"New York continues to struggle with others who have not benefited from these great programs; those who may be eligible but have not accessed the programs or who simply do not have access to insurance coverage" said Senator Hannon. Often times employer-based coverage is available but may not be affordable, so workers may choose not to enroll. Secondly, people who lose their jobs or change jobs may lose their health insurance coverage. And third, buying individual coverage in the private insurance market can be prohibitively expensive. "Examining how other states approach this conundrum is a smart exercise" said Senator Hannon.

The June 6th Public Hearing on State Initiatives for Extending Health Coverage for the Uninsured focused on the recent expansion plans and proposals implemented in other states. The goal was to explore all avenues in which New York might expand upon its already enriched programs. A wide array of experts was invited to give their testimony and recommendations before the New York State Senate. Each shared their own experiences with health care expansion proposals and the potential implications of employing similar plans here in New York. Experts were asked to consider the following issues:

1. Explore who is without health insurance coverage in New York and how lack of health insurance affects their access to health care services.
2. Investigate reasons why employer-sponsored insurance is not sufficient in providing health insurance coverage and the role of public-sponsored health insurance in increasing access to health care.
3. Analyze the concept of employer and individual mandates to provide/buy health insurance.
4. Define "affordable" health insurance coverage.
5. Discuss health maintenance organizations’ ability to maintain flexibility in benefit and pricing design for products via a high deductible plan or a health savings account. Also, analyze how HMOs provide comprehensive care through these plans.
6. Evaluate New York’s current legislative proposals that would create an employer mandate on businesses in New York, whereby employers would be required to provide health insurance to their employees or pay an assessment and look into primary factors that influence whether or not businesses offer health insurance coverage to their employees.
7. Consider reforms to current insurance law and regulation that could be adopted to reduce the skyrocketing cost of health insurance premiums and promote greater access to coverage.
8. Explore new measures that New York could implement that would make it easier for businesses owners to offer health insurance to their employees.

It is estimated that over 45 million Americans under the age of 65 (16% of the population) are uninsured. Nearly 16 million are underinsured, with insurance that does not adequately cover overall health needs, including the possibility of a catastrophic health event. Of the estimated 45 million American adults who were uninsured in the last year, 67% were in families where at least one person was working full time. Employer-based health insurance, which was once regarded as the cornerstone of the American health care system, has eroded.

A recent study by the Commonwealth Fund suggested that more than 25% of workers in companies with 500 or more employees do not receive employer based coverage. Workers and their families have turned to government funded health care with increasing frequency in recent times. As job-based health coverage declines, the employers cost shifts to their employees. Such cost shifting has increased the State’s health care expenditures. These expenditures have begun to outpace the overall rate of inflation.

Many business owners express fear that government mandates to shift cost sharing back onto businesses will result in the mass closure of enterprises and widespread economic unrest. The cost of providing health care, and the technology employed to provide that care, has increased dramatically since the times when most employers covered their workers. The members of the business community, who arrived to give testimony, mirrored this sentiment. This in turn provided added insight into the attentiveness that New York State must have when weighing any type of "fair share" legislation. Many community members feared the worst: employer’s payments for health insurance reducing their worker’s wages, businesses altering hiring practices to avoid the mandate and businesses relocating to another state, or curtailing positive expansion, because of a mandate.

Proponents of universal coverage remind us that research has consistently provided evidence that the lack of health insurance ultimately compromises one’s overall health. Individuals, who are less likely to receive preventative care, are more likely to be hospitalized for avoidable problems. Additionally, they are more likely to be diagnosed in the advanced stages of a serious disease.

An important aspect that one must explore, prior proposing an expansion plan, is the estimated cost, beyond what is currently being spent on state medical care, that the new plan will generate.

One study from the Kaiser Commission on Medicaid and the Uninsured estimated that the total spending for those who would gain coverage under a universal expansion, in 2004, would increase the total cost by $48 billion, on top of the spending level of almost $125 billion, which includes all uncompensated care, out-of-pocket payments and insurance payments for those covered for only part of the year.

Other state initiatives have provided a window into the type of questions that New York will ask before acting on any health insurance expansion proposal. For example: Who is not currently covered and why? Who is currently eligible for our current State programs (Medicaid, Family and Child Health Plus and Healthy New York), but are not covered by these plans and why? What are the characteristics of those who just miss eligibility (for example, in some other states there is a trend of young working adults with no, or limited, coverage) If a new plan is implemented, how will that affect all of those who are currently enrolled in our State’s programs?

The testimony of various hearing experts consistently relayed the sentiment that, in designing a plan for all, we must remain cognizant of cost, not only to the State, but also to those who will share the cost of coinsurance, deductibles co-payments for the plan. Business owners, community agencies, recipients of care, insurers, care managers and the providers of care each play an important role in the expansion of care. Each must be considered, separately and in connection to one another and each must be considered not simply for what they can offer, or for what can be offered to them, but as a base framework expanded coverage. We must be able to glean from experts in the field what the ultimate price of providing coverage, or nor providing it, will be.

Health insurance premiums rose nearly 13% last year, which represented the fifth straight year of double-digit increase. Small business owners are especially burdened by the rising health care cost. Often they must decide between providing insurance to their employees or none at all. Many provide the insurance and then are forced to either shift more of the cost to employees, or to terminate benefits altogether. Many times, the small business employer and employee work side by side, which only adds to the difficulty of making such a decision. It is clear that New York will continue to remain interested in seeking novel strategies to make health insurance more affordable and accessible for working individuals and their employers.

New York currently holds an uninsured rate of 14.7%. This is below the national average, due largely to the expansion of its publicly-sponsored health insurance programs, Medicaid, Child Health Plus, Family Health Plus, and Healthy New York. Over 800,000 or 15% of adults in New York, however, are eligible for Medicaid and Family Health Plus but remain uninsured. Still, much of the uninsured and underinsured are lower and middle-income working individuals, with incomes that fall above the eligibility rate for the public programs. Unfortunately, the same individuals still cannot afford to purchase health insurance in the individual market. Several work for businesses that simply cannot afford to offer health plans to their employees. "Both small and large businesses within New York see the rewards of providing benefits, including health insurance coverage to their workers through the retention of a well-trained and highly motivated workforce. We want to support businesses in this endeavor" said Senator Hannon.

New York has made great strides in expanding coverage to its uninsured residents. In 1990, through state legislation, New York enacted the Child Health Plus Program (CHP) to ensure that children, up to the age of 13, from families who have a low-income, receive comprehensive outpatient health care services. In 1997, services were expanded to include inpatient health care services as well as raise the age limit to 19. Today, CHP has enrolled 415,000 children and is currently available at a subsidized rate to families that have net incomes of 200% FPL ($40,000 for a family of four) and Medicaid has enrolled 1.8 million children.

In 1995, there were approximately 160 school-based health centers in New York serving 140,000 students. Today, there are 191 school-based health centers serving more than 200,000 children.

In 1997, New York’s section 1115 Medicaid Demonstration Project, the Partnership Plan, was approved. The demonstration moved approximately 2 million Medicaid beneficiaries from a primarily fee-for-service delivery system, to a mandatory managed care environment. In 2001, the Family Health Plus (FHP) amendment was approved. FHP expanded health insurance to working families up to 150% FPL ($14,700 annually). Prior to 2001, these populations were covered in the state’s Safety Net program. FHP is delivered via managed care organizations and has a smaller benefit package versus traditional Medicaid.

In 2001, New York established Healthy New York as a model for improving access to insurance for small businesses, the self-employed and low-wage workers. Health plans are reimbursed for 90% of claims paid between $5,000 and $75,000 on behalf of a member in a calendar year. Approximately 57% of enrollees are working individuals, 18% are sole proprietors and 25% are enrolled through small employer groups. As of October 2005, Healthy New York has taken off with more than 100,000 active enrollees, and averages more than 7,000 new enrollees per month.

New York reduced barriers while increasing retention in publicly sponsored programs by:

0. Aligning Medicaid and Child Health Plus eligibility rules for children.

0. Unveiling a new, more user-friendly, application form.

0. Eliminating the requirement for a face-to-face interview for persons renewing their Medicaid eligibility by allowing them to use a simplified renewal form.

0. Streamlining the renewal form for Child Health Plus permitting self-attestation for most eligibility factors, including income. The renewal rates for CHP increased from 50% in 2003 to 72% in 2006.

0. In 2000, the Department launched a facilitated enrollment program to provide applicants with assistance in applying for health insurance.

Since 1998, the number of uninsured children in New York has declined by 40 percent. Since the implementation of Family Health Plus, the number of uninsured adults in New York has declined by eight percent.

During the public hearing, several recommendations were made on how to best achieve a permanent, yet flexible form of, coverage for all. It was decided that a "cookie cutter approach" would not be useful in our State. Rather, a plan would be required, that would support consumers while avoiding excessive mandates on recipients, providers, employers and insurers. Models for consideration included: plans with flexible benefits and product design, the possibility of health maintenance organizations (HMOs) offering health savings accounts, consumer directed health care, health insurance portability between employers and geographic locales, individual and employer mandates, chronic disease management programs, "buy-in programs" and plans that raise the income limits of those over Federal Poverty Level standards for inclusion in State plans.

Consumer directed health care plans consist of a number of strategies, which attempt to galvanize the power of consumers, by creating potentially cost-containing choices as health insurance options. The hope is that a consumer driven model would eventually constrain the rising cost of health care, which is now estimated to increase, from 16% of our gross domestic product (GDP) in 2004, to 20% by 2015.

Health savings accounts (HSAs) are often viewed as a key component to increasing the flexibility and affordability of benefit design. They are a central feature of consumer directed health care. HSAs, a form of medical savings account, are accompanied by a health plan. These typically feature a high deductible, for example $1,050 for an individual and $2,100 for a family. The plan allows individuals to save and withdraw tax free money to pay for their medical expenses by extending the tax subsidy for health insurance premiums to their out-of-pocket medical spending. Employers would have the option of contributing to employees’ accounts from pre-taxed income.

The desired end result of the HSA is to enable employees and consumers, to use their own money for care. In this way, HSAs have the potential to create an environment conducive to careful review of one’s health care pricing and then shopping for the most affordable health packages (as one might do for any other product). Through the "Connector", Massachusetts allows an individual, or an employer group, to purchase any type of health insurance product that is appropriate for them. One such option is a HSA with a high deductible plus catastrophic coverage.

Arguments against HSAs, which were not necessarily articulated by witness, assert that plans would undermine access to health care when a significant number of adults, with deductibles of $1,000 or more, reported at least one of four cost-related access problems. These problems include: not filling one’s prescription, not going to a specialist for care when medically necessary, and skipping a recommended test or follow-up. Additionally, if insurance is left to a catastrophic coverage plan only, a potential disincentive is created. One might delay seeking preventative care until acute care is required. This is not only dangerous, but costly to all.

Data suggest that health care costs are inextricably linked to chronic disease care management some are piloting programs which create incentives for physicians who participate. Percentage discounts can be made to employers whose employees participate in disease management activities. Private entities can also provide chronic care management through public funded coverage (such as with Medicaid Managed Care).

In Vermont, the cost of treating chronically ill patients accounts for 75% of health spending in the State (over $3 billion per year). Thus, Vermont has implemented legislation which focuses, in part, on chronic disease management plans. Several other states also offer consumer directed initiatives, within their Medicaid Programs, which center on empowering the consumer through disease management and wellness activities that are fostered by special premiums. Individuals are incentivized to maintain healthy wellness profiles. Opponents to these methods site the potential drawbacks for those who are living with hard to manage chronic conditions.

In Massachusetts, individuals are able to purchase health insurance through pre-tax dollars and are able to keep that insurance even if they transfer to another job. In other words the health insurance is attached to the person and not the job. The idea of "blanket continuation policies" emerged. Under this model, health plans are created which adjoin states within a given geographic region to facilitate interstate portability.

Massachusetts and Maryland have enacted "pay or play", or "fair share" legislation mandating employers to provide health insurance to their workers. Hawaii has also implemented an employer mandate. Massachusetts’ proposal mandates individual responsibility and requires all residents to purchase health insurance by July 1, 2007. Employers with 11 or more workers can either provide health coverage or pay an annual fee of $295 per worker. In Massachusetts, residents with an annual household income up to 300% of the federal poverty level ($60,000 for a family of four) are provided with a subsidy to assist in purchasing health insurance

The overall cost associated with state mandated programming, and implementation, is still unrealized. The success of the individual mandate hinges upon the affordability of plans, the subsidies available to those who must purchase plans and the contributions from state government and employers that fund the subsidies. The estimated cost of implementation for the Massachusetts program is $1.2 billion over the next three years, to cover 550,000 uninsured individuals. Using the same ratio for implementation, the cost per person in New York would be $2,182.82, or $6.5 billion total to cover nearly 3 million uninsured individuals.

In January 2006, Maryland became the first state to pass legislation that would hold large, profitable corporations responsible for offering affordable health care coverage to their employees. Maryland’s Fair Share Health Fund Act or the "Wal-Mart bill" seeks to tax only companies of 10,000 or more employees. Further, the companies do not provide at least 8 percent of total wages in the state in health insurance benefits to employees. Those spending less must increase such expenditures to the required level, or else pay the difference into a newly created public health care fund. Large nonprofit employers in the state must spend at least 6 percent of their payroll on health care. Because of these requirements, Wal-Mart was the only company that qualified for the mandate. Revenue generated from the assessment will be allocated to the State’s Medicaid Program. Money deposited into the fund is then used to defray the cost of the uninsured in the State’s Medicaid Program.

At the time of our hearing, Maryland’s Fair Share Health Fund Act was under challenge in Federal Court. The Retail Industry Leaders Association (RILA) had filed a lawsuit claiming that the law preempts the Employee Retirement Income Security Act (ERISA) of 1974 and cited it as "an unlawful intrusion on the comprehensive federal framework for the administration and regulation of employee benefits plans..." They also argued that it is, "a discriminatory, irrational regulation of commercial activity in violation of the Equal Protection Clause of the Fourteenth Amendment to the U.S. Constitution..." On July 19th, US District Judge Frederick Motz ruled that the Maryland law violates the federal ERISA. Maryland's Attorney General vowed to appeal this ruling, and lawmakers said they would rewrite the legislation to comply with ERISA failing other judgment.

Wal-Mart’s Executive Vice President, Susan Chamber stated that Wal-Mart’s "coverage is expensive for low-income families, and Wal-Mart has a significant percentage of employees and their children on public assistance and in 2004, 38% of enrolled Wal-Mart associates spent more than 16% of the average Wal-Mart income on health care."

Many states are considering "fair share" bills like Maryland, however, policy makers are waiting the outcome of the court challenge. RILA has also filed a similar lawsuit against companies in Suffolk County, New York.

The success of any individual mandate will depend on the affordability of the plans, the subsidies available to those who must purchase plans and the contributions from state government and employers that fund those subsidies. Several witnesses in the business community worried that employers could become the focus of costly experimentation for health care cost containment projects. Overall, businesses stood opposed to New York’s "Fair Share" (S.7090 in New York State) legislation, which would mandate a levy (per hour based upon each covered employee) on employers that employ 100 or more employees. This financial assessment would be paid annually to a state fund earmarked for the subsidization of the health care costs of all uninsured and underinsured New Yorkers. Those in the business community estimate that the "fair share" assessment would generate the largest tax increase in the history of New York, at $8.4 billion.

Many businesses currently endorse the "Freedom Health Insurance Plans" bill (S. 1405A in New York State), which boasts a multiple strategy approach to reducing the number of uninsured and a means of helping people afford health insurance. It employs the private market, tax advantages and state subsidy of the commercial market to bring health insurance within the means of every New Yorker. It also makes use of health savings accounts.

Proponents of "fair share" legislation argue that large businesses are shifting the cost of providing health care coverage for their employees to government sponsored insurances (Medicaid, Child Health Plus and Family Health Plus). Furthermore, they argue that 40% of New York’s businesses already pay at least $3 per hour in health benefits; another 30% of businesses pay between $2 and $3 per hour. Their assertion is that the "fair share" bill would not impose any additional costs on businesses. Proponents of the "fair share" bill estimate that it would provide coverage to 450,000 to 500,000 uninsured and 200,000 to 300,000 employees who are currently enrolled in Medicaid or Family Health Plus. It would result in approximately $4 billion in additional health care spending by businesses.

In Illinois, the Kids Care Rebate Program allows for a Medicaid eligible family to make a choice between enrolling in the State Medicaid Program, or an employer sponsored and State fortified health plan, which affords consumers some further choice on the matter.

Vermont’s Catamount Health, Maine’s Dirigo Choice and Massachusetts' Commonwealth Care products expand coverage to those with a low-income, who are uninsured, by offering sliding scale premiums for individuals below 300 % of the federal poverty level. These programs are funded by a variety of sources including: cigarette tax, individual premiums, employer assessments and private health plans that participate on a voluntary basis. Funding for Maine’s program is based on savings realized from other State programs.

In recent months, Massachusetts, Maryland, Illinois and Florida have enacted health care reform proposals to expand health care coverage to the uninsured and underinsured. These activities range drastically from one another. Some have implemented the Federal 1115 Medicaid Waivers, which afford states the ability to share the cost of health care expansion. Through demonstration projects, with the Federal Government. Others have extended coverage to specific segments of the population, for example to children. Others still, have created employer and individual mandates to purchase health insurance coverage.

Still unresolved in Massachusetts, are the issues of the individual mandate and the cost of implementing the program. The success of the individual mandate hinges upon the affordability of the plans, the subsidies available to those that must purchase plans and the contributions from state government and employers that fund the subsidies. Also, it is estimated implementation of the program will cost Massachusetts $1.2 billion over the next 3 years to cover 550,000 uninsured. When fully implemented, using the same ratio, the cost per person in New York would be $2,182.82, and the total cost to New York would be $6.5 billion to cover its nearly 3 million uninsured.

On April 12, 2006, Governor Mitt Romney signed into law landmark legislation aimed at expanding health care coverage to nearly all of the 550,000 uninsured residents in the state. Two main factors led to passage of the bill. Massachusetts stood to loose $385 million per year for two years if it did not pass a reform plan to cover the uninsured. Also, a ballot proposal, prepared by a powerful coalition of health policy advocates. It required a more substantial payroll tax based contribution from employers. Other factors included the lobbying of the business community to accept and compromise on the employer assessment and increasing Medicaid payments to providers. The Massachusetts Health Care Reform Plan is expected to the cost $1.2 billion over three years.

The cornerstone of this plan is the "Connector," which is a marketplace in which consumers can shop for and buy health coverage from competing health insurers. It enables small-business employees and individuals to buy the personal, portable health insurance of their choice. It has been compared to the Federal Employee Health Benefit Program, which allows federal employees to choose from a variety of competing, private health insurance plans and keep the plan of their choice if they change jobs within the federal system.

1. The Individual Mandate: Everyone in the state is required to purchase health insurance by July 1, 2007 and if they choose not to purchase the plan they will incur financial penalties of up to 50% for the cost of a health insurance plan. Residents will be able to satisfy the mandate by purchasing catastrophic coverage through a high-deductible health plan or a Health Savings Account (HSA).

2. The Employer Mandate: Employers with more that 10 employees will be required to offer a Section 125 "cafeteria plan" that allows employees to purchase health insurance with pre-tax dollars. They would be able to transfer that benefit to other employers. If they chose not to offer the "cafeteria plan," they are required to pay a "fair share" contribution of up to $295 annually per employee, which is deposited into the State’s uncompensated care pool. Businesses with 10 or fewer employees will not be subject to this levy.

3. The Deregulation of the Health Insurance Market: The Massachusetts Health Care Reform Plan allows small businesses and individuals to buy insurance through the "Connector," which will expand coverage options, especially for those in the individual market. It also allows health maintenance organizations to offer HSA-qualified high-deductible health plans, which are more affordable than other plans. Third, it permits insurance plans offered through the Connector to contract with health care providers as they choose, relieving them of the costly "any willing provider" requirements, thereby ensuring patients are allowed to see providers that offer the best value. And fourth it permits insurers to offer plans to individuals between the ages of 19 and 26 and places a moratorium on any new insurance mandates while the State conducts a review of all mandated benefits.

4. The Expansion of Medicaid Coverage and Benefits: The Commonwealth Care Health Insurance Program expands the number of low-income unemployed who can receive MassHealth (Medicaid) and preserves eligibility coverage for immigrants and individuals with disabilities. It also allocates funding to help reach out to people who are currently eligible but not enrolled in state coverage program. Three million dollars has been allocated to increase Mass Health eligibility for children up to 300% FPL or $60,000 for a family of four and Medicaid-like coverage is extended to adults below 100% FPL ($9,600 for an individual), who are eligible for comprehensive benefits with no premiums or deductible.

5. The Quality Improvement Initiatives: The plan also includes provisions to reduce racial and ethnic disparities and create funding for public health and prevention programs (e.g. smoking cessation) and a Computerized Physician Order Entry (CPOE) initiative. Providers will receive increased Medicaid payments for meeting the aforementioned quality improvement initiatives.

Funding for the plan will be derived from leveraged federal matching dollars, enhanced State spending, redeployment of uncompensated care dollars, employer contributions and $308M from the General Fund.

Illinois has also expanded health insurance coverage for its uninsured children. On November 15, 2005, Illinois Governor Rod Blagojevich signed the Covering All Kids Health Insurance Act ("All Kids"). Beginning in July 2006, All Kids will expand coverage to an estimated 253,000 uninsured Illinois children, whose families over the Medicaid or SCHIP (Kid Care) limit. Monthly premiums will be charged on a sliding scale by income.

0. Families of four with annual household incomes between 201% and 300% FPL, or $40,000 to $60,000, will pay $10 co-pays for physician office visits and a $40 monthly premium for one child. In families with two or more children, monthly premiums will total $80. Maximum per child per year co-payments is $500.

0. Families with annual household incomes between 301% and 400% FPL or $60,000 to $79,000 will pay $15 co-pays for physician office visits and a $70 monthly premium for one child or a $140 monthly premium for two or more children. Maximum per child per year co-payments is $750.

0. Families with annual household incomes between 401% and 500% FPL or $80,000 to 99,000 will pay $20 co-pays for physician office visits and a $100 monthly premium per child. In addition, such families will pay 15% or prescription drug costs. Maximum per child per year co-payments is $500.

Families with higher annual household incomes also qualify, but there is a substantial increase in monthly premiums.

All Kids is open to all children under the age of 19, including undocumented children and state employees’ children, who are currently not eligible for KidCare. Advocates predict that All Kids will cast a broad net and enroll hard-to-reach children who qualify for KidCare, but whose parents have not applied because of doubts about their eligibility.

All Kids will be funded through Illinois’s application for a Federal Medicaid Waiver. Hopefully, this plan will shift an estimated 1.6 million beneficiaries enrolled in KidCare, Family Care and traditional Medicaid into a primary-care case management program (Medicaid managed care). This plan also incorporates disease management for the chronically ill into public programming. The estimated savings is $56 million in the first year.

On October 19, 2005, the Centers for Medicaid and Medicare Services (CMS) approved a Section 1115 waiver. With this, Florida reshaped their role from health care centralized decision maker, creating and managing health care services, to a purchaser of health care services, responsible for ensuring systems of care and delivery of quality services.

The premise of the Florida reform plan is increased market competition. This, they believe, will inspire innovation, efficiency in Medicaid coverage, as well as patient responsibility and empowerment.

1. Private-sector health care provider networks will be allowed to create benefit packages that cater to the needs of Medicaid recipients. Participants choose the plan that best meets their needs with the help of their "choice counselor";
2. The State will pay provider networks a monthly, risk-adjusted premium per patient;
3. Medicaid participants will be allowed to opt-out of Medicaid plans and use their state-paid premium to purchase employer-sponsored insurance;
4. Participants will be able to earn enhanced benefits, to be placed in flexible spending accounts, by participating in healthy practices and making responsible lifestyle choices. These benefits will give participants extra funds with which to purchase health care services not covered by their plan; and
5. Providers will be free to compete for the membership of participants by offering innovative care, convenient networks, and optional services.

Currently, two-thirds of Florida’s Medicaid recipients are served through the traditional fee-for-service program. The waiver will initially be implemented as a pilot in Broward and Duval counties and will require participation by disabled adults, parents and pregnant women (incomes below 23% of FPL or approximately $300 per month for a family of three) and children (age 0-1 under 200% FPL, age 1-6 under 133% FPL and 6-21 under 100% FPL). The program will be phased in over five years to other counties in Florida and will begin on July 1, 2006.

A common thread relayed throughout the testimonies was: a "one size fits all" model does not seem to work for New York State. To realize the goal of affording all residents with a financially reasonable and accessible health insurance coverage, we need to find programming actually reducing the number of the uninsured while  recognizing present stake holding groups. Moreover, it became clear the political and regulatory environments in each State are unique.

     New York has made trailblazing strides in health care through the implementation of its special programs. There is, however, cause to investigate the additional health insurance concepts emerging in other states. It is important we stay informed and current to each state’s developments and the respective successful strategies and sub-strategies employed in reducing the size of  their un-insured population.