National concern about Americans without health insurance often comes down to numbers and caricatures: U.S. Census estimates place the number of uninsured people at 45 million, but politicians often paint members of that group as unemployed, earners of low wages or victims of large corporations that do not provide health insurance because of cutthroat business practices.
But among the growing pool of the uninsured nationwide are workers employed by small businesses that do not have enough employees to negotiate bulk discounts on health insurance premiums. In Rhode Island, a state with only two major insurance companies, the price of health insurance has increased an estimated 200 percent between 1997 and 2003. In response, small- and medium-sized businesses have been shedding employee health insurance plans or shifting more costs to employees.
Two proposals introduced this year look to pool self-employed workers, uninsured individuals and small businesses into one group of buyers to negotiate for lower premiums from Blue Cross and Blue Shield and United Healthcare. But while plans from Gov. Donald Carcieri '65 and others examine how to provide cheaper insurance and slow the growth of costs in the health care system as a whole, Carcieri's budget proposal reflects concern about the state's rising share of the costs of entitlement health care programs, cutting some middle-income parents and 3,000 illegal immigrant children from the state's successful RIte Care children's health care program.
"RIte Care spending has been increasing at an unsustainable rate," said Carcieri spokesman Jeff Neal. "We are reversing the last major addition (to eligibility), so that we can preserve the core services."
One plan, announced in January by Lt. Gov. Charles Fogarty and Sen. Elizabeth Roberts '78 - who plan to run together for governor and lieutenant governor this November - would also establish a $3 million reinsurance fund to pay unusually high health care costs for people enrolled through the state program, reducing the risk for insurance companies and, hopefully, greatly reducing the premiums for the program.
Although the program is primarily aimed at "modest income" workers, "we have to recognize that not everyone has an attachment to the workforce" in crafting future health care policy, said Maureen Maigret, Fogarty's director of policy. "Our program will allow individuals who don't have an attachment to the workforce to get a break on their premium."
A plan introduced by Carcieri in February as part of a larger proposal to address health care costs in the state would similarly negotiate for lower premiums by pooling small businesses and individuals and by offering a reinsurance fund for lower-income businesses and individuals. Carcieri's fund, however, comes largely from a planned $110 million settlement from tobacco companies to states, intended to offset anticipated stresses on the health care system from smoking-related illnesses.
Both plans also pull from an assessment on insurance companies' profits and administrative costs to create reinsurance funds.
Neither plan will fully absorb the estimated 6,800 parents and 3,000 children the governor is proposing eliminating from RIte Care, according to Maigret and Neal. "Not everybody will fit into that category," Neal said.
Carcieri's plan also creates a state bond to transition to electronic recordkeeping for medical records. Although providers and hospitals are moving away from paper-based recordkeeping, state and federal support is necessary for those records to be available to patients and emergency care providers, according to Carcieri's press release on the program.
Meanwhile, a bill introduced by District 3 State Sen. Rhoda Perry and District 2 State Rep. Paul Moura would provide discounts on prescription drugs for elderly uninsured patients through state negotiations directly with pharmaceutical companies. Similar plans have been adopted in two other states, Perry said, who worked with the AFL-CIO and the Pharmaceutical Research and Manufacturers of America in crafting the plan.
"The discount plan is analogous to the discounted medicines that are currently available to the state employees of Rhode Island," she said.
Although some have raised concerns about the plan, called "Rhode Island's Best Rx" plan by Perry, because it does not require an income test for program eligibility for any uninsured patients over the age of 60, she said the wide eligibility will help the people who need it.
"Some people say, 'Oh my God, Rhoda, they could be rich people.' But you show me a rich person who does not have a rich insurance plan," Perry said.
States serve as an important laboratory to test out new approaches to national problems in health care, particularly rising costs and declining access to care. Health policy makers, however, have mixed opinions on Rhode Island's use as a laboratory - its small size, Neal said, is a liability when trying to negotiate bulk deals with pharmaceutical companies and other national organizations.
"The cost of prescription drugs is a larger issue than Rhode Island, and it needs a national solution," Neal said.
But, Maigret said, new ideas can be passed and implemented faster in Rhode Island, and the state can always join other states to negotiate for better prescription drug prices.
