Designing health insurance market constructs for shared responsibility: insights from California.

Moving toward universal participation in health insurance using a "shared responsibility" approach requires new, more accessible, and more efficient ways for people who are not offered employer coverage to obtain coverage. California's recent health reform plan-which failed to pass-incorporated individual market reform and choice-pool constructs to achieve critically important risk spreading, assure solvency, and reduce cost shifts. These measures, as well as the considerations that led to their design, offer important insights for health reform at the federal level.

Affording shared responsibility for universal coverage: insights from California.

This paper presents key insights from California's recent experience in developing a plan for universal health coverage with "shared responsibility" among individuals, employers, and governments. A major challenge was finding an acceptable balance among the goals of affordability, equity, and cost to the state. Although reform did not pass, the state's approach-particularly differences from Massachusetts regarding modest-income workers and related employer and public roles-provides important insights for federal reform.

Insuring Californians: a proposal that matters.

The basic provisions of the proposal by George Halvorson and colleagues provide a realistic way for many states to afford coverage for their uninsured residents. In this commentary we suggest some modifications to achieve a more viable plan.

Use of subsidies to low-income people for coverage through small employers.

If tax credits or other public subsidies are made available only for health insurance that is not employment-based, serious erosion of employer coverage could result. To prevent this, public subsidies targeted to low-income workers and families could be applied in ways that broaden employer coverage for low-income workers and their families by encouraging small employers with largely low-wage workforces to offer and partially fund health coverage for their workers. To accomplish this, such employers--very few of which now provide health coverage--must be allowed to contribute much less than normally required in the commercial market.