and 43 cosponsors initiated 

legislation in the House (H.R.1177) to provide additional choice regarding unused 

health benefits in cafeteria plans and flexible spending accounts.5 

Other Considerations. Although many employees enjoy the flexibility afforded by 

cafeteria plans, there are some potential pitfalls that both business owners and 

workers should consider. First, employees may not have the necessary 

knowledge or expertise to select the right mix of benefits to fit their particular 

situation. This could result in inadequate employee protection and major loss for 

the worker. For instance, younger workers may be motivated to choose the cash 

option, considering themselves to be healthy and invulnerable, instead of 

selecting high-option health coverage or disability insurance. Yet, should the 

employee experience a serious illness or suffer a disabling accident, that 

individual is exposed to serious physical and financial risk. Second, cafeteria 

plans usually offer a reduced level of benefits as the core coverage, and then a 

menu of optional benefits (or cash). Because these plans carry higher 

administrative costs than do traditional benefit plans, employers may compensate 

by lowering the dollar allocation for each benefit offered in the menu compared 

with the benefits offered under a more traditional plan. Thus, the employee may 

end up with inadequate coverage. Third, the employer may feel financial 

3-12 
pressures to “remodel” or adjust some of the benefits in the future to keep pace 

with increases in the cost of the core coverage.26 

3.8 Flexible Spending Accounts 

Description. Flexible spending accounts (FSAs) are a type of cafeteria plan first 

authorized by Congress in 1978 and regulated under Section 125 of the Internal 

Revenue Service Code. FSAs function exactly as MSAs do, except any funds not 

used by the end of the year must be returned and cannot be carried forward for 

future expenses. FSAs were born out of the changing needs of employees 

seeking to tailor their health care benefits to their individual circumstances, such 

as expenses for child care or an elderly or disabled dependent. Even taxpayers 

who do not itemize on their tax returns can receive a tax break with a health care 

or dependent care FSA by paying for these out-of-pocket expenses with pretax 

dollars.27 

There are two kinds of FSAs: health care FSAs to reimburse general medical 

expenses, and dependent care FSAs to recoup costs associated with the care of 

children, the elderly, and adults with disabilities.28 The types of expenses that can 

be reimbursed to employees in a health care FSA include deductibles or 

copayments associated with conventional health insurance plans. Also covered 

are physician-prescribed expenses for the diagnosis, treatment, cure, or 

prevention of a medical condition, and outlays for prescription drugs, orthodontia, 

a chiropractor, and hearing or vision aids. The types of costs that can be 

reimbursed in a dependent care FSA include fees for babysitting of dependent 

children age 13 or younger, and expenses associated with day care centers and 

before- and after-school care programs.28 The account can also be used to pay 

elder care expenses if the employee is responsible for at least 50 percent of the 

support of an elderly parent. Such benefits can likewise apply to persons of any 

age living with the employee who are physically or mentally incapable of caring for 

3-13 
themselves and are listed as dependents on the employee’s income tax 

statements. 

Rules. Specific rules that FSAs must follow are listed below. 

• An employee must voluntarily elect how much she or he will place into the FSA 

at the beginning of the year; however, all the money does not have to be 

contributed by the employee at that time. This amount is contributed through 

salary reduction.28 

• The amount of the salary reduction cannot be changed during the plan year 

unless there is a change in the employee’s family status—such as a birth or 

death of a dependent, marriage, divorce, or loss of employment by the 

spouse—or a major change in the health plan coverage or cost.28 

• The full amount that the employee has chosen to contribute to a health care 

FSA must be made available by the employer at all times throughout the 

coverage period to reimburse expenses.28 

• If there is a balance left in the FSA at the end of the plan year, the funds are 

forfeited by the employee and becomes the property of the employer. This is 

referred to as the “use it or lose it” rule. Employers, in turn, can do just about 

anything with this money, such as use it to offset administrative expenses, 

except return it to the employee who forfeited it. Employers can decide, 

however, to return unused monies to all employees if it is done on an equitable 

basis (i.e., each employee receives the same amount).26,28 

• The maximum amount that an employee can contribute in a plan year for 

either type of FSA is $5,000. Some FSAs establish a minimum that must be 

satisfied (e.g., $25 or $50) before an expense will be reimbursed.28 

3-14 
 

• After the end of the plan year, the employer should allow 90-120 days for 

participants to submit claims for expenses incurred during the plan year.28 

• An employee who participates in an FSA and is entitled to COBRA benefits 

can elect to continue the FSA upon leaving the employer; the business would 

have to continue to honor claims and accept payments. 28 

Other Considerations. FSAs can benefit both employers and employees. 

Employees can set aside a portion of their pretax salaries to pay for certain 

unreimbursed health and dependent care expenses or for health insurance 

premiums. An FSA can stand on its own or become part of a larger cafeteria plan. 

Employers benefit because FSAs are not subject to payroll tax, thereby reducing 

the employer’s tax obligation.27 

3.9 Health Reimbursement Accounts 

Description. One of the newest vehicles for providing more employee choice and 

control over their health care benefits is the health reimbursement account (HRA). 

This option is also known as a personal contribution account, defined contribution 

account, consumer-directed health care account, or self-funded medical 

reimbursement account. Authorized by the U.S. Treasury Department and 

announced in June 2002, this type of account gives both employers and 

employees more flexibility in health plans. 

HRAs resemble several products already on the market. They are similar to FSAs 

with one major difference—at the end of the year employees do not lose their 

money but instead can rollover any unused funds to the next year. There are no 

limits on the amount that can be carried forward. These accounts are also similar 

to MSAs except that HRAs are funded by the company, are available to 

employers of all sizes, and are flexible in design.29, 30 

3-15 
Formally, such products are known as health reimbursement arrangements, which 

have existed for years, although they were not offered as an option to employees 

until full cafeteria plans gained popularity in the late 1980s. Now, as employers 

seek new ways to cope with extraordinarily high health care costs, the concept 

has been given new life by the Internal Revenue Service and the U.S. Treasury 

Department, which issued new guidelines for HRAs last year. 

The guidance, which consists of a notice and revenue ruling, “provides that 

medical benefits paid by HRAs that meet certain requirements are not taxable. 

The guidance also clarifies that HRAs generally are not subject to the complex 

design requirements for health flexible spending arrangements funded through 

salary reduction under a cafeteria plan.”31 

Rules. The rules for an HRA are as follows:32 

• Tax treatment. Coverage under an HRA and all expenses that are reimbursed 

through it are excluded from the gross income of the covered person. 

However, as with FSAs, individuals cannot claim an income tax deduction for 

expenses that have been reimbursed through their HRAs. 

• Strictly an employer-paid benefit. An HRA must be funded solely by the 

employer and may not be directly or indirectly paid for through an employee 

salary reduction; nor can it be provided through the employer’s cafeteria plan. 

• Reimbursement for medical expenses. Monies placed in an HRA can be 

used to reimburse employees only for medical expenses (as defined under 

Sec. 213 in the tax law), which must be substantiated properly by the 

employee. Allowable reimbursable expenses include costs paid for premiums 

for health or accident coverage. HRAs can also be used to pay long-term care 

premiums, but not direct long-term care expenses. At no time can employees 

3-16 
receive any cash, directly or indirectly, or any taxable or nontaxable benefits 

from their HRAs. 

• Carry-over of unused funds. One of the most appealing features of HRAs is 

that any unused portion of this plan coverage can be carried forward to 

subsequent coverage years. Even better, there are no limits on how much or 

how far into the future an amount can be carried. However, there can be no 

cash disbursement of unused funds, directly or indirectly. 

• Retirees and former employees. Both current and former employees 

(including retired persons) and their spouses and tax dependents may be 

covered under an HRA. Thus, persons with an HRA who no longer work for 

the employer can maintain access to unused reimbursements. Furthermore, a 

surviving spouse, as well as dependents of a deceased employee, may be 

covered. 

• Coordination with major medical plan. An HRA may be offered in 

conjunction with the employer’s principal group health plan. For instance, a 

business could offer a major medical plan that carries a high deductible along 

with health coverage under an HRA. In this manner, the HRA could be used to 

receive reimbursement for deductibles, copayments, and other expenses that 

the primary medical plan does not cover. 

• Subject to COBRA. HRAs are group health plans and, therefore, are subject 

to COBRA continuation requirements. Thus, employees with unused 

reimbursements in an HRA who leave an employer can use this coverage to 

pay health premiums if they find themselves temporarily uninsured. 

With issuance of new guidance by the U.S. Treasury Department last year, 

Secretary Paul O’Neill stated that “we clear the way for employers to adopt health 

3-17 
plans with patient-directed features so that employees have more choice and 

greater control over their health care coverage.”31 

Other Considerations. HRAs can be instituted rather easily by small businesses 

that may be unable to afford the expense of large health insurance premiums. For 

example, by deciding how much the business can afford to spend on health 

coverage and dividing this amount among all employees in the form of an HRA, 

the business can provide some level of health coverage to protect its workers. 

Employees can use the funds in their HRA to purchase health insurance on their 

own. Alternatively, an employer can reduce its health care costs by selecting 

group insurance plans with higher deductibles, offer HRAs in exchange, and use a 

percentage of the savings (since high deductible plans are cheaper than lowdeductible plans) to fund the HRAs. 

Many companies are bundling their health benefit offerings with an HRA. In fact, 

the most successful HRA plans are those that are a part of a larger health plan 

design.29 For example, an HRA can coexist with a Section 125 Cafeteria Plan with 

certain restrictions. As noted earlier, these cafeteria plans operate as salary 

reduction plans in which employees have a predetermined amount deducted from 

their salaries and deposited in their health plan. Employees can then use the 

money to pay expenses that they incur over a period of time, but will lose all 

monies that are not exhausted by the end of that time. Under the IRS guidance, 

an employer could offer both an HRA and a Section 125 cafeteria plan; however, 

medical expenses must be reimbursed first from the 125 plan before the HRA can 

contribute. 

3.10 Small-Group Purchasing Cooperatives 

Description. In the early 1990s, many state governments and businesses 

responded to the lack of access to affordable health care by legislating various 

insurance reforms and creating employer health insurance purchasing alliances. 

3-18 
These alliances are known by many different names, and differences between the 

entities are often unclear.33 The most common names are multiple employer 

welfare associations (MEWAs), consumer choice health purchasing groups 

(CHPGs), and health insurance purchasing cooperatives (HIPCs). 34 Purchasing 

cooperatives purport to help level the playing field for small employers by offering 

them some of the same advantages that larger businesses enjoy. These include 

choice of multiple insurers and benefits packages, administrative simplicity, and 

leverage in negotiating lower health insurance premiums.33 

In 1999, more than 20 states had enacted legislation that created or authorized 

the creation of such purchasing cooperatives for private companies, state or local 

governments, or both, although specific laws varied considerably by state. Many 

states limited the participation to groups of 50-100 employees. Some of the 

functions exercised by the purchasing cooperatives include gathering and 

disseminating comparative information on plan quality and rates, negotiating with 

health plans, and providing consumer support.34 Small-employer purchasing 

cooperatives are usually prohibited from rejecting groups or individual employees 

on the basis of adverse health status or risk. 

CHPGs are organizations that bring employers and consumers together for the 

purpose of collectively purchasing health plans from insurers.35 Governed by an 

employer-consumer board, a CHPG establishes criteria for selecting the health 

plans, along with sets of standardized benefits and data-reporting requirements. It 

may also determine the need for related administrative services (e.g., enrollment 

of participants and collection and payment of premiums) and provide employees 

with information to compare the price, characteristics, and performance of each 

plan. A CHPG can likewise help resolve problems between consumers and the 

health plans. CHPGs are currently offered in just six states.35 

Other Considerations. To explore the advantages of small-employer purchasing 

cooperatives, the Government Accounting Office examined the experiences of 

3-19 
five such cooperatives, all of which provided coverage to businesses with 50 or 

fewer employees and offered at least two fully insured coverage options.33 The 

study found that these small-group purchasing cooperatives offered several 

advantages, including administrative services and a number of benefit options. 

“By participating in a cooperative, small employers have a single point of entry to 

multiple insurers’ plans with standardized benefit packages that can be 

compared easily instead of having to individually identify insurers and their 

agents, review widely varying benefit options, and determine price and terms of 

coverage.”33 Such findings are in sharp contrast to the single-plan option to 

which many small employers have grown accustomed. 

The cooperatives, however, did not provide leverage in negotiating lower health 

insurance premiums. The study attributes this reality to limited market share, the 

inability of cooperatives to lower the administrative costs for insurers, and state 

laws and regulations that restrict the degree to which insurers can vary premiums 

charged to different groups purchasing the same health plan.33 The study also 

found that small-group purchasing cooperatives have had mixed success in 

maintaining their viability (i.e., ensuring the participation of sufficient insurers and 

employers). Such difficulties have been due in part to the perception by many 

insurers that such entities are likely to attract high-risk individuals and groups. 

“Today, there are probably fewer than 20 small group health care purchasing 

pools that are close to the original ... concept. Few, if any, of these pools 

currently sell their products based on favorable price or even expanded access. 

Instead pool sponsors focus on ease of administration for the employer, 

expansion of employee choice, and access to information about quality of care.” 36 

3.11 Health Marts 

Description. A health mart is a type of pooled purchasing arrangement that 

employers can join to buy health coverage.34 Spearheaded by Representative 

Tom Bliley (R-VA), health marts are non-profit administrative entities or 

3-20 
cooperatives of employers, workers, insurers, and consumers that are formed to 

offer more choice in employer-based coverage and care to firms with two to 50 

employees. In lieu of selecting a health insurance carrier for all of a firm’s 

employees, the employer signs up with a health mart that, in turn, offers a wide 

range of health coverage options (e.g., HMOs, PPOs, MSAs and others). 

Employees then choose the options that are most attractive to them.37 

Rep. Bliley modeled health mart legislation after the Federal Employee Health 

Benefits Plan (FEHBP), which offers congressional members and Federal 

employees multiple managed fee-for-service, point-of-service, and HMO plans. 

Health marts build upon the FEHBP model of consumerism by “fostering the 

creation of private, competitive, and patient-empowering voluntary choice 

cooperatives.”38 Health mart legislation “would pre-empt insurance mandates that 

have had the unintended effect of increasing the cost and decreasing the array of 

health insurance plans. Indeed, according to Blue Cross/Blue Shield, there were 

more than 1,000 state laws mandating that specific benefits and providers be 

covered by health insurers in 1998. This doesn’t include laws regulating managed 

care plans or coverage for specific patient populations. The impact these 

mandates have had on the cost of coverage is significant, with General 

Accounting Office estimates ranging as high as 22 percent.”38 

3-21 
 

REFERENCES 

Association Health Plans 

1 “Affordability in Health Care Survey: Trends in American Micro-Business,” 

National Association for the Self-Employed, June 2002. www.nase.org 

2 “Remarks Prepared for Delivery by U.S. Secretary Elaine L. Chao at the 

National Women’s Business Roundtable on Affordable Health Care for Small 

Businesses,” February 27, 2003. 

3 “Association Health Plans Issue Paper,” National Lumber and Building 

Materials Dealers Association, March 2003. www.dealer.org 

4 “Patients’ Rights Stalls in House,” VOICE, National Federation of Independent 

Business, July 30, 2001. www.nfib.org 

5 “Bill Summary and Status,” Library of Congress. http://www.loc.gov 

6 “Study of the Administrative Costs and Actuarial Values of Small Health Plans,” 

Rose Chu and Gordon Trapnell, Actuarial Research Corporation for the Office 

of Advocacy, U.S. Small Business Administration, January 2003. 

www.sba.gov 

7 “Increasing Small-Firm Health Insurance Coverage Through Association Health 

Plans and Health Marts,” Congressional Budget Office, January 2000. 

www.cbo.gov 

8 “Roundtable Report on Access to Affordable Health Coverage by WomenOwned Businesses and Other Small Firms,” National Women’s Business 

Council, March 2003. www.nwbc.org 

3-22 
9 “Private Health Insurance: Number and Market Share of Carriers in the Small 

Group Health Insurance Market,” GAO-02-536R, March 25, 2002. 

www.gao.gov 

10 “Small Businesses, Insurers at Odds Over Health Plans,” Bill Lewis, March 19, 

2003. www.tennessean.com 

11 “Association Health Plans: Improving Access to Affordable Quality Health Care 

for Small Businesses,” U.S. Department of Labor, December 2002. 

www.dol.gov 

Medical Savings Accounts 

12 “MSAs Can Be a Windfall for All,” Greg Scandlen, Policy Backgrounder No. 

157, November 2, 2001. www.ncpa.org 

13 “Medical Savings Accounts,” National Association of Health Underwriters. 

www.nahu.org 

14 “Archer MSAs: A Good Beginning—A Better Future,” Issues and Answers No. 

105, Council on Affordable Health Insurance, July 2002. www.cahi.org 

15 “Health Coverage 2000: Meeting the Challenge of the Uninsured,” U.S. 

Chamber of Commerce, February 2000. www.uschamber.org 

Refundable Tax Credits 

16 “The Bush Health Agenda—Part II: Tax Credits for the Uninsured, ”Mark 

McClellan, National Center for Policy Analysis, Brief Analysis No. 415, August 

20, 2002. www.ncpa.org 

3-23 
 

 

17 “Small Employer Health Insurance Purchasing Arrangements: Can They 

Expand Coverage?” Elliot K. Wicks and Jack A. Meyer, National Coalition on 

Health Care, May 1999. www.nchc.org 

18 “Individual Insurance: How Much Financial Protection Does It Provide?” Jon 

Gabel, Kelley Dhont, Heidi Whitmore, and Jeremy Pickreign, Health Affairs, 

April 17, 2002. www.healthaffairs.org 

19 “2001 Small Business Survey,” The Kaiser Family Foundation, April 2002. 

www.kff.org 

20 “Employer Health Benefits: 2002 Annual Survey,” The Kaiser Family 

Foundation/Health Research and Educational Trust, 2002. www.kff.org 

State High-Risk Pools 

21 “CTS Survey,” Center for Health Systems Change, July 2002. 

www.hschange.org 

22 “High-Risk Pools Unaffordable for Many Who Are Denied Individual Health 

Coverage,” Lori Achman and Deborah Chollet, Publication No. 472, The 

Commonwealth Fund, August 2001. www.cmwf.org 

23 “Getting Started: A State Checklist for Creating High-Risk Pools,” Issues and 

Answers No. 111, Council on Affordable Health Insurance, December 2002. 

www.cahi.org 

Defined Contribution Accounts 

24 “Defined Contribution Health Plans: A Greenlight for HRAs,” Kilpatrick 

Stockton, July 2002. www.kilstock.com 

3-24 
 

25 “Defined Contribution Health Insurance,” Greg Scandlen, National Center for 

Policy Analysis, Policy Backgrounder No. 154, October 26, 2000. 

www.ncpa.org 

Cafeteria Plans 

26 “Your Money or Your Health: Designing Health Plan Options,” www.afscme.org 

Flexible Spending Accounts 

27 “Flexible Spending Accounts,” Rick Snyder, Ceridian Benefits, March 1, 1999. 

www.ceridian.com 

28 “Flexible Spending Accounts: Basic Rules of FSAs,” www.toolkit.cch.com 

Health Reimbursement Accounts 

29 “As Consumers Take Charge of Their Health Care, HRAs Increase in 

Popularity,” Ceridian Solutions, Winter 2002-2003, www.ceridian.com 

30 “New Health Reimbursement Accounts Give Companies More Benefit Choices 

for Employees,” Deloitte & Touche, September 24, 2002. www.deloitte.com 

31 “Treasury and IRS Issue Guidance on Health Reimbursement,” PO-3204, June 

26, 2002, www.ustreas.gov 

32 “Health Reimbursement Accounts Are the Best News in Health Plans in Many 

Years,” Business Guide to Affordable Benefits. www.busowner.nomohmo.com 

3-25 
 

 

Small Group Purchasing Cooperatives 

33 “Private Health Insurance: Cooperatives Offer Small Employers Plan Choice 

and Market Prices: Report to the Chairman, Committee on Commerce, House 

of Representatives,” U.S. Government Accounting Office (GAO/HEHS-00-49), 

March 2000. www.gao.gov 

34 “Employer Purchasing Alliances: An Evolutionary Step Toward ‘Voluntary 

Choice Cooperatives’ Under Individually Selected and Owned Health 

Insurance,” Report 5 of the Council on Medical Service (A-99), American 

Medical Association, June 1999. www.ama-assn.org 

35 “Consumer Choice Health Purchasing Groups,” Institute for Health Policy 

Solutions. www.ihps.org 

36 “Improving the Functioning of the Small Group and Individual Markets: The 

Role of Health Care Purchasing Pools,” Laura Tollen and Robert Crane, 

Institute for Health Policy, Kaiser Foundation Health Plan, Inc. www.kff.org 

Health Marts 

37 “Health Marts, A Free Market Health Care Solution,” Peter J. Ferrara, Policy 

Brief, Americans for Tax Reform, October 4, 1999. www.atr.org 

38 “Commentary: The Evolution of Voluntary Choice Cooperatives,” Terry S. 

Ward, Contingencies, American Academy of Actuaries, March/April 2001. 

www.contingencies.org 

3-26 
 

CONCLUSION 

The challenge facing women business owners and other entrepreneurs in 

accessing affordable health coverage is one that has persisted for well over a 

decade. Health insurance premiums remain high, and choice in health plans is 

still limited. Many small business owners, however, are becoming more proactive 

in finding ways to overcome these obstacles. These owners realize the adverse 

health consequences of workers’ living without coverage. At stake are not only 

the health and well-being of their employees, but also the ability of business to 

attract and retain a qualified work force. 

On the basis of information presented in this report, the following suggestions are 

offered to guide entrepreneurs as they evaluate health plan options: 

• Be Realistic About Health Care Costs. It is unlikely that new legislation and 

innovative insurance vehicles will immediately alter the health care 

landscape. Given that health care costs have been rising steadily since the 

1990s, business owners should not expect to see huge differences between 

current premiums and those that would result from any one of several 

proposed solutions. 

• Plan Strategically for Health Coverage. Many small firms do not offer 

coverage when launching the business, but tend to add it as they grow. It is 

important for business owners to realize that health insurance is a major 

expense that can significantly impact the company’s bottom line and 

corporate talent pool year after year. By planning strategically at the outset for 

health coverage, entrepreneurs may become better positioned for business 

success. 

• Take Advantage of Existing Opportunities for More Affordable 

Coverage. There may be resources within reach of business owners who are 

4-1 
 

not offering coverage that would improve employee access to affordable 

health care. For example, business owners can find out whether there are 

any AHPs operating in their state that could offer coverage to them. Also, 

health insurance is available to business owners through a number of 

business associations. Additionally, business owners can still set up MSAs 

through health insurers through the end of 2003. 

• Become More Knowledgeable About Health Benefits. Given the variety of 

health care plans and products that exist today, it is important that business 

owners understand insurance terminology. Familiarity with the technical 

language will enable owners to evaluate different health plan options and 

products and to choose ones that work best for them. In this regard, 

workshops or other assistance from human resource professionals, financial 

planners, local insurance brokers, and business associations may prove 

beneficial. 

4-2 
 

APPENDIX A: TOPICAL RESOURCE LIST 

ACCESS TO AFFORDABLE HEALTH COVERAGE 

BY WOMEN-OWNED BUSINESSES 

ASSOCIATION HEALTH PLANS 

“Small Business, Insurers at Odds Over Health Plans,” Bill Lewis, March 19, 2003, 

Tennessean, http://www.tennessean.com 

“Association Health Plans Issue Paper,” March 2003, National Lumber and Building 

Materials Dealers Association. http://www.dealer.org 

“Roundtable on Access to Affordable Health Care by Women-Owned Businesses and 

Other Small Firms,” February 27, 2003, National Women’s Business Council. 

http://www.nwbc.gov 

“Study of the Administrative Costs and Actuarial Values of Small Health Plans,” Rose Chu 

and Gordon Trapnell, Actuarial Research Corporation for the Office of Advocacy, U.S. 

Small Business Administration, January 2003, Small Business Administration. 

http://www.sba.gov 

“Association Health Plans Will Hurt Small Businesses Long Term,” December 6, 2002, 

National Small Business United. http://www.nsbu.org 

“Association Health Plans: Improving Access to Affordable Quality Health Care for Small 

Business,” December 2002, Department of Labor. http://www.dol.gov 

“Fact Sheet: Association Health Plans – Quality, Affordable Health Insurance,” November 

13, 2002, Department of Labor. http://www.dol.gov/pwba/newsroom/fsahp.html 

“Association Health Plan – Part One: Lowering Small Group Costs,” Greg Scandlen, 

October 2002, Brief Analysis No. 419, National Center for Policy Analysis. 

http://www.ncpa.org 

“Patients’ Rights Stalls in House,” VOICE, July 30, 2001, National Federation of 

Independent Business. http://www.nfib.org 

“Hispanic Business Leaders Strongly Support the Small Business Health Fairness Act,” 

May 9, 2001, The Latino Coalition. http://www.TheLatinoCoalition.com 

“Hispanic Business Leaders Strongly Support Bipartisan Effort to Address the Uninsured,” 

April 2, 2001, Hispanic Business Roundtable. http://www.hbrt.org 

“Statement of James R. Baumgardner, Acting Deputy Assistant Director for Health Policy, 

on Association Health Plans Before the Committee on Small Business, U.S. House 

Representatives,” February 16, 2000, Congressional Budget Office. http://www.cbo.gov 

“Increasing Small-firm Health Insurance Coverage Through Association Health Plans and 

HealthMarts,” January 2000, Agency for Health Care Research and Quality. 

http://www.ahrq.gov 

A-1 
“Small Employer Health Insurance Purchasing Arrangements: Can They Expand 

Coverage?” Elliot K. Wicks and Jack A. Meyer, May 1999, National Coalition on Health 

Care. http://www.nchc.org 

“AHPs Would Operate in a Regulatory Vacuum and ‘Cherry-Pick’ Only the Healthiest 

Groups, New BCBSA Analyses Find,” Blue Cross and Blue Shield Association of America. 

http://www.bcbshealthissues.com 

“Association Health Plans,” National Association for the Self-Employed. 

http://www.nase.org 

“Association Health Plans,” White House. 

http://www.whitehouse.gov/infocus/medicare/health-care/health-plans.html 

CAFETERIA HEALTH PLANS 

“Implementing a Cafeteria Health Plan,” T. Michael Regan, March 1998, Physicians News. 

http://www.physiciansnews.org 

“Cafeteria Plans: Frequently Asked Questions,” http://www.irs.ustreas.gov/fags/ 

DEFINED CONTRIBUTION ACCOUNTS 

“Defined Contribution and Participant Behavior Research Program,” March 2003, EBRI 

Issue Brief No. 255, Employee Benefit Research Institute. http://www.ebri.org 

“Defined Contribution Health Plans: A Greenlight for HRAs,” Kilpatrick Stockton, July 

2002. http://www.kistock.com 

“Are Defined Contributions a New Direction for Employer-Sponsored Coverage?” Sally 

Trude and Paul B. Ginsburg, October 2000, Issue Brief No. 32, Center for Studying Health 

System Change. http://www.hschange.org 

“Defined Contribution Health Insurance,” October 26, 2000, Policy Backgrounder, No. 154, 

National Center for Policy Analysis. http://www.ncpa.org 

“Defining ‘Defined Contributions’: A New Direction for Employer-Sponsored Coverage?” 

Sally Trude and Paul B. Ginsburg, October 2000, Center for Studying Health System 

Change. http://www.hschange.org 

“Health Insurance: Letting Employees Choose,” Greg Scandlen, July 6, 2002, Brief 

Analysis No. 325, National Center for Policy Analysis. http://www.ncpa.org 

FLEXIBLE SPENDING ACCOUNTS 

“The Vagaries of Health-Care Flexible Spending Accounts,” August 8, 2001, National 

Center for Policy Analysis. http://www.ncpa.org 

“Health Flexible Spending Arrangements: Frequently Asked Questions,” 

http://www.irs.ustreas.gov 

HEALTH CARE ACTS/LEGISLATION 

“The Health Insurance Portability and Accountability Act – HIPAA,” November 13, 2002, 

Department of Labor. http://www.dol.gov/pwba/newsroom/fsahp.html 

A-2 
“Patients’ Rights Stalls in House,” VOICE, July 30, 2001, National Federation of 

Independent Business. http://www.nfib.org 

“The Shadegg Health Bill: Expanding Access and Choice,” James Frogue, May 19, 1999, 

Heritage Foundation Executive Memorandum NO. 598, Heritage Foundation. 

http://www.heritage.org 

“Bill Summary and Status,” Library of Congress. http://www.loc.gov 

HEALTH CARE PURCHASING COOPERATIVES/ALLIANCES/GROUPS 

“Stability and Variation in Employment-Based Health Insurance Coverage, 1993-1997,” 

Stephen H. Long and M. Susan Marquis, 2000, Doc. No. LRP-1999911-11, RAND. 

http://www.rand.org 

“How to Make Tax Credits for Health Insurance Work: The Role of Purchasing Pools,” 

Conference Proceedings, April 10, 2001, Center for Studying Health System Change. 

http://www.hschange.org 

“Private Health Insurance Cooperatives Offer Small Employers Plan Choice and Market 

Prices, Report to the Chairman, Committee on Commerce, House of Representatives,“ 

March 2000, GAO/HEMS-0049, General Accounting Office. http://www.gao.gov 

“Small Employer Health Insurance Purchasing Arrangements: Can They Expand 

Coverage?” Elliot K. Wicks and Jack A. Meyer, May 1999, National Coalition on Health 

Care. http://www.nchc.org 

“Pooled Purchasing: Who Are the Players?” Stephen H. Long and M. Susan Marquis, 

1999, Doc. RP-814, RAND. http://www.rand.org 

“Consumer-Choice Health Purchasing Groups,” 1999, Institute of Health Policy Solutions. 

http://www.ihps.org 

“Have Small-Group Health Insurance Purchasing Alliances Increased Coverage? No, But 

They Have Produced Demonstrable Benefits to Participating Employers and Employees,” 

Stephen H. Long and M. Susan Marquis, 2001, Doc. No. LRP-200101-03, RAND. 

http://www.rand.org 

“Improving the Functioning of the Small Group and Individual Markets: The Role of Health 

Care Purchasing Pools,” Laura Tollen and Robert Crane, Institute for Health Policy, Kaiser 

Foundation Health Plan, Inc. http://www.kff.org 

HEALTH CARE TAX CREDITS 

“Restoring Health Freedom: The Case for a Universal Tax Credit for Health Insurance,” 

Sue A. Blevins, December 2002, Policy Analysis No. 290, Cato Institute. 

http://www.cato.org 

“The Individual Health Insurance Market: Researched, Policymakers Seek Common 

Ground in Tax Credits for the Uninsured,” December 2002, Issue Brief No. 58, Center for 

Studying Health System Change. http://www.hschange.org 

A-3 
“Ensuring Health Security: Is the Individual Market Ready for Prime Time? – Expanding 

the Current System Through a Tax-Credit Scheme,” Karen Pollitz and Richard Sorian, 

October 23, 2002, Health Affairs. http://www.healthaffairs.org 

“Expanding Health Coverage for the Uninsured: Fundamentals of the Tax Credit Option,” 

NHPF background paper, Beth Fuchs, Mark Merlis, Julie James, August 28, 2002, George 

Washington University. http://www.nhpr.org 

“The Bush Health Agenda – Part II: Tax Credits for the Uninsured,” Mark McClellan, 

August 20, 2002, Brief Analysis No. 415, National Center for Policy Analysis. 

http://www.ncpa.org 

“Tax Credits and the Affordability of Individual Health Insurance,” Jack Hadley and James 

D. Reschovsky, July 2002, Issue Brief No. 53, Center for Studying Health System Change. 

http://www.hschange.org 

“A Crisis in Health Care: Small Business Responds,” Perri Morgan, NFIB/North Carolina 

State Director, March 13, 2002, National Federation of Independent Business. 

http://www.nfib.org 

“White House Renews Call for Health Insurance Tax Credits,” Amy Snow Landa, AMA 

News, February 18, 2002, American Medical Association. http://www.ama-assn.org 

“AMA Statement to the House Ways and Means Committee on Reducing the Number of 

Uninsured Through Tax Credits, “ February 13, 2002, American Medical Association. 

http://www.ama-assn.org 

“Health Insurance Tax Credits: Potential for Expanding Coverage,” Linda J. Blumberg, 

August 2001, Health Policy Brief No. 1, Urban Institute. http://www.urban.org 

“Stand-Alone Health Insurance Tax Credits Aren’t Alone”, July 2001, Issue Brief No. 41, 

Center for Studying Health System Change. http://www.hschange.org 

“AMA: Expanding Health Insurance Coverage Through Individual Tax Credits”, February 

23, 2001, American Medical Association. http://www.ama-assn.org 

“Making Tax Credits Work: How Much Do Individuals Pay for Private Health Insurance and 

What Do They Get for Their Money?” Briefing, August 10, 2001, Alliance for Health 

Reform. http://www.allhealth.org 

“Letter to the Honorable Don Nickles Regarding the Estimated Ultimate Effect of S. 283 on 

Premiums for Employer-Sponsored Health Insurance,” April 2001, Congressional Budget 

Office. http://www.cbo.gov 

“Getting Real: Timely Ways to Insure the Uninsured,” April 6, 2001, Alliance for Health 

Reform. http://www.allhealth.org 

“A Tax Agenda for Small Business,” Joint Roundtable Before the Committee on Small 

Business, United States Senate, and the Committee on Small Business, House of 

Representatives, April 4, 2001. http://www.access.gpo.gov/index.html 

“CBO’s Analysis of the Health Insurance Initiatives in the Mid-Session Review,” July 2000, 

Congressional Budget Office. http://www.cbo.gov 

A-4 
“Private Health Insurance: Potential Tax Benefit of a Health Insurance Deduction 

Proposed in H.R. 2990,” Letter to Congressman Charles B. Rangel, Ranking Minority 

Member, Committee on Ways and Means, House of Representatives, from Kathryn G. 

Allen, Associate Director, Health Financing and Public Health Issues, April 2000, General 

Accounting Office. http://www.gao.gov 

“Tax Subsidies for Health Insurance: Costs and Benefits,” Jonathan Gruber and Larry 

Levitt, January/February 2000, Vol. 19, No. 1, Health Affairs. http://www.healthaffairs.org 

“Down a Dangerous Path: The Erosion of Health Insurance Coverage in the United 

States,” Stephen Findlay and Joel Miller, May 1999, National Coalition on Health Care 

Policy Studies. http://www.nchc.org 

“Access to Health Care for the Uninsured in Rural and Frontier America,” May 1999, 

National Rural Health Association. http://www.nrharural.org 

“Health Insurance and Taxes: The Impact of Proposal Changes in Current Federal Policy,” 

John Shiels, Paul Hogan, and Randall Haught, The Lewin Group, Inc, October 1999, 

National Coalition on Health Care. http://www.nchc.org 

“Options for Expanding Health Insurance Coverage: A Report on a Policy Roundtable,” 

Judith Feder and Sheila Burke, October 1999, Henry J. Kaiser Family Foundation. 

http://www.kff.org 

“Private Health Insurance Estimates of Effects of Health Insurance Tax Credits and 

Deductions as Proposed in H.R. 2261,” Letter of Congresswoman Nancy L. Johnson From 

Kathryn G. Allen, Associate Director, Health Financing and Public Health Issues, 

September 13, 1999, General Accounting Office. http://www.gao.gov/docdblite 

“Proposals to Subsidize Health Insurance for the Unemployment,” January 1998, 

Congressional Budget Office. http://www.cbo.gov 

“Health Care Tax Credits,” National Association for the Self-Employed. 

http://www.nase.org 

HEALTH INSURANCE COVERAGE AND COSTS 

“National Agenda: Health Care,” November 11, 2002, National Federation of Independent 

Business. http://www.nfib.org 

“Cutting Back But Not Cutting Out: Small Employers Respond to Premium Increases,” 

Ashley C. Short and Cara S. Lesser, October 2002, Issue Brief No. 56, Center for 

Studying Health System Change. http://www.hschange.org 

“Individual Health Insurance Widely Available, Affordable,” October 22, 2002, Health 

Insurance Association of America. http://www.hiaa.org 

“The Erosion of Employer-Based Health Coverage and the Threat to Workers’ Health 

Care,” Jennifer N. Edwards, Michelle M. Doty, and Cathy Schoen, August 2002, Issue 

Brief, Commonwealth Fund. http://www.cmwf.org 

A-5 
“2000 Employer-Sponsored Health Insurance Data,” Medical Expenditure Panel Survey 

(MEPS) Tables, August 2002, Agency for Health Care Research and Quality. 

http://www.meps.ahrg.gov 

“The Small Business Health Market: Bad Reforms, Higher Prices, and Fewer Choices,” 

Testimony provided by Raymond J. Keating, Chief Economist on Behalf of Small Business 

Survival Committee to Subcommittee on Regulatory Reform and Oversight, Committee on 

Small Business, House of Representatives, July 11, 2002, Small Business Survival 

Committee. http://www.sbsc.org 

“Expanding Access of Quality Health Care: Solutions for Uninsured Americans,” 

Testimony of Harry Kraemer, Jr., Chairman and CEO, Baxter International, and Member of 

the Healthcare Leadership Council before the Committee on Education and the Workforce 

Subcommittee on Employer-Employee Relations, United States House of 

Representatives, July 9, 2002, Healthcare Leadership Council. http://www.hlc.org 

“Underinsured in America: Is Health Coverage Adequate?” July 2002, Kaiser Commission 

on Medicaid and the Uninsured Kaiser Commission on Medicaid and the Uninsured. 

http://www.kff.org 

“Wall Street Comes to Washington: Market Watchers and Policy Analysts Evaluate the 

Health Care Market,” July 2002, Issue Brief No. 54, Center for Studying Health System 

Change. http://www.hschange.org 

“Research Highlights – Institute of Medicine Finds Insurance Coverage Promotes Good 

Health While No Coverage Results in Higher Adverse Outcomes,” July 2002, American 

Association of Health Plans. http://www.aahp.org 

“Survey Shows Small Business Owners Concerned About Economic Crisis – Final CA 

Survey Results,” July 22, 2002, Communicating for Agriculture (CA), Inc. 

http://www.cainc.org 

“Expanding Health Insurance Coverage by Creating New Options,” Testimony by Len 

Nichols Before House Commerce Committee, Subcommittee on Health and Environment, 

June 16, 2000, Urban Institute. http://www.urban.org 

“Care Without Coverage: Too Little, Too Late,” Committee on Consequences of 

Uninsured, May 2002, National Academy of Sciences/Institute of Medicine. 

http://www.nap.edu/books/0309083435/html/ 

“Health Insurance Coverage in America: 2000 Data Update,” March 19, 2002, Pub. No. 

4007, Kaiser Commission on Medicaid and the Uninsured Kaiser Commission on 

Medicaid and the Uninsured. http://www.kff.org 

“The Uninsured and Affordable Health Care Coverage,” Testimony of Mary R. Grealy, 

President, Healthcare Leadership Council, before the Committee on Energy and 

Commerce, Subcommittee on Health, United States House of Representatives, February 

28, 2002, Healthcare Leadership Council. http://www.hlc.org 

“Key Facts: The Uninsured and Their Access to Health Care,” February 2002, Pub. No. 

1420-03, Kaiser Commission on Medicaid and the Uninsured. http://www.kff.org 

A-6 
“2002 National Survey of Hispanic Adults,” August 2-14, 2002, Kaiser Commission on 

Medicaid and the Uninsured. http://www.kff.org 

“Job-Based Health Benefits in 2002: Some Important Trends,” John Gabel, Larry Levitt, 

Erin Holve, Jeremy Pickreign, Heidi Whitmore, Kelley Dhont, Samantha Hawkins, and 

Diane Rowland, Vol. 21 No. 4, Health Affairs. http://www.healthaffairs.org 

“The Insurance Gap and Minority Health Care, 1997-2001,” J. Lee Hargraves, June 2002 

Tracking Report No. 2, Center for Studying Health System Change. 

http://www.hschange.org 

“Affordability in Health Care Survey: Trends in American Micro-Business,” June 2002, 

National Association for the Self-Employed. http://www.nase.org 

“Insurance Markets: Small Businesses Face Greater Cost-Sharing and Increasing 

Complexity,” April 2002, California HealthCare Foundation. http://www.chcf.org 

“The Factors Fuelling Rising Healthcare Costs,” prepared for the American Association of 

Health Plans, April 2002, PriceWaterhouseCooper. http://www.bcbshealthissues.com 

“Treading Water: Americans’ Access to Needed Medical Care, 1997-2001,” Bradley C. 

Struck and Peter J. Cunningham, March 2002, Tracking Report No. 1, Center for Studying 

Health System Change. http://www.hschange.org 

“2002 Membership Survey of the National Association of Women Business Owners,” 

2002, National Association of Women Business Owners. http://www.nawbo.org 

“Blue Plans: Playing the Blues No More,” Joy M. Grossman and Bradley C. Strunk, 

January 23, 2002, Center for Studying Health System Change. http://www.hschange.org 

“Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” Brian D. 

Smedley, Adrienne Y. Stith, and Alan R. Nelson, ed., Committee on Understanding and 

Eliminating Racial and Ethnic Disparities in Health Care, 2002, National Academy of 

Sciences/Institute of Medicine. http://www.nap.edu/books 

“Greater Cleveland Growth Association: 2002-2006 Public Policy Agenda for Northeast 

Ohio,” 2002, Council on Small Enterprises (COSE). http://www.clevelandgrowth.com 

“Employer Health Benefits 2002: Summary of Findings,” Pub. No. 3252, Henry J. Kaiser 

Family Foundation, and the Health Research and Educational Trust. http://www.kff.org 

“2002 Employer Health Benefits Survey: Report,” 2002, Henry J. Kaiser Family 

Foundation and the Health Research and Educational Trust. http://www.kff.org 

“Health Confidence Survey: 2002”, Employee Benefit Research Institute. 

http://www.ebri.org/hcs/ 

“Low-wage Workers and Health Insurance Coverage: Can Policymakers Target Them 

Through Their Employers?“ Stephen H. Long and M. Susan Marquis, 2002, Doc. No. LRP200109-20, RAND. http://www.rand.org 

A-7 
“Double-Digit Health Care Cost Increase Expected to Continue in 2002,” October 29, 

2001, Hewitt Associates. http://www.hewitt.com 

“Employer Health Insurance and Local Labor Market Conditions,” M. Susan Marquis and 

Stephen H. Long, 2002, Doc. No. LRP-200109-20, RAND. http://www.rand.org 

“As Corporate Concerns About Health Care Continue to Rise, Many Employers Plan to 

Shift More Costs to Their Employees,” October 9, 2001, Harris Poll. 

http://www.harrisinteractive.com 

“Diagnosing Disparities in Health Insurance for Women: A Prescription for Change,” Jean 

M. Lambrew, George Washington University, August 2001, Commonwealth Fund. 

http://www.cmwf.org 

“Insuring the Uninsurable: An Overview of State High-risk Health Insurance Pools,” Lori 

Achman and Deborah Chollet, Mathematica Policy Research, Inc., August 2001, Pub. No. 

472, Commonwealth Fund. http://www.cmwf.org 

“Health Insurance: A Family Affair—A National Profile and State-by-State Analysis of 

Uninsured Parents and Their Children,” Jeanne M. Lambrew, George Washington 

University, May 2001, Commonwealth Fund. http://www.cmwf.org 

“Getting Real: Timely Ways to Insure the Uninsured,” April 6, 2001, Alliance for Health 

Reform. http://www.allhealth.org 

“Because That’s Where the People Are: Reducing the Uninsured Population Through the 

Employer-Based Health Care System,” Mary R. Grealy, April 6, 2001, Healthcare 

Leadership Council. http://www.hlc.org 

“Small Employers’ Health Insurance Attitudes and Purchasing Trends,” March 2001, 

National Association of Health Underwriters. http://www.nahu.org 

“National Program Project Report: Research on the Rise in Employer Health Care Costs,” 

January 2001, Robert Wood Johnson Foundation. 

http://www.rwjf.org/reports/grr/017084.htm 

“Assessing the Impact of Health Plan Choice,” Schone and Cooper, Health Affairs, 

January 2001, Vol. 20, No. 1, pp. 267-275. http://www.healthaffairs.org 

“Statement of the Healthcare Leadership Council to the Subcommittee on Health of the 

Committee on Ways and Means on the Nation’s Uninsured,” April 4, 2001, Healthcare 

Leadership Council. http://www.hlc.org 

“Small Businesses, Information, and the Decision to Offer Health Insurance,” Marian R. 

Mulkey and Jill M. Yegian, 2001, Health Affairs. http://www.healthaffairs.org 

“To Offer or Not to Offer: The Role of Price in Employers’ Health Insurance Decisions,” M. 

Susan Marquis and Stephen H. Long, 2001, Doc. No. LRP-200110-01, RAND. 

http://www.rand.org 

“Latest National Poll Says Health Care Issues May Influence 40% of Votes in Tuesday’s 

Congressional Election,” November 4, 2000, Harris Poll. http://www.harrisinteractive.com 

A-8 
 

 

“Tax Subsidies for Health Insurance: Costs and Benefits,” Jonathan Gruber and Larry 

Levitt, January/February 2000, Vol. 19, No. 1, Health Affairs. http://www.healthaffairs.org 

“Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 

1999 Current Population Survey,” Paul Fronstin, January 2000, EBRI Issue Brief No. 211, 

Employee Benefit Research Institute. http://www.ebri.org 

“A Perfect Storm: The Confluence of Forces Affecting Health Care Coverage,” Joel E. 

Miller, November 2001, National Coalition on Health Care. http://www.nchc.org 

“Expanding Employment-Based Health Coverage: Lessons from Six State and Local 

Programs,” Sharon Silow-Carroll, Emily K. Waldman, and Jack A. Meyer, February 2001, 

Pub. No. 445, Commonwealth Fund. http://www.cmwf.org 

“In Their Own Words: The Uninsured Talk About Living Without Health Insurance,” 

Martha Shirk, September 2000, Pub. No. 2207, Kaiser Commission on Medicaid and the 

Uninsured. http://www.kff.org 

“State Legislative Health Care and Insurance Issues: 2000 Survey of Plans,” February 

2001, Blue Cross and Blue Shield Association of America. 

http://www.bcbshealthissues.com 

“Challenges and Options for Increasing the Number of Americans With Health Insurance,” 

Sherry A. Glied, January 2001, Pub. No. 415, Commonwealth Fund, Task Force on the 

Future of Health Insurance. http://www.cmwf.org 

“Employer-Sponsored Health Insurance Among Small Businesses: The 2000 

CHCF/Mercer Survey,” 2001, California Healthcare Foundation. http://www.chcf.org 

“Challenges and Options for Increasing the Number of Americans With Health Insurance,” 

S.A. Glied, Summer 2001, Commonwealth Fund. http://www.cmwf.org 

“Why Don’t More Small Businesses Offer Health Insurance? Summary Report on the 2000 

CHCF Survey,” 2001, California Healthcare Foundation. http://www.chcf.org 

“A 2020 Vision for American Health Care,” Karen Davis, Cathy Schoen, and Stephen C. 

Schoenbaum, December 2000, Commonwealth Fund. http://www.cmwf.org 

“Barriers to Health Coverage for Hispanic Workers: Focus Groups Findings,” Michael 

Perry and Susan Kannel, Lake Snell Perry and Associates with Enrique Castillo, Castillo & 

Associates, December 2000, Commonwealth Fund. http://www.cmwf.org 

“The Changing Sources of Health Insurance,” William S. Custer and Pat Ketsche, Center 

for Risk Management and Insurance Research, Georgia University, December 14, 2000, 

Health Insurance Association of America. http://www.hiaa.org 

“Employment-Based Health Insurance Coverage,” William S. Custen, Pat Ketsche, Center 

for Risk Management and Insurance Research, Georgia State University, December 11, 

2000, Health Insurance Association of America. http://www.hiaa.org 

“Race/Ethnicity and Health Insurance Status: 1987 and 1996,” Monheit and Vistnes, Vol. 

57, November 2002, Suppl. 1, pp. 11-35, Pub. No. 01-R009, Medical Care Research and 

Quality. http://www.ahrq.gov 

A-9 
“Job-Based Health Insurance in 2002: Premium Rise Sharply While Coverage Grows,” J. 

Gabel, L. Levitt, J. Pickreign, H. Whitmore, E. Holve, S. Hawkins, and N. Miller, 

September/October 2000, Vol. 19, pp. 144-151, Health Affairs. http://www.healthaffairs.org 

“Disparities in Health Insurance and Access to Care for Residents Across U.S. Cities,” E. 

Richard Brown, Roberta Wyn, and Stephanie Teleki, UCLA Center for Health Policy 

Research, August 2000, Publication No. 92, Commonwealth Fund. http://www.cmwf.org or 

http://www.healthpolicy.ucla.edu 

“On Their Own: Young Adults Living Without Health Insurance,” Kevin Quinn, Cathy 

Schoen, and Louisa Bautt, May 2000, Publication 391, Commonwealth Fund and Abt 

Associates. http://www.cmwf.org 

“Public Subsidies for Employee Contributions to Employer-Sponsored Insurance,” J. 

Lemieux, D. Kendall, and R. Levine, Summer 2001, Inquiry. http://www.inquiry.org 

“Working Without Benefits: The Health Insurance Crisis Confronting Hispanic Americans,” 

Kevin Quinn, Abt Associates, March 2000, Pub. No. 370, Commonwealth Fund. 

http://www.cmwf.org 

“Changes in Usual Sources of Medical Care Between 1987 and 1992,” Ernest Moy, 

Barbara Bartman, Clancy, and Llewellyn J. Cornelius, 1998, Vol. 9, No. 2, AHCPR Pub. 

No. 98-R071, Journal of Health Care for the Poor and Uninsured. http://www.ahrg.gov 

“Stability and Variation in Employment-Based Health Insurance Coverage, 1993-1997,” 

Stephen H. Long and M. Susan Marquis, 2000, Doc. No. LRP-1999911-11), RAND. 

http://www.rand.org 

“Options for Expanding Health Insurance Coverage: A Report on a Policy Roundtable”, 

Judith Feder and Sheila Burke, October 1999, Henry J. Kaiser Family Foundation. 

http://www.kff.org 

“Real Choice: A Dynamic Action Plan for Health Insurance Coverage,” National 

Association of Health Underwriters. http://www.nahu.org 

“Recent Trends in Self-Insured Employer Health Plus,” M. Susan Marquis and Stephen L. 

Long, 1999, Doc. No. RP-785, No. LRP-RAND. http://www.rand.org 

“Grant Results Report: Survey of Business Leaders’ Opinions on Health Care,” January 

1999, Robert Wood Johnson Foundation. http://www.rwjf.org/reports/grr/028052s.htm 

“Can’t Afford to Get Sick: A Reality for Millions of Working Americans,” J. Budetti, L. 

Duchon, C. Schoen, and J. Shikles, September 1999, Commonwealth Fund. 

http://www.cmwf.org 

“Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of 

Low-Wage Workers,” E. O’Brien and J. Feder, May 1999, Henry J. Kaiser Family 

Foundation. http://www.kff.org 

“Working Families at Risk: Coverage, Costs, and Worries,” Louis Harris and Associates, 

Henry J. Kaiser Family Foundation, 1997, Commonwealth Fund. http://www.cmwf.org 

A-10 
 

“1997 National Survey of Health Insurance, “ December 1997, Henry J. Kaiser Family 

Foundation. http://www.kff.org 

“1997 Economic Census: Minority- and Women-Owned Businesses – United States,” 

Bureau of Census. http://www.census.gov/epcd/mwb97/us/us.html 

“Small Employers: Their Diversity and Health Insurance,” Len M. Nichols, Linda J. 

Blumberg, Gregory P. Acs, Cori E. Uccello, and Jill A. Marsteller, June 1, 1997, Urban 

Institute. http://www.urban.org/health/smemployers.htm 

“Health Insurance Coverage and the Uninsured: 1990-1998,“ 2000, Health Insurance 

Association of America. http://www.hiaa.org 

“Grant Results Report: Analysis of State Policymaking Regarding the Uninsured,” 

December 1998, Robert Wood Johnson Foundation. 

http://www.rwjf.org/reports/grr/018947s.htm 

“Health Insurance: Management Strategies Used by Large Employers to Control Costs,” 

Report to the Chairman, Committee on Labor and Human Resources, U.S. Senate, May 

1997, GOA/HEHS-97-71, General Accounting Office. http://www.gao.gov/docdblite 

“1997 Robert Wood Johnson Foundation Employer Health Insurance Survey,” Robert 

Wood Johnson Foundation. http://www.rwjf.org 

“The Maine Small Business Health Insurance Project,” Consumers for Affordable Health 

Care Foundation. http://www.mainecahc.org/foundation/researchandpolicy.htm 

“Coverage for Small Business: The Issue,” Blue Cross and Blue Shield Association of 

America, Consumers for Affordable Health Care Foundation. 

http://www.bcbshealthissues.com 

“Helping Small Businesses Expand Access to Health Insurance,” Blue Cross and Blue 

Shield Association of America. http://www.bcbshealthissues.com 

“Tax Policies Affecting Rural Small Businesses,” Issue briefing paper, Communicating for 

Agriculture (CA), Inc. http://www.cainc.org 

“The Challenging Face of Health Insurance,” April 5, 2002, Alliance for Health Reform. 

http://www.allhealth.org 

“AMA Statement to the House of Energy and Commerce Committee, Subcommittee on 

Health, Regarding the Uninsured and Affordable Health Care Coverage,” February 28, 

2002, American Medical Association. http://www.ama-assn.org 

“Changes in Job-Related Health Insurance, 1996-99”, MEPS Chartbook No. 10, AHRQ 

Pub. No. 02-0030, Agency for Health Care Research and Quality. 

http://www.meps.ahrq.gov 

“Women in the Health Care System; Health Status, Insurance, and Access to Care,” 

MEPS, Research Findings No. 17, AHRQ Pub. No. 02-0004, Agency for Health Care 

Research and Quality. http://www.ahrq.gov 

“Employer Health Benefits Survey –Report Highlights 2002,” Rochester Health 

Commission. http://www.rhealth.org 

A-11 
“Health Insurance Is Enough to Make You Sick: Uninsured Women at Risk,” Working 

paper, March 14, 2001, American College of Physicians/American Society of Internal 

Medicine. http://www.acponline.org/uninsured/index.html 

“Health Insurance Status of the U.S. Civilian Non-institutional Population: 1996,” MEPS, 

Research Findings No. AHCPR Pub. No. 97-0030, Agency for Health Care Research and 

Quality. http://www.ahrg.gov 

“State Differences in Job-Related Health Insurance,” J.M. Branscome and E. Brown, 

MEPS Chartbook No. 7, AHRQ Publ. 01-0036, Agency for Health Care Research and 

Quality. http://www.meps.ahrq.gov 

“Employment-Based Health Insurance: 1997,” Shailesh Bhandari, December 2002, 

Current Population Reports No. P70-81. http://www.census.gov 

“Fact Sheet: General Facts on Women and Job-Based Health,” November 13, 2002, 

Department of Labor. http://www.dol.gov/pwba/newsroom/fshlth5.html 

“Accessing Health Care-Affordable Quality Health Care Needed,” Women’s Bureau 

Newsletter, November 13, 2002, Department of Labor. 

http://www.dol.gov/wb/media/newsletter/e-news4art1-02.htm 

“Daily Health Policy Report: New Figures on Uninsured Unlikely to Spur Congressional 

Action, CQ’s Goldreich Says,” September 30, 2002, Henry J. Kaiser Family Foundation. 

http://www.kff.org 

“Health Insurance Coverage 2001,” Current Population Reports, September 2002, Agency 

for Health Care Research and Quality. http://www.census.gov 

“Daily Health Policy Report: After Declining for Two Years, Number of Uninsured 

Increased Last Year, Census Bureau Says,” September 30, 2002, Henry J. Kaiser Family 

Foundation. http://www.kff.org 

“Mandated Health Insurance Benefits: Tradeoffs Among Benefits, Coverage and Costs?” – 

Issue Brief, July 30, 2002, Henry J. Kaiser Family Foundation. http://www.kff.org 

“Employee Benefits in Private Industry,” 2000, July 16, 2002, Department of Labor. 

http://www.bls.gov/news.release/ebs2.nr0.tm 

“Private Health Insurance: Small Employers Continue to Face Challenges in Providing 

Coverage,” October 31, 2001, GAO-02-8, General Accounting Office. 

http://www.gao.gov/docdblite 

“The Uninsured: A Primer, Key Facts About American Without Health Insurance,” May 31, 

2001, Henry J. Kaiser Family Foundation. http://www.kff.org 

“National Survey of Small Businesses,” April 2, 2002, Henry J. Kaiser Family Foundation. 

http://www.kff.org 

“The Uninsured and Their Access to Health Care,” March 19, 2002, Henry J. Kaiser 

Family Foundation. http://www.kff.org 

“The New Challenge of the Uninsured: Coverage in the Current Economy,” February 28, 

2002, Henry J. Kaiser Family Foundation. http://www.kff.org 

A-12 
“Health Coverage 2002: Meeting the Challenge of the Uninsured,” February 2000, U.S. 

Chamber of Commerce. http://www.uschamber.org 

“Statement of Dan L. Crippen, Director, Congressional Budget Office, on Health Care 

Costs and Insurance Coverage Before the Subcommittee on Employer Employee 

Relations, Committee on Education and Workforce, U.S. House of Representatives,” June 

11, 1999, Congressional Budget Office. http://www.cbo.gov 

“2001 California Employer Health Benefits Survey,” February 19, 2002, Henry J. Kaiser 

Family Foundation. http://www.kff.org 

“Fact Sheet: Women’s Health Insurance Coverage,” July 2001, Pub. No. 6000, Henry J. 

Kaiser Family Foundation. http://www.kff.org 

“Employee Benefits in Medium and Large Private Establishments, 1997,” January 7, 1999, 

Department of Labor. ftp://ftp.gov/pub/news.release/eb3.txt 

“Severing the Link Between Health Insurance and Employment: What Happens if 

Employers Stop Offering Health Benefits?” ERF Policy Forum, May 5, 1999, Employee 

Benefit Research Institute. http://www.ebri.org 

“Trends in Employer Health Coverage: Where Is the Market Taking Us?” Karl Polzer, 

March 7, 1997, Issue Brief No. 699, George Washington University. http://www.nhpf.org 

“Trends in Health Care Spending by the Private Sector,” CBO Paper, April 1997, 

Congressional Budget Office. http://www.cbo.gov 

“The State of Health Insurance in California, 1999,” Helen Halpin Schauffler and E. 

Richard Brown, July 31, 2000, University of California, Berkeley Center for Health and 

Public Policy Studies and UCLA Center for Health Policy Research. 

http://chpps.berkeley.edu/hipp 

“Increasing Access to Private and Public Health Insurance for California’s Chronologically 

Uninsured Population,” Policy alert, Helen Schauffler and Sara McMenamin, February 

2000, University of California, Berkeley Center for Health and Public Policy Studies and 

UCLA Center for Health Policy Research. http://chpps.berkeley.edu/hipp 

“Changes in Insurance Coverage: 1994-2000 and Beyond,” Pub. No. 4065, Henry J. 

Kaiser Family Foundation. http://www.kff.org 

“Employment-Based Health Insurance: A Look at Tax Issues and Public Opinion,” Paul 

Fronstin, EBRI Issue Brief No. 211, July 1999, Employee Benefit Research Institute. 

http://www.ebri.org 

“Employers Respond to Rising Costs,” Kate Sullivan, U.S. Chamber of Commerce. 

http://www.bcbshealthissues.com 

“To Buy or Not to Buy: A Profile of California’s Non-Poor Uninsured,” Survey, California 

Healthcare Foundation. http://www.chcf.org/uninsured/fieldsurvey.cfm 

“Programs to Improve Health Insurance Access for Small Business: What Works and 

What Doesn’t,” Zachary Dyckman and Joanna Burnette, Center for Health Policy Studies. 

http://www.sba.gov/advo/research/rs126.html 

A-13 
 

“Tax Subsidies for Health Insurance Coverage Within Families With Children,” Karla L. 

Hanson, Health Affairs. http://www.healthaffairs.org 

“A Consumer’s Glossary of Health Insurance Terms, Health Insurance Resource Center,” 

Health Insurance Resource Center. http://www.healthinsurance.org/insterms.html 

“Workers Without Health Insurance: Who Are They and How Can Policy Reach Them?” 

Bowen Garrett, Len M. Nichols, and Emily K. Greenman, Urban Institute. 

http://www.communityvoices.org 

HEALTH MARTS 

“Commentary: The Evolution of Voluntary Choice Cooperatives,“ Terry S. Ward, 

Contingencies, March/April 2001, American Academy of Actuaries. http://www.actuary.org 

“Increasing Small-Firm Health Insurance Coverage Through Association Health Plans and 

Health Marts, “January 2000, Agency for Health Care Research and Quality. 

http://www.ahrq.gov 

“Health Marts, A Free Market Health Care Solution,” Policy brief, Peter Ferrara, October 4, 

1999, Americans for Tax Reform. http://www.atr.org 

“Small Employer Health Insurance Purchasing Arrangements: Can They Expand 

Coverage?” Elliot K. Wicks and Jack A. Meyer, May 1999, National Coalition on Health 

Care. http://www.nchc.org 

HEALTH REIMBURSEMENT ACCOUNTS 

“Treasury and IRS Issue Guidance on Health Reimbursement Arrangements,” June 26, 

2002, PO-3204, U.S. Treasury. http://www.ustreas.gov 

“Defined Contribution Health Plans: A Greenlight for HRAs,” Kilpatrick Stockton, July 

2002. http://www.kistock.com 

“New Health Reimbursement Accounts Give Companies More Benefit Choices for 

Employees,” September 24, 2002, Deloitte & Touche. http://www.deloitte.com 

“Health Reimbursement Arrangements: Practical Approach to Health Spending,” Editorial, 

August 12, 2002, American Medical Association. http://www.ama.assn.org 

“Treasury and IRS Guidance on Health Reimbursement Arrangements,” June 26, 2002, 

PO-3204, Department of Treasury. http://www.ustreas.gov 

“Health Reimbursement Arrangements (HRAs),” HRA Helper, Employers Council on 

Flexible Compensation. http://www.benefits.net 

“Health Reimbursement Arrangements,” National Association of Health Underwriters. 

http://www.nahu.org 

“As Consumers Take Charge of Their Health Care, HRAs Increase in Popularity,” Winter 

2002-2003, Ceridian Solutions. http://www.ceridian.com 

“Health Reimbursement Accounts Are the Best News in Health Plans in Many Years,” 

Business Guide to Affordable Benefits. http://busowner.nomohmo.com 

A-14 
“What Are the Rules for Health Reimbursement Accounts?” Producer’s Guide to 

Consumer-driven Health Plans. http://producer.nonohmo.com 

HIGH-RISK POOLS 

“Expanding Individual Health Insurance Coverage: Are High Risk Pools the Answer? – 

Although 30 States Operate High-Risk Pools, Only a Few Have Found Success,” Deborah 

Chollet, Mathematica Policy Research, October 23, 2002, Health Affairs. 

http://www.healthaffairs.org 

“Getting Started: A State Checklist for Creating High-Risk Pools,” December 2002, Issues 

and Answers No. 111. http://www.cahi.org 

Medical Savings Accounts: Progress and Problems Under HIPAA, “ Victoria Craig Bruce, 

August 8, 2001, Cato Institute. http://www.cato.org 

“High-Risk Pools Unaffordable for Many Who Are Denied Individual Health Coverage,” 

Lori Achman and Deborah Chollet, August 2001, Pub. No. 472, Commonwealth Fund, 

Task Force on the Future of Health Insurance. http://www.cmwf.org 

“Insuring the Uninsurable: An Overview of State High-Risk Health Insurance Pools,” Lori 

Achman and Deborah Chollet, Mathematica Policy Research, Inc., August 2001, Pub. No. 

472, Commonwealth Fund, Task Force on the Future of Health Insurance. 

http://www.cmwf.org 

“What is a Risk Pool? State Health Insurance Pools for the High-Risk Population—25 

Years of Proven Service in Guaranteeing Access to Coverage,” Response to the 

Commonwealth Foundation Study on Risk Pools, Bruce Abbe, Communicating for 

Agriculture (CA), Inc. http://www.cainc.org 

“The Problem of the Uninsured,” National Association of Health Underwriters. 

http://www.nahu.org 

MEDICAL SAVINGS ACCOUNTS 

“MSAs Are Not FSAs Are Not HRAs,” December 2002, Issues and Answers No. 110, 

Council on Affordable Health Insurance. http://www.cahi.org 

“Four Years of MSAs: The Lessons So Far,” Issue brief, July 6, 2002, National Center for 

Policy Analysis. http://www.ncpa.org 

“Archer MSAs: A Good Beginning-A Better Future,” July 2002, Issues and Answers No. 

105, Council on Affordable Health Insurance. http://www.cahi.org 

“MSAs Can Be a Windfall for All, Greg Scandlen, November 2, 2001, Policy Backgrounder 

No. 157, National Center for Policy Analysis. http://www.ncpa.org 

“Cato: Removing Crippling Restrictions on MSA,” August 22, 2001, National Center for 

Policy Analysis, Brief Analysis No. 415, National Center for Policy Analysis. 

http://www.ncpa.org 

“Medical Savings Accounts: Progress and Problems Under HIPAA, “ Victoria Craig Bruce, 

August 8, 2001, Cato Institute. http://www.cato.org 

A-15 
“MSA for Everyone, Part 1,” Issue brief, John Goodman, March 31, 2000, Brief Analysis 

No. 415, National Center for Policy Analysis. http://www.ncpa.org 

“MSAs for Everyone, Part II,” Issue Brief, Greg Scanlon, March 31, 2000, National Center 

for Policy Analysis. http://www.ncpa.org 

“Archer/Lipinski Congressional ‘Dear Colleague’ Letter on the Bipartisan Medical Savings 

Account Effectiveness Act of 1999,” from Rep. Bill Archer (R-TX) and Rep. William Lipinski 

(D-IL), April 6, 1999, American Medical Association. http://www.ama-assn.org 

“Fact Sheet: Guide to Medical Savings Account (MSA) High Deductible Plans,” 1999 

NWHIC Record Number P-5327, National Women’s Health Information Center. 

http://www.hiaa.org 

“Medical Savings Accounts: Obstacles to Their Growth and Ways to Improve Them,” 

NCPA Policy Report No. 216, July 1998, National Center for Policy Analysis. 

http://www.ncpa.org 

“What’s Next for Medical Savings Accounts?” May 1, 1997, National Center for Policy 

Analysis, National Center for Policy Analysis. http://www.ncpa.org 

“Medical Savings Accounts: Results From Surveys of Insurers,” December 31, 1998, 

HEHS-99-34, General Accounting Office. http://www.gao.gov 

“Medical Savings Accounts: A Policy Analysis,” Marilyn Moon, Len Nichols, and Susan 

Wall Wallin, March 1, 1996, Urban Institute. http://www.urban.org 

“Publication 969: Medical Savings Accounts (MSAs),” Internal Revenue Service. 

http://www.irs.gov 

“Medical Savings Accounts,” National Association of Health Underwriters. 

http://www.nahu.org 

NATIONAL HEALTH CARE AGENDA 

“Background on the Bush Administration’s Health Care Agenda,” March 2002, White 

House. http://www.whitehouse.gov/news/releases/2002/03/20020314-3.html 

“More Power to Provide Health Care for Uninsured Employees, and Better Health Care 

Options for Employees,” White House. 

http://www.whitehouse.gov/infocus/smallbusiness/healthcare.html 

“The President’s Small Business Agenda,” White House. 

http://www.whitehouse.gov/infocus/smallbusiness 

PRIVATE HEALTH INSURANCE 

“The Individual Health Insurance Market: Researchers, Policy Makers Seek Common 

Ground on Tax Credits for the Uninsured,” December 2002, Issue Brief No. 58, Center for 

Health Policy Studies. http://www.hschange.org 

“The Private Health Insurance Market: Treatable or Terminal?” March 5, 2002, Urban 

Institute. http://www.urban.org 

A-16 
 

“Individual Insurance: How Much Financial Protection Does It Provide?” Jon Gabel, Kelley 

Dhont, Heidi Whitmore, and Jeremy Pickreign, April 17, 2002, Health Affairs. 

http://www.healthaffairs.org 

“Options and Opportunities for Individuals and Families in the Private Health Insurance 

Market – Tax Credits and Recently Passed Trade Adjustment Assistance Act Should 

Bolster the Existing Individual-Market System of Coverage,” Janet Stokes Trautwein, 

National Association of Health Underwriters, October 23, 2001, Health Affairs. 

http://www.healthaffairs.org 

“The Nongroup Market as One Element of a Broader Coverage Expansion Strategy,” 

Lauren Tollen, Robert M. Crane, Ruth Liu, and Steve Zatkin, Kaiser Permanente Institute 

for Health Policy, October 23, 2002, Health Affairs. http://www.healthaffairs.org 

“Ensuring Health Security: Is the Individual Market Ready for Prime Time? Expanding the 

Current System Through a Tax-Credit Scheme,” Karen Pollitz and Richard Sorian, 

October 23, 2002, Health Affairs. http://www.healthaffairs.org 

“Health Insurance Subsidies for Low-Income Workers Most Efficient Way to Expand 

Coverage, Says New Urban Institute Report,” August 29, 2001, Urban Institute. 

http://www.urban.org 

“Expanding Coverage: Maintain a Role for the Individual Market–It Protects Millions of 

Americans From Unexpected High Medical Bills,” Donald A. Young and Thomas F. 

Wildsmith, Health Insurance Association of America, October 23, 2002, Health Affairs. 

http://www.healthaffairs.org 

“Individual Health Insurance Widely Available, Affordable,” October 22, 2000, Health 

Insurance Association of America. http://www.hiaa.org 

“Guaranteed Renewability and the Problem of Risk Variation in Individual Health 

Insurance Markets–A Way to Stabilize Coverage With Less Government Interference,” Vip 

Patel and Mark V. Pauly, e-Health Insurance and the Wharton School, University of 

Pennsylvania, August 28, 2002, Health Affairs. http://www.healthaffairs.org 

“Tax Credits and the Affordability of Individual Health Insurance,” Jack Hadley and James 

D. Reschovsky, July 2002, Issue Brief No. 53, Center for Studying Health System Change. 

http://www.hschange.org 

“Impact of the Changing Market for Individual Coverage,” April 17, 2002, Health Affairs. 

http://www.healthaffairs.org 

“Individual Versus Employer Insurance Markets: Digging Deeper into the Differences,” 

April 17, 2002, Health Affairs. http://www.healthaffairs.org 

“Individual Health Insurance: How Much Financial Protection Does it Provide?” Jon Gabel, 

Kelley Dhont, Heide Whitmore, and Jeremy Pickreign, Health Research and Educational 

Trust, April 17, 2000, Health Affairs. http://www.healthaffairs.org 

“Steps Toward a Healthier Individual Health Insurance Market,” Statement of Bruce Abbe 

at the National Conference of State Legislatures, November 17, 2001, Communicating for 

Agriculture (CA), Inc. http://www.cainc.org 

A-17 
 

“Private Health Insurance: Federal Role in Enforcing New Standards Continues to Evolve,” 

Letter to Senator James M. Jeffords, Chairman, Committee on Health Education, Labor, 

and Pensions, from Kathryn G. Allen, Director, Health Care–Medicaid and Private 

Insurance Issues, May 7, 2001, General Accounting Office. http://www.gao.gov 

“Benefits and Limitations of an Individual Mandate for Individually Owned Health 

Insurance,” June 2000, CMS Report 5-A-00, American Medical Association. 

http://www.ama-assn.org 

“Rethinking Health Insurance: The AMA’s Proposal for Reforming the Private Health 

Insurance System,” 1999, American Medical Association. http://www.ama-assn.org 

“Private Insurance: Millions Relying on Individual Market Face Cost and Coverage 

Tradeoffs,” November 25, 1996, GAO/HEHS-97-8, General Accounting Office. 

http://www.gao.gov/docdblite 

“Private Health Insurance: Estimates of Expanded Tax Deductibility of Premiums for 

Individually Purchased Health Insurance,” 1998, GAO/HEHS-98-190R, General 

Accounting Office. http://www.gao.gov/docdblite 

“Rethinking Employment-Based Health Benefits: Enabling Consumer-driven Health Care,” 

American Medical Association. http://www.ama-assn.org 

“State Mandates on Private Insurance,” Gail A. Jenson, Cato Institute. http://www.cato.org 

“Health Insurance: Proposals for Expanding Private and Public Coverage,” Statement of 

William J. Scanlon, Director, Health Care Issues, Testimony before the Committee on 

Finance, U.S. Senate, March 15th 2001, GAO-01-481T, General Accounting Office. 

http://www.gao.gov/docdblite 

“Health Insurance: Characteristics and Trends in the Uninsured Population”, State of 

Kathryn G. Allen, Director, Health Care, Medicaid and Private Health Insurance Issues, 

Testimony before the Committee on Finance, U.S. Senate, March 13, 2001, GAO-01-

507T, General Accounting Office. http://www.gao.gov 

“Private Health Insurance: Progress and Challenges in Implementing 1996 Federal 

Standards,“ Report to the Chairman, Committee on Health, Education, Labor, and 

Pensions, U.S. Senate, May 1999 GAO/HEHS-99-100, General Accounting Office. 

http://www.gao.gov/docdblite 

“Health Insurance Standards: Implications of New Federal Law for Consumers, Insurers, 

and Regulators,” February 25, 1998, GAO/T-HEHS-98-67, General Accounting Office. 

http://www.gao.gov/docdblite 

“Private Health Insurance: Continued Erosion of Coverage Linked to Cost Pressures,” 

Report to the Chairman, Committee on Labor and Human Resources, U.S. Senate, July 

1997, GAO/HEHS-97-122, General Accounting Office. http://www.gao.gov 

“Market Failure? Individual Insurance Markets for Older Americans,“ Elisabeth Simantov, 

Cathy Schoen, and Stephanie Bruegman, Health Affairs. http://www.healthaffairs.org 

A-18 
“Of Magic Wands and Kaleidoscopes: Fixing Problems in the Individual Market–We Must 

Not Simply Hand Out Subsidies and Send People to the Unstructured and Relatively 

Unregulated Individual Market for Coverage,” Mark A. Hall, Wake Forest University, Health 

Affairs. http://www.healthaffairs.org 

“Reducing Uninsurance Through the Nongroup Market: Health Insurance Credits and 

Purchasing Groups-A Combined Approach Centered on the Individual Health Insurance 

Market,” Mark McClellan and Katherine Baicker, Council of Economic Advisors and 

Dartmouth College, Health Affairs. http://www.healthaffairs.org 

“The Individual Market: A Delicate Balance–The Task Requires Balancing the Three Rs: 

Risk, Rates, and Regulations,” Scott Serota, Blue Cross and Blue Shield, Health Affairs. 

http://www.healthaffairs.org 

SMALL BUSINESS OWNER TESTIMONIES 

“Written Statement by the National Association for the Self-Employed at the National 

Women’s Business Council Roundtable,” February 27, 2003. http://www.nase.org 

“Small Business Access to Health Care,” Statement of Mary Blankenbaker, Co-owner of 

Benjamin’s Restaurant, before the House Committee on Small Business, August 14, 2002. 

http://www.house.gov 

“Small Business Access to Health Care,” Statement of Brad Close, National Federation of 

Independent Business, August 14, 2002, House of Representatives, Committee on Small 

Business. http://www.house.gov 

“Small Business Access to Health Care,” Statement of Michelle Kuhn, President, Aeffect, 

Inc., before the House Committee on Small Business, July 9, 2001. http://www.house.gov 

“Small Business Access to Health Care,” Statement of Patrick H. Canary, Owner, PHC 

Enterprises, Inc., DBA Alpha Graphics, before the House Committee on Small Business, 

July 9, 2001. http://www.house.gov 

“Small Business Access to Health Care,” Statement of Sammy Davis, Jr., President and 

Owner, Handyman at Work, before the House Committee on Small Business, July 9, 

2001. http://www.house.gov 

SMALL BUSINESS ROLE IN ECONOMY 

“American Small Business Driving Innovation and Creating Jobs/President’s Agenda,” 

White House. http://www.whitehouse.gov/infocus/smallbusiness 

“The State of Small Business: A Report of the President, 1999-2000,” December 2002, 

Small Business Administration. http://www.sba.gov 

“Tax Policy and Small Business: New Firm Foundation, Growth, and Survival,” Conference 

proceedings, July 2001, Small Business Administration. http://www.sba.gov 

“Women in Business, 2001,” October 2001, Small Business Administration, Office of 

Advocacy. http://www.sba.gov 

A-19 
 

 

SOURCE

 

 

APPENDIX B: ORGANIZATION RESOURCE LIST 

ACCESS TO AFFORDABLE HEALTH COVERAGE 

BY WOMEN-OWNED BUSINESSES 

TITLE 

Agency for Health Care 

Research and Quality 

“2000 Employer-Sponsored Health Insurance Data,” MEPS Tables, 

August 2002. http://www.meps.ahrq.gov 

“Changes in Job-related Health Insurance, 1996-99,” MEPS 

Chartbook No. 10, AHRQ Pub. No. 02-0030. 

http://www.meps.ahrq.gov 

“Women in the Health Care System: Health Status, Insurance, and 

Access to Care,” Medical Expenditure Panel Survey (MEPS), 

Research Findings No. 17, AHRQ Pub. No. 02-0004. 

http://www.ahrq.gov 

“Changes in Usual Sources of Medical Care Between 1987 and 

1992,” Ernest Moy, Barbara Bartman, Clancy, and Llewellyn J. 

Cornelius, 1998, Vol. 9, No. 2, AHCPR Pub. No. 98-R071. 

http://www.ahrq.gov 

“Health Insurance Status of the U.S. Civilian Non-institutional 

Population: 1996,” Medical Expenditure Panel Survey (MEPS), 

AHCPR Pub. No. 97-0030. http://www.ahrq.gov. 

“State Differences in Job-related Health Insurance,” J.M. 

Branscome and E. Brown, MEPS Chartbook No. 7, AHRQ Pub. No. 

01-0036. http://www.meps.ahrq.gov 

Alliance for Health 

Reform 

“The Changing Face of Health Insurance,” April 5, 2002. 

http://www.allhealth.org 

“Making Tax Credits Work: How Much Do Individuals Pay for 

Private Health Insurance and What Do They Get for Their Money?” 

Briefing, August 10, 2001. http://www.allhealth.org 

“Getting Real: Timely Ways to Insure the Uninsured,” April 6, 2001. 

http://www.allhealth.org 

American Academy of 

Actuaries 

“Commentary: The Evolution of Voluntary Choice Cooperatives,” 

Terry S. Ward, Contingencies, March/April 2001. 

http://www.contingencies.org 

B-1 
 

SOURCE TITLE 

American Association of 

Health Plans 

American College of

Physicians/American 

Society of Internal 

Medicine 

American Medical 

Association 

“Research Highlights—Institute of Medicine Finds Insurance 

Coverage Promotes Good Health While No Coverage Results in 

Higher Adverse Outcomes,” July 2002. http://www.aahp.org 

“Health Insurance Is Enough to Make You Sick: Uninsured Women 

at Risk,” Working paper, March 14, 2001. 

http://www.acponline.org/uninsured/index.html 

“Health Reimbursement Arrangements: Practical Approach to 

Health Spending,” Editorial, August 12, 2002. 

http://www.ama-assn.org 

“AMA Statement to the House Energy and Commerce Committee, 

Subcommittee on Health Re: The Uninsured and Affordable Health 

Care Coverage,” February 28, 2002. http://www.ama-assn.org 

“White House Renews Call for Health Insurance Tax Credits,” Amy 

Snow Landa, AMA News, February 18, 2002. 

http://www.ama-assn.org 

“AMA Statement to the House Ways and Means Committee on 

Reducing the Number of Uninsured Through Tax Credits,” February 

13, 2002. http://www.ama-assn.org 

“Benefits and Limitations of an Individual Mandate for Individually 

Owned Health Insurance,” June 2000, CMS Report 5-A-00. 

http://www.ama-assn.org 

“Employer Purchasing Alliances: An Evolutionary Step Toward 

‘Voluntary Choice Cooperatives’ Under Individually Selected and 

Owned Health Insurance,” June 1999, Report 5 of the Council on 

Medical Service (A-99). http://www.ama-assn.org 

“AMA Letter Supporting Introduction of the ‘Patient’s Health Care 

Choice Act of 1999,” from E. Ratcliffe Anderson, Jr., M.D., and Rep. 

John Shadegg (R-AZ), April 28, 1999. http://www.ama-assn.org 

“Archer/Lipinski Congressional ‘Dear Colleague’ Letter on the 

Bipartisan Medical Savings Account Effectiveness Act of 1999,” 

from Rep. Bill Archer (R-TX) and Rep. William Lipinski (D-IL), April 

6, 1999. http://www.ama-assn.org 

“Rethinking Health Insurance: The AMA’s Proposal for Reforming 

the Private Health Insurance System,” 1999. 

http://www.ama-assn.org 

B-2 
 

SOURCE TITLE 

American Medical 

Association 

Americans for Tax 

Reform 

Blue Cross and Blue 

Shield Association of 

America 

Bureau of Census 

Business Owner 

“Rethinking Employment- based Health Benefits: Enabling 

Consumer-driven Health Care.” http://www.ama-assn.org

 “Issues and Legislation: Current Action Alerts, Current Legislation, 

and Key Votes.” updated daily. http://www.capwiz.com/ama 

“Health Marts; A Free Market Health Care Solution, Policy Brief,” 

Peter Ferrara, October 4, 1999. http://www.atr.org 

“The Factors Fueling Rising Healthcare Costs,” prepared for the 

American Association of Health Plans, April 2002. 

http://www.bcbshealthissues.com 

“State Legislative Health Care and Insurance Issues: 2000 Survey 

of Plans,” February 2001. http://www.bcbshealthissues.com 

“Coverage for Small Business: The Issue.” 

http://www.bcbshealthissues.com 

“Helping Small Businesses Expand Access to Health Insurance.” 

http://www.bcbshealthissues.com 

“AHPs Would Operate in a Regulatory Vacuum and ‘Cherry-Pick’ 

Only the Healthiest Groups, New BCBSA Analyses Find.” 

http://www.bcbshealthissues.com\ 

“Employment-based Health Insurance: 1997,” Shailesh Bhandari, 

December 2002, Current Population Reports No. P70-81. 

http://www.census.gov 

“Nonemployer Statistics: 2000,” October 2002. 

http://www.census.gov

 “Health Insurance Coverage 2001,” Current Population Reports, 

September 2002. 

http://www.census.gov 

“1997 Economic Census: Minority- and Women-Owned 

Businesses—United States.” 

http://www.census.gov/epcd/mwb97/us/us.html 

“Health Reimbursement Accounts Are the Best News in Health 

Plans in Many Years,” Business Guide to Affordable Benefits. 

http://busowner.nomohmo.com 

B-3 
 

SOURCE TITLE 

Business Owner 

California Health Care 

Foundation 

Cato Institute 

“What Are the Rules for Health Reimbursement Accounts?” 

Producer’s Guide to Consumer-driven Health Plans. 

http://producer.nomohmo.com 

“Insurance Markets: Small Businesses Face Greater Cost-Sharing 

and Increasing Complexity,” April 2002. http://www.chcf.org 

“Employer-sponsored Health Insurance Among Small Businesses: 

The 2000 CHCF/Mercer Survey,” 2001. http://www.chcf.org 

“Why Don’t More Small Businesses Offer Health Insurance?” 

Summary report on the 2000 CHCF Survey, 2001. 

http://www.chcf.org 

“To Buy or Not to Buy: A Profile of California’s Non-poor Uninsured.” 

Survey. http://www.chcf.org/uninsured/fieldsurvey.cfm 

“Restoring Health Freedom: The Case for a Universal Tax Credit for 

Health Insurance,” Sue A. Blevins, December 2002, Policy Analysis 

No. 290. http://www.cato.org 

“Medical Savings Accounts: Progress and Problems Under HIPAA,” 

Victoria Craig Bruce, August 8, 2001. http://www.cato.org 

“State Mandates on Private Insurance,” Gail A. Jenson. 

http://www.cato.org 

“The Individual Health Insurance Market: Researchers, Policy 

Makers Seek Common Ground on Tax Credits for the Uninsured,” 

December 2002, Issue Brief No. 58. http://www.hschange.org 

“Design and Methods for the Community Tracking Study,” 

November 6, 2002. http://www.hschange.org 

“Cutting Back but Not Cutting Out: Small Employers Respond to 

Premium Increases,” Ashley C. Short and Cara S. Lesser, October 

2002, Issue Brief No. 56. http://www.hschange.org 

“The Role of Health Insurance Brokers: Providing Small Employers 

With a Helping Hand,” Leslie Jackson Conwell, October 2002, 

Issue Brief No. 57. http://www.hschange.org 

“Wall Street Comes to Washington: Market Watchers and Policy 

Analysts Evaluate the Health Care Market,” July 2002, Issue Brief 

No. 54. http://www.hschange.org 

B-4 
 

SOURCE TITLE 

Center for Studying 

Health System Change 

“Tax Credits and the Affordability of Individual Health Insurance,” 

Jack Hadley and James D. Reschovsky, July 2002, Issue Brief No. 

53. http://www.hschange.org 

“The Insurance Gap and Minority Health Care, 1997-2001,” by J. 

Lee Hargraves, June 2002, Tracking Report No. 2. 

http://www.hschange.org 

“Treading Water: Americans’ Access to Needed Medical Care, 

1997-2001,” by Bradley C. Strunk and Peter J. Cunningham, March 

2002, Tracking Report No. 1. 

http://www.hschange.org 

“Options for Expanding Health Insurance for People With Chronic 

Conditions,” Ha T. Tu and Marie C. Reed, February 2002, Issue 

Brief No. 50. http://www.hschange.org 

“Triple Jeopardy: Low-income, Chronically Ill and Uninsured in 

America,” by Marie C. Reed and Ha T. Tu, February 2002 (Issue 

Brief No. 49). http://www.hschange.org 

“Blue Plans: Playing the Blues No More,” Joy M. Grossman and 

Bradley C. Strunk, January 23, 2002. http://www.hschange.org 

“Stand-alone Health Insurance Tax Credits Aren’t Alone,” July 2001, 

Issue Brief No. 41. http://www.hschange.org 

“Stand-alone Health Insurance Tax Credits Aren’t Alone,” 

Conference transcript, July 2001. http://www.hschange.org 

“How to Make Tax Credits for Health Insurance Work: The Role of 

Purchasing Pools,” Conference proceedings, April 10, 2001. 

http://www.hschange.org 

“Tax Credits and Purchasing Pools: Will This Marriage Work?” Sally 

Trude and Paul B. Ginsburg, April 2001, Issue Brief No. 36. 

http://www.hschange.org 

“Defined Contributions: The Search for a New Vision,” Sally Trude, 

April 2001,Issue Brief No. 37. http://www.hschange.org 

“Premium Subsidies for Employer-sponsored Health Coverage: An 

Emerging State and Local Strategy to Reach the Uninsured,” by 

Leslie Jackson Conwell and Ashley C. Short, December 2001, Issue 

Brief No. 47. http://www.hschange.org 

B-5 
 

SOURCE

 

TITLE 

Center for Studying 

Health System Change 

Ceridian Solutions 

Commonwealth Fund 

“Employer Health Insurance Premium Subsidies Unlikely to 

Enhance Coverage Significantly,” James D. Reschovsky and Jack 

Hadley, December 2001, Issue Brief No. 46. 

http://www.hschange.org 

“Are Defined Contributions a New Direction for Employer-sponsored 

Coverage?” Sally Trude and Paul B. Ginsburg, October 2000, Issue 

Brief No. 32. http://www.hschange.org 

“Defining ‘Defined Contributions’: New Directions for Employersponsored Health Insurance Coverage—Conference Transcript,” 

October 2000. http://www.hschange.org 

“Community Tracking Survey.” http://www.hschange.org 

“As Consumers Take Charge of Their Health Care, HRAs Increase 

in Popularity,” Winter 2002-2003. http://www.ceridian.com 

“On Their Own: Young Adults Living Without Health Insurance,” 

Kevin Quinn, Cathy Schoen, and Louisa Buatti, The Commonwealth 

Fund and Abt Associates, May 2000, Publication No. 391. 

http://www.cmwf.org 

“Can’t Afford to Get Sick: A Reality for Millions of Working 

Americans,” J. Budetti, L. Duchon, C. Schoen, and J. Shikles, 

September 1999. http://www.cmwf.org 

“Targeting Long- and Short-term Gaps in Health Insurance,” P.F. 

Short and J. Kleman, June 1998. http://www.cmwf.org 

“The Erosion of Employer-based Health Coverage and the Threat to 

Workers’ Health Care,” Jennifer N. Edwards, Michelle M. Doty, and 

Cathy Schoen, August 2002, Issue Brief. http://www.cmwf.org 

“High-risk Pools Unaffordable for Many Who Are Denied Individual 

Health Coverage,” Lori Achman and Deborah Chollet, August 2001, 

Pub. No. 472. http://www.cmwf.org. 

“Health Insurance: A Family Affair—A National Profile and State-byState Analysis of Uninsured Parents and Their Children,” Jeanne M. 

Lambrew, George Washington University, May 2001. 

http://www.cmwf.org 

B-6 
 

SOURCE TITLE 

Commonwealth Fund 

Communicating for

Agriculture, Inc. 

“Expanding Public Programs to Cover the Sick and Poor 

Uninsured,” Invited Testimony at a Hearing on the Uninsured, 

Senate Finance Committee, Karen Davis, March 15, 2001, Pub. No. 

462. http://www.cmwf.org 

“Expanding Employment-based Health Coverage: Lessons from Six 

State and Local Programs,” Sharon Silow-Carroll, Emily K. 

Waldman, and Jack A. Meyer, February 2001, Pub. No. 445. 

http://www.cmwf.org 

“Challenges and Options for Increasing the Number of Americans 

With Health Insurance,” Sherry A. Glied, January 2001, Pub. No. 

415. http://www.cmwf.org 

“Challenges and Options for Increasing the Number of Americans 

With Health Insurance,” January 2001. http://www.cmwf.org

 “A 2020 Vision for American Health Care,” Karen Davis, Cathy 

Schoen, and Stephen C. Schoenbaum, December 2000. 

http://www.cmwf.org 

“Barriers to Health Coverage for Hispanic Workers: Focus Groups 

Findings,” Michael Perry and Susan Kannel, Lake Snell Perry & 

Associates with Enrique Castillo, Castillo & Associates, December 

2000. http://www.cmwf.org 

“State and Local Initiatives to Enhance Health Coverage for the 

Working Uninsured,” Sharon Silow-Carroll, Stephanie E. Anthony, 

and Jack A. Meyer, Economic and Social Research Institute, 

November 2000, Pub. No. 424. http://www.cmwf.org 

“Disparities in Health Insurance and Access to Care for Residents 

Across U.S. Cities,” E. Richard Brown, Roberta Wyn, and 

Stephanie Teleki, UCLA Center for Health Policy Research, August 

2000, Publication No. 92. http://www.cmwf.org or 

http://www.healthpolicy.ucla.edu 

“Survey Shows Small Business Owners Concerned About 

Economic Crisis—Final CA Survey Results,” July 22, 2002. 

http://www.cainc.org 

“Steps Toward a Healthier Individual Health Insurance Market,” 

Statement of Bruce Abbe at the National Conference of State 

Legislatures, November 17, 2001. http://www.cainc.org 

B-7 
 

SOURCE TITLE 

Communicating for

Agriculture, Inc. 

Congressional Budget

Office 

Congressional Institute 

“What is a Risk Pool? State Health Insurance Pools for the HighRisk Population—25 Years of Proven Service in Guaranteeing 

Access to Coverage,” Response to the Commonwealth Foundation 

Study on Risk Pools, Bruce Abbe. http://www.cainc.org 

“Tax Policies Affecting Rural Small Businesses,” Issue briefing 

paper. http://www.cainc.org 

“Letter to the Honorable Don Nickles Regarding the Estimated 

Ultimate Effect of S. 283 on Premiums for Employer-Sponsored 

Health Insurance,” April 2001. http://www.cbo.gov 

“CBO’s Analysis of the Health Insurance Initiatives in the MidSession Review,” July 2000. http://www.cbo.gov 

“Increasing Small-firm Health Insurance Coverage Through 

Association Health Plans and HealthMarts,” January 2000. 

http://www.cbo.gov 

“Statement of Dan L. Crippen, Director, Congressional Budget 

Office, on Health Care Costs and Insurance Coverage Before the 

Subcommittee on Employer-Employee Relations, Committee on 

Education and the Workforce, U.S. House of Representatives,” 

June 11, 1999. http://www.cbo.gov 

“An Analysis of the President’s Budgetary Proposals for Fiscal Year 

2000,” April 1999. http://www.cbo.gov 

“Statement of James R. Baumgardner, Acting Deputy Assistant 

Director for Health Policy, on Association Health Plans Before the 

Committee on Small Business, U.S. House of Representatives,” 

February 16, 2000. http://www.cbo.gov 

“Proposals to Subsidize Health Insurance for the Unemployed,” 

January 1998. http://www.cbo.gov 

“Trends in Health Care Spending by the Private Sector,” CBO 

Paper, April 1997. http://www.cbo.gov 

“Health Insurance.” http://www.conginst.org 

“Health Care Reform Update: Increased Patient Protection.” 

http://www.conginst.org 

B-8 
 

SOURCE TITLE 

Consumers for 

Affordable Health Care 

Foundation 

Council on Affordable 

Health Insurance 

Council on Smaller 

Enterprises 

Deloitte & Touche 

Department of Labor 

“The Maine Small Business Health Insurance Project.” 

http://www.mainecahc.org/foundation/researchandpolicy.htm 

“MSAs Are Not FSAs Are Not HRAs,” December 2002, Issues & 

Answers No. 110. http://www.cahi.org 

“Getting Started: A State Checklist for Creating High-risk Pools,” 

December 2002, Issues and Answers N. 111. http://www.cahi.org 

”Archer MSAs: A Good Beginning—A Better Future,” July 2002, 

Issues and Answers No. 105. http://www.cahi.org 

“Greater Cleveland Growth Association: 2002-2006 Public Policy 

Agenda for Northeast Ohio,” 2002. http://www.clevelandgrowth.com 

“New Health Reimbursement Accounts Give Companies More 

Benefit Choices for Employees,” September 24, 2002. 

http://www.deloitte.com 

“Association Health Plans: Improving Access to Affordable Quality 

Health Care for Small Business,” December 2002. 

http://www.dol.gov 

“Fact Sheet: Association Health Plans—Quality, Affordable Health 

Insurance,” November 13, 2002. 

http://www.dol.gov/pwba/newsroom/fsahp.html 

“The Health Insurance Portability and Accountability Act—HIPAA,” 

November 13, 2002. 

http://www.dol.gov/pwba/newsroom/fshipaa.html 

“Fact Sheet: General Facts on Women and Job-based Health,” 

November 13, 2002. 

http://www.dol.gov/pwba/newsroom/fshlth5.html 

“Accessing Health Care—Affordable Quality Health Care Needed,” 

Women’s Bureau Newsletter, November 13, 2002. 

http://www.dol.gov/wb/media/newsletter/e-news4artl-02.htm 

“Employee Benefits in Private Industry, 2000,” July 16, 2002. 

http://www.bls.gov/news.release/ebs2.nr0.htm 

“Employee Benefits in Private Industry, 1999,” December 19, 2001. 

http://www.bls.gov/ncs/ebs/sp/ebnr0006.txt 

B-9 
 

SOURCE TITLE 

Department of the

Treasury 

Employee Benefit 

Research Institute 

Employee Council on 

Flexible Compensation 

“Employee Benefits in Medium and Large Private Establishments, 

1997,” January 7, 1999. http://www.ustreas.gov

 “Treasury and IRS Issue Guidance on Health Reimbursement,” 

June 26, 2002, PO-3204. http://www.ustreas.gov 

“Publication 969: Medical Savings Accounts (MSAs).” 

http://www.irs.gov/formspubs/page/0,,id%3D12945,00.html 

“Retiree Health Benefits: Public Perception vs. National Reality,” 

September 2002. http://www.ebri.org 

“2002 Health Benefits Survey.” http://www.ebri.org 

“EBRI Health Care Research: 2002 Findings.” 

http://www.ebri.org/findings/health_findings.html 

“Health Confidence Survey: 2002.” http://www.ebri.org/hcs/ 

“Nonelderly Individuals With Employment-Based and Individually 

Purchased Health Care Coverage,” EBRI Notes, May 2000. 

http://www.ebri.org 

“Sources of Health Insurance and Characteristics of the Uninsured: 

Analysis of the March 1999 Current Population Survey,” Paul 

Fronstin, January 2000, EBRI Issue Brief No. 211. 

http://www.ebri.org 

“Employment-based Health Insurance: A Look at Tax Issues and 

Public Opinion,” Paul Fronstin, EBRI Issue Brief No. 211, July 

1999. http://www.ebri.org 

“Severing the Link Between Health Insurance and Employment: 

What Happens if Employers Stop Offering Health Benefits?” ERF 

Policy Forum, May 5, 1999. http://www.ebri.org 

“Health Reimbursement Accounts Are the Best News in Health 

Plans in Many Years,” Business Guide to Affordable Benefits. 

http://busowner.nomohmo.com 

“What Are the Rules for Health Reimbursement Accounts?” 

Producer’s Guide to Consumer-driven Health Plans. 

http://producer.nomohmo.com 

B-10 
 

SOURCE TITLE 

General Accounting

Office 

“Private Health Insurance: Small Employers Continue to Face 

Challenges in Providing Coverage,” October 31, 2001, GAO-02-8. 

http://www.gao.gov/docdblite 

“Private Health Insurance: Federal Role in Enforcing New 

Standards Continues to Evolve,” Letter to Senator James M. 

Jeffords, Chairman, Committee on Health Education, Labor, and 

Pensions, from Kathryn G. Allen, Director, Health Care—Medicaid 

and Private Health Insurance Issues, May 7, 2001. 

http://www.gao.gov 

“Health Insurance: Proposals for Expanding Private and Public 

Coverage,” Statement of William J. Scanlon, Director, Health Care 

Issues, Testimony before the Committee on Finance, U.S. Senate, 

March 15, 2001,GAO-01-481T. http://www.gao.gov/docdblite 

“Health Insurance: Characteristics and Trends in the Uninsured 

Population,” Statement of Kathryn G. Allen, Director, Health Care, 

Medicaid and Private Health Insurance Issues, Testimony before 

the Committee on Finance, U.S. Senate, March 13, 2001, GAO-01-

507T. http://www.gao.gov 

“Private Health Insurance: Potential Tax Benefit of a Health 

Insurance Deduction Proposed in H.R. 2990,” Letter to 

Congressman Charles B. Rangel, Ranking Minority Member, 

Committee on Ways and Means, House of Representatives, from 

Kathryn G. Allen, Associate Director, Health Financing and Public 

Health Issues, April 2000. http://www.gao.gov 

“Private Health Insurance: Cooperatives Offer Small Employers 

Plan Choice and Market Prices, Report to the Chairman, Committee 

on Commerce, House of Representatives,” March 2000, 

GAO/HEMS-00-49. http://www.gao.gov 

“Private Health Insurance: Estimates of Effects of Health Insurance 

Tax Credits and Deductions as Proposed In H.R. 2261,” Letter to 

Congresswoman Nancy L. Johnson from Kathryn G. Allen, 

Associate Director, Health Financing and Public Health Issues, 

September 13, 1999. http://www.gao,gov/docdblite 

“Private Health Insurance: Progress and Challenges in 

Implementing 1996 Federal Standards,” Report to the Chairman, 

Committee on Health, Education, Labor, and Pensions, U.S. 

Senate, May 1999, GAO/HEHS-99-100. 

http://www.gao.gov/docdblite 

B-11 
 

SOURCE TITLE 

General Accounting

Office 

George Washington

University/National 

Health Policy Forum 

Harris Poll 

Health Affairs 

“Medical Savings Accounts: Results From Surveys of Insurers,” 

December 31, 1998, HEHS-99-34. http://www.gao.gov 

“Health Insurance Standards: Implications of New Federal Law for 

Consumers, Insurers, and Regulators,” February 25, 1998, GAO/THEHS-98-67. http://www.gao.gov/docdblite 

“Health Insurance Standards: New Federal Law Creates Challenges 

for Consumers, Insurers, Regulators,” February 25, 1998, 

GAO/HEHS-98-67. http://www.gao.gov/docdblite 

“The Health Insurance Portability and Accountability Act of 1996: 

Early Implementation Concerns,” September 2, 1997, GAO/HEHS97-8. http://www.gao.gov/docdblite 

“Private Health Insurance: Continued Erosion of Coverage Linked to 

Cost Pressures,” Report to the Chairman, Committee on Labor and 

Human Resources, U.S. Senate, July 1997, GAO/HEHS-97-122. 

http://www.gao.gov 

“Health Insurance: Management Strategies Used by Large 

Employers to Control Costs,” Report to the Chairman, Committee 

on Labor and Human Resources, U.S. Senate, May 1997, 

GAO/HEHS-97-71. http://www.gao.gov 

“Expanding Health Coverage for the Uninsured: Fundamentals of 

the Tax Credit Option,” NHPF background paper, Beth Fuchs, 

Merlis, and Julie James. http://www.nhpf.org 

“Trends in Employer Health Coverage: Where Is the Market Taking 

Us?” Karl Polzer, March 7, 1997, Issue Brief No. 699. 

http://www.nhpf.org 

“As Corporate Concerns About Health Care Continue to Rise, Many 

Employers Plan to Shift More Costs to Their Employees,” October 

9, 2001. http://www.harrisinteractive.com 

“Latest National Poll Says Health Care Issues May Influence 40% of 

Votes in Tuesday’s Congressional Election,” November 4, 2000. 

http://www.harrisinteractive.com 

“Individual Insurance: How Much Financial Protection Does It 

Provide?” Jon Gabel, Kelley Dhont, Heidi Whitmore, and Jeremy 

Pickreign, April 17, 2002. http://www.healthaffairs.org 

B-12 
 

SOURCE TITLE 

Health Affairs “Job-based Health Insurance in 2000: Premiums Rise Sharply While 

Coverage Grows,” J. Gabel, L. Levitt, J. Pickreign, H. Whitmore, E. 

Holve, S. Hawkins, and N. Miller, September/October 2000, Vol. 19, 

pp. 144-151. http://www.healthaffairs.org 

“Options and Opportunities for Individuals and Families in the 

Private Health Insurance Market—Tax Credits and Recently Passed 

Trade Adjustment Assistance Act Should Bolster the Existing 

Individual-Market System of Coverage,” Janet Stokes Trautwein, 

National Association of Health Underwriters, October 23, 2002. 

http://www.healthaffairs.org 

“Trends in Employer Health Coverage: Where Is the Market Taking 

Us?” Karl Polzer, March 7, 1997, Issue Brief No. 699. 

http://www.nhpf.org 

Harris Poll “As Corporate Concerns About Health Care Continue to Rise, Many 

Employers Plan to Shift More Costs to Their Employees,” October 

9, 2001. http://www.harrisinteractive.com 

“Latest National Poll Says Health Care Issues May Influence 40% of 

Votes in Tuesday’s Congressional Election,” November 4, 2000. 

http://www.harrisinteractive.com 

Health Affairs “Individual Insurance: How Much Financial Protection Does It 

Provide?” Jon Gabel, Kelley Dhont, Heidi Whitmore, and Jeremy 

Pickreign, April 17, 2002. http://www.healthaffairs.org 

“Job-based Health Insurance in 2000: Premiums Rise Sharply While 

Coverage Grows,” J. Gabel, L. Levitt, J. Pickreign, H. Whitmore, E. 

Holve, S. Hawkins, and N. Miller, September/October 2000, Vol. 19, 

pp. 144-151. http://www.healthaffairs.org 

“Options and Opportunities for Individuals and Families in the 

Private Health Insurance Market—Tax Credits and Recently Passed 

Trade Adjustment Assistance Act Should Bolster the Existing 

Individual-Market System of Coverage,” Janet Stokes Trautwein, 

National Association of Health Underwriters, October 23, 2002. 

http://www.healthaffairs.org 

B-13 
 

SOURCE

 

TITLE 

Health Affairs 

Health Insurance 

Association of America 

“Expanding Coverage: Maintain a Role for the Individual Market—It 

Protects Millions of Americans From Unexpected High Medical 

Bills,” Donald A. Young and Thomas F. Wildsmith, Health Insurance 

Association of America, October 23, 2002. 

http://www.healthaffairs.org 

“Ensuring Health Security: Is the Individual Market Ready for Prime 

Time?— Expanding the Current System Through a Tax-Credit 

Scheme,” Karen Pollitz and Richard Sorian, October 23, 2002. 

http://www.healthaffairs.org 

“The Nongroup Market as One Element of a Broader Coverageexpansion Strategy—With Major Modifications, the Nongroup 

Health Insurance Market Could Be Used as Part of a Broader 

Strategy to Expand Coverage,” Lauren Tollen, Robert M. Crane, 

Ruth Liu, and Steve Zatkin, Kaiser Permanente Institute for Health 

Policy, October 23, 2002. http://www.healthaffairs.org 

“Joint Custody: Bipartisan Interest Expands Scope of Tax-Credit 

Proposals,” Robert Cunningham, Health Affairs, September 18, 

2002. http://www.healthaffairs.org 

“Guaranteed Renewability and the Problem of Risk Variation in 

Individual Health Insurance Markets—A Way to Stabilize Coverage 

with Less Government Interference,” Vip Patel and Mark V. Pauly, 

e-Health Insurance and the Wharton School, University of 

Pennsylvania, August 28, 2002. http://www.healthaffairs.org 

“Impact of the Changing Market for Individual Coverage,” April 17, 

2002. http://www.healthaffairs.org 

“The Nongroup Market: A Web Symposium,” Mark V. Pauly, Len M. 

Nichols, et al., November/December 2002. 

http://www.healthaffairs.org 

“Expanding Individual Health Insurance Coverage: Are High Risk 

Pools the Answer—Although 30 States Operate High-Risk Pools, 

Only a Few Have Found Success,” Deborah Chollet, Mathematica 

Policy Research, October 23, 2002. http://www.healthaffairs.org

“Individual Health Insurance Widely Available, Affordable,” October 

22, 2002. http://www.hiaa.org 

“Employment-Based Health Insurance Coverage,” December 2000. 

http://www.hiaa.org 

B-14 
 

SOURCE

 

TITLE 

Health Insurance 

Association of America 

Health Insurance 

Resource Center 

Henry J. Kaiser Family

Foundation 

“Health Insurance Coverage and the Uninsured: 1990-1998, “ 2000. 

http://www.hiaa.org 

“Health Insurance Coverage and the Uninsured,” January 1999. 

http://www.hiaa.org 

“The Changing Sources of Health Insurance,” William S. Custer 

and Pat Ketsche, Center for Risk Management and Insurance 

Research, Georgia State University . http://www.hiaa.org 

“A Consumer’s Glossary of Health Insurance Terms,” for internal 

project use. http://www.healthinsurance.org/insterms.html 

“The Unsecured and Affordable Health Care Coverage,” Testimony 

of Mary R. Grealy, President, Healthcare Leadership Council, 

before the Committee on Energy and Commerce, Subcommittee on 

Health, United States House of Representatives, February 28, 

2002. http://www.hic.org 

“Because That’s Where the People Are: Reducing the Uninsured 

Population Through the Employer-based Health Care System,” 

Mary R. Grealy, April 6, 2002. http://www.hic.org 

“Statement of the Healthcare Leadership Council to the 

Subcommittee on Health of the Committee on Ways and Means on 

the Nation’s Uninsured,” April 4, 2002. http://www.hic.org 

“Daily Health Policy Report: Richmond, VA Forum Explores Ways to 

Improve Health Care for the Uninsured,” October 23, 2002. 

http://www.kff.org 

“Daily Health Policy Report: After Declining for Two Years, Number 

of Uninsured Increased Last year, Census Bureau Says,” 

September 30, 2002. http://www.kff.org 

“Daily Health Policy Report: New Figures on Uninsured Unlikely to 

Spur Congressional Action, CQ’s Goldreich Says,” September 30, 

2002. http://www.kff.org 

“Mandated Health Insurance Benefits: Tradeoffs Among Benefits, 

Coverage, and Costs,” Issue Brief, July 30, 2002. http://www.kff.org 

“The Uninsured: A Primer,” May 31, 2002. http://www.kff.org 

B-15 
 

SOURCE

 

TITLE 

Henry J. Kaiser Family

Foundation 

Henry J. Kaiser Family

Foundation and the 

Research and 

Educational Trust 

Heritage Foundation 

“National Survey of Small Businesses,” April 2, 2002. 

http://www.kff.org 

“The Uninsured and Their Access to Health Care,” March 19, 2002. 

http://www.kff.org 

“The New Challenge of the Uninsured: Coverage in the Current 

Economy,” February 28, 2002. http://www.kff.org 

“2001 California Employer Health Benefits Survey,” February 19, 

2002. http://www.kff.org

 “Fact Sheet: Women’s Health Insurance Coverage,” July 2001, 

Pub. No. 6000. http://www.kff.org 

“Changes in Insurance Coverage: 1994-2000 and Beyond,” Pub. 

No. 4065. http://www.kff.org 

“The Difference Different Approaches Make: Comparing Proposals 

to Expand Health Insurance,” J. Feder, C. Uccello, and E. O’Brien, 

The Henry J. Kaiser Family Foundation-Institute for Health Care 

Research and Policy, and the Urban Institute, October 1999. 

http://www.kff.org 

“Options for Expanding Health Insurance Coverage: A Report on a 

Policy Roundtable,” Judith Feder and Sheila Burke, October 1999. 

http://www.kff.org 

“Employment-based Health Insurance Coverage and Its Decline: 

The Growing Plight of Low-Wage Workers,” E. O’Brien and J. 

Feder, May 1999. http://www.kff.org 

“Working Families at Risk: Coverage, Access, Costs and Worries,” 

Louis Harris and Associates, Henry J. Kaiser Family Foundation, 

Commonwealth Fund, 1997 National Survey of Health Insurance, 

December 1997. http://www.kff.org 

“Employer Health Benefits 2002: Summary of Findings,” Pub. No. 

3252. http://www.kff.org 

“2002 Employer Health Benefits Survey: Report,” 2002. 

http://www.kff.org 

“The Shadegg Health Bill: Expanding Access and Choice,” James 

Frogue, May 19, 1999, Heritage Foundation Executive 

Memorandum No. 598. http://www.heritage.org 

B-16 
 

SOURCE TITLE 

Heritage Foundation “Back to the Drawing Board: Why Tax Reform Is the Key to Health 

Care Reform,” Carrie J. Gavora, Backgrounder Executive Summary 

No. 1189, June 9, 1998. http://www.heritage.org 

Hewitt Associates “Double-Digit Health Care Cost Increases Expected to Continue in 

2002,” October 29, 2001. http://www.hewitt.com 

Hispanic Business

Roundtable 

“Hispanic Business Leaders Strongly Support Bipartisan Effort to 

Address the Uninsured,” April 2, 2001. http://www.hbrt.org 

House of 

Representatives,

Committee on Small 

Business 

“Small Business Access to Health Care,” Statement of Mary 

Blankenbaker, Co-owner of Benjamin’s Restaurant, before the 

House Committee on Small Business, August 14, 2002. 

http://www.house.gov 

“Small Business Access to Health Care,” Statement of Brad Close, 

National Federation of Independent Businesses, before the House 

Committee on Small Business, August 14, 2002. 

http://www.house.gov 

“Small Business Access to Health Care,” Statement of Michelle 

Kuhn, President, Aeffect, Inc., before the House Committee on 

Small Business, July 9, 2001. http://www.house.gov 

"Small Business Access to Health Care,” Statement of Patrick H. 

Canary, Owner, PHC Enterprises, Inc., DBA AlphaGraphics," before 

the House Committee on Small Business, July 9, 2001. 

http://www.house.gov 

"Small Business Access to Health Care,” Statement of Sammy 

Davis, Jr., President and Owner, Handyman at Work, before the 

House Committee on Small Business, July 9, 2001. 

http://www.house.gov 

“A Tax Agenda for Small Business,” Joint Roundtable Before the 

Committee on Small Business, United States Senate, and the 

Committee on Small Business, House of Representatives, April 4, 

2001. http://www.access.gpo.gov/index.html 

Inquiry “Challenges and Options for Increasing the Number of Americans 

With Health Insurance,” S.A. Glied, Summer 2001. 

http://www.inquiry.org 

B-17 
 

SOURCE TITLE 

Inquiry 

Institute for Health 

Policy Solutions 

Journal of Women’s 

Health 

Kaiser Commission on 

Medicaid and the 

Uninsured 

Kilpatrick Stockton 

Latino Coalition 

Library of Congress 

“Public Subsidies for Employee Contributions to Employersponsored Insurance,” J. Lemieux, D. Kendall and R. Levine, 

Summer 2001. http://www.inquiry.org 

“Consumer-choice Health Purchasing Groups,” 1999. 

http://www.ihps.org 

“Gaps and Transitions in Health Insurance: What Are the Concerns 

of Women?” August 1998. http://www.womenshealthjournal.com 

“Gaps and Transitions in Health Insurance: What Are the Concerns 

of Women?” August 1998. http://www.womenshealthjournal.com 

“Underinsured in America: Is Health Coverage Adequate?” July 

2002. http://www.kff.org
 

“Health Insurance Coverage in America: 2000 Data Update,” March 

19, 2002, Pub. No. 4007. http://www.kff.org 

“Key Facts: The Uninsured and Their Access to Health Care,” 

February 2002, Pub. No. 1420-03. http://www.kff.org
 

“In Their Own Words: The Uninsured Talk About Living Without 

Health Insurance,” Martha Shirk, September 2000, Pub. No. 2207. 

http://www.kff.org 

“Improving the Functioning of the Small Group and Individual 

Markets: The Role of Health Care Purchasing Pools,” Laura Tollen 

and Robert Crane, Institute for Health Policy. http://www.kff.org 

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B-20 
 

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B-21 
 

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B-23