What do Consumers and Businesses Want in State Health Insurance Reform? Evidence from Surveys and Focus Groups in New York State, 2008 Preliminary, please do not quote without authors’ permission Kosali Simon William White Department of Policy Analysis and Management and the Sloan MHA Program Cornell University Funded by a grant to Cornell University from the New York State Health Foundation.

 Many states are currently considering policy changes to cover the uninsured.  Health insurance reform is prominent in presidential candidate platforms.  We conducted four surveys and a series of focus groups in New York State in February-May  What aspects of health care insurance New Yorkers like and dislike?  What do they think of different options?  What is willingness to pay for reducing uninsurance? Introduction

Survey Methods (Consumer) Main survey, Empire State Poll (ESP) –Conducted by Cornell University SRI annually –800 telephone respondents randomly chosen upstate and downstate; results shown are weighted –25 questions about health reform Rural oversample to ESP –300 respondents –Abbreviated set of ESP questions Cell-only sample –100 respondents who use cell phone only –Captures opinions of those not included in traditional landline surveys Four focus groups –Buffalo, Ithaca, Jamaica, Rochester –Allowed us to flesh out questions on the survey, and generate ground-up alternative proposals

Importance of Issues New York consumers view health insurance and health care costs as extremely or very important issues which should be addressed this year (2008) by New York’s government leaders. Importance of health insurance and health care costs: Extremely Important: 59% Very Important: 33% Somewhat Important: 6% Not Important: 2% 6% 2% 33% 59% “It doesn’t seem to me that with the increased amounts of money that everyone’s paying for health insurance, that we’re getting more benefits; in fact, in some cases, we’re getting less benefits, less days in the hospital, higher co-pays and things like that for the same things you got before.”

Reducing Uninsurance Importance of reducing the number of uninsured: Extremely Important: 52% Very Important: 37% Somewhat Important: 9% Not Important: 2% “I had insurance and I lost it because I couldn’t make the payments. It’s becoming overwhelming to the point where I don’t even want to pursue it anymore, I just want to try to stay healthy” “In one of the most progressive nations on earth, every one of our people should have access to healthcare“ 9% 2% 52% 37%

Support for public coverage up to certain income limits: Cover everyone: 41% Up to 400% FPL: 7% Up to 250%: 16% Up to 150%: 19% 100% FPL or below: 18% Consumer Views on Insurance Reform Support is high for the expansion of public coverage as a means to reduce the number of uninsured. “I think we really need to look at the requirements that make you eligible for public programs. Basically, my understanding now is you really gotta be destitute. You’ve got to give it all up if you want to get something.” 7% 16% 19% 18% 41%

Consumer Support for Specific Reforms Shared responsibility found greatest support, employer mandates least supported. 41% 77% 67% 73%27% 33% 23% 59% Favor Oppose “[A company] could run by hiring sub-contractors. What would stop them? They have people employed, but not on their books… and they could hire these people for a year, 2 years.”

Willingness to Pay for Reforms More than 80% report willingness to pay something at all, and more than 60% report willingness to pay at least $50 a year, to reduce uninsurance by 25% of current level. Variant 1 (regardless of income) Variant 2 (to <300% FPL)

1.475 private sector businesses surveyed, stratified by firm size. 2.Four focus groups were conducted with small business owners (Buffalo, Ithaca, Brooklyn, Rochester) Survey Methods (Employers) High cost is the most cited key factor by employers who do not offer health insurance to their workers. A majority of employers agree that responsibility for health insurance rests with employers as well as workers above poverty level, but there is mixed support for employer mandates. Many employers are likely to change their health insurance offerings if public coverage expands to cover workers and their families substantially above the poverty level.

Responsibility for Insurance New York employers of all firm sizes agree that both employers and individuals bear some responsibility for paying for health insurance. Small firms (<10) Medium firms (10-49) Large firms (50+)

Taxation of Large Employers Small firms (<10) Medium firms (10-49) Large firms (50+) “[D]oing business, especially for small businesses in New York State is very tax burdening. (…) [I]mposing another responsibility like this would just add financial pressure on us, especially as a small business.” Views on taxing firms to finance health insurance coverage are divided. Phrased as taxing employers with more than 10 workers

Subsidized Plan Participation Small firms (<10) Medium firms (10-49) Large firms (50+) Employers were also divided about their possible responses to subsidies for covering low income workers

How Would Employers Respond if Medicaid Expanded to All Below 300% FPL? Some employers would stop offering coverage, but the majority would not 72% of small firm establishments, 78% of medium firm establishments, and 81% of large firm establishments said they would not reduce coverage. Most would make changes to existing coverage (e.g. affect raises, change eligibility rules) 53% of small firms, 63% of medium firms, and 52% of large firm establishments said such a program would change the way they ran their insurance program. Close to a third said it would affect decisions about giving raises to workers near the income threshold, and that they would change their eligibility rules for health insurance. However, employer focus groups reveal concerns about the quality of coverage under public programs. One said: “Nobody seems to want to participate with those. I mean, who at this table would want to say, I want to just opt out of my private-paid plan for Medicaid? Last I understood, there’s some pretty stringent limitations under the public plans.”

Conclusions Lack of health insurance, cost of health insurance and health care are substantial problems for NY consumers and businesses owners. Consumers are open to a variety of options, favorable towards shared responsibility, single payer like Medicare, less favorable to employer mandates. Consumer WTP results are encouraging, but what is the realistic amount to ask people if they are prepared to pay? –need to have options spelled out in greater detail to get proper sense of support. Policy makers need to consider possible employer responses to expanded Next steps in analysis: compare to national and other state polls, examine patterns of support by SES, demographics