Federalism, intergovernmental relations, and the challenge of the medically uninsurable: a retrospective on high risk pools in the states.
Abstract: While relatively overlooked in health policy research and analysis, state high risk insurance pools play a notable role in contemporary health policy arrangements. Also know as State Comprehensive Health Insurance Plans, high-risk pools emerged in the late 1970s as states began to grapple with the challenges of the medically uninsured. Today, thirty-five states operate these programs. To further our understanding of health and human services administration, it is important to examine these plans, especially in context of intergovernmental health policy in the United States. This analysis provides an overview of high risk pool evolution and gives attention to forces that have shaped their development, such as model legislation, funding arrangements, and increasing federal-level interest in their use as platforms to advance national policy initiatives.
Subject: Administrative agencies (Health policy)
Administrative agencies (Services)
Health insurance (Analysis)
Health insurance industry (Management)
Author: Plein, L. Christopher
Pub Date: 09/22/2010
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2010 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Fall, 2010 Source Volume: 33 Source Issue: 2
Topic: Event Code: 970 Government domestic functions; 360 Services information; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 6322000 Medical Care Insurance; 6320000 Accident & Health Insurance NAICS Code: 524114 Direct Health and Medical Insurance Carriers; 5241 Insurance Carriers SIC Code: 6321 Accident and health insurance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033478

Since the late 1970s, various state governments have supported programs that provide health insurance coverage for those who would not otherwise be able to obtain or afford health insurance due to "high-risk" medical conditions. These high-risk pool programs--also known as State Comprehensive Health Insurance Plans--have largely been overlooked in both popular and academic discussions and reviews of health policy and programming in the United States. To more fully understand health policy and administration in the United States, it is necessary to place these programs in context and to understand their origins, their functions, and their influence on health coverage and insurance reforms. As an introduction to high risk insurance programs, this article has two purposes. The first is to describe and document these little known programs that have largely been unexplored in the public administration and health policy literature. The second purpose is to outline some of the current as well as possible federal and state intergovernmental dynamics relating to high-risk insurance pools.

Specifically, this analysis explores: 1) how high risk pools evolved into a public policy function in state government, 2) how state-level policy reforms are informed by national professional associations that provide guidance through model legislation and through informal networks of consultants and contractors, 3) the numerous funding mechanisms used for pool funding that reveal state variation amidst otherwise common program design, and 4) how high risk pools have come to be seen as platforms to implement federal policy. From a broader theoretical perspective, the high risk pool insurance experience points out the need to further study health policy diffusion in circumstances where there has been an absence of catalyzing federal law and funding to initiate policy adoption.


Health insurance in the United States consists of a mix of programs and approaches utilizing publicly-supported programs, such as Medicare and Medicaid; group or employer-based private insurance, such as that provided by private insurance carriers; insurance plans offered directly by employers; and various individual coverage options offered by private insurance carriers. Various observers have discussed the fragmented nature of health insurance in the United States, noting that it has evolved with no particular design in mind (Starr, 1982; Frakt et al., 2004; Quadagno, 2005; Gawande, 2009). In recent decades, there have been frequent calls for reform and action to bring order to the system. The 2008 presidential election was shaped, in part, by health care reform and it has become a prominent feature in the Obama domestic policy agenda. Current and past reform efforts share common concerns that the nation's health insurance system is inefficient, expensive, demanding on public finances, and ineffective in providing for the health coverage needs of many.

Based on various estimates, the number of uninsured in the United States hovers at about 45 million, representing approximately 15 percent of the population (National Association of Comprehensive Health Insurance Programs, 2007: 26). Of these, approximately one million are "medically uninsurable" because of preexisting health conditions (Frakt et al., 2004: 74; America's Health Insurance Plans, 2004). For these high-risk individuals, health insurance may not be available or may be too expensive--especially in the non-group or individual insurance market.

In an uncoordinated system of public and private insurance coverage, it is inevitable that individuals will fall "between the cracks" finding it difficult, if not impossible, to obtain health insurance. Cost is often the major barrier to health insurance access. Without an employer or other group-based plan to participate in--the individual carries the full burden of a premium. Case-by-case underwriting is often practiced. As noted by the National Association of State Comprehensive Health Insurance Programs (2007: 7), "Because of the voluntary nature of the health insurance market, individual health insurers require medical screening as part of the application process. They reserve the right to reject, rate-up, or impose exclusions for individuals who have pre-existing medical conditions." Obviously, this can prove problematic for those seeking health insurance in the individual private insurance market. There is little interest in underwriting those deemed to be high-risk. Since the 1970s, the challenges of providing affordable health insurance has increased given the decline of employer-based insurance coverage and the higher costs associated with health care associated with medical advances that allow for treatment of acute medical conditions and the maintenance of chronic conditions that extend life-expectancy (Bovbjerg and Koller, 1986; Quadagno, 2005).

As is often the case in American federalism, the first answers to this problem emerged in the states. Minnesota and Connecticut were the first to adopt high-risk pools to cover the uninsurable. The Minnesota Comprehensive Health Insurance Association was chartered in 1976 as a non-profit organization. Its organizational structure, utilizing a board of directors drawn from insurance, health, and consumer interests, became a template for others to follow. Its program design elements, including the definition of benefits and coverage, the structure and pricing of premiums, and the utilization of assessments and other funding mechanisms to cover program losses proved influential as well (Bovbjerg and Koller, 1986: 112-115; Sumner et al., 1997: 361; Gruber, 2007: 5).

The early high-risk pools operated with oversight from state insurance commissions or their equivalent, yet maintained a great deal of autonomy and independence (Communicating for Agriculture, 2004:12-13). These programs were largely self-funded through assessments placed on insurers and self-regulated by members of the insurance industry. Over time, high-risk pools moved toward arrangements that were more tightly integrated with public authority and funding. Most were established as, or became, public or quasi-public entities that relied on a combination of public funding and premium payments for support. By the late 1980s this state-led approach was the norm (Bovbjerg and Koller, 1986: 112,116). These arrangements characterize most plans today.

As of 2009, thirty-five high-risk insurance pools had been established in the states. Total national enrollment averaged 197,000 in 2007. Enrollment was as small as 439 in West Virginia to as high as 29,188 in Minnesota (NASCHIP, 2008: 31). Plans are found in large states, like California and Texas, as well as states that are small and rural, such as South Dakota, North Dakota, and West Virginia. They are found in traditionally progressive states, such as Minnesota, and those known for more conservative political cultures, such as Mississippi and Alabama.

The adoption and diffusion of these programs has been gradual. The first programs emerged in the late 1970s. By 1990, there were fifteen plans in operation. By 2000, the number of states operating high risk pools had grown to twenty-seven. In addition to the 35 states that now have plans, others are considering adopting high-risk pools. In Ohio, high risk pool legislation has been introduced. In Georgia, New York, Rhode Island and Vermont feasibility studies have been authorized or undertaken (NASCHIP, 2008: 19, 93, 190, 220, 249). The table below identifies those states that currently have high risk pools.


It is common for the federal government and the states to share in the funding and administration of publicly-supported health insurance programs. This is exemplified by such programs as Medicaid and the State Children's Health Insurance Program (SCHIP). It is also common for the federal government to be the lead partner in these arrangements--providing the bulk of funding and setting the legislative and regulatory parameters for program operation. In this intergovernmental dynamic, the conventional model of program development is that a few states, acting as "laboratories of democracy," serve as trail blazers in advancing new initiatives. Once adopted in whole or in part at the national level, the federal government dominates and sets priorities and practices through its fiscal and regulatory power. Policy adoption and diffusion across the states then follows. Under federal law, states are tasked with program implementation and are given some leeway in administration. They are also expected to help pay for program operations. From this foundation, new innovations at the state level and new mandates from the federal level lead to program growth and change. This experience epitomizes the evolution of Medicaid and helps to explain why it has grown from a program with limited purposes to a major feature of the American health care system (Brown and Sparer, 2003). Brown and Sparer (2001) refer to his push-pull relationship as "catalytic federalism." In the realm of health and human services administration, the State Children's Health Insurance Program and welfare reform under the Temporary Assistance for Needy Families Block Grant, also fit neatly within this framework.

Another common dynamic follows the passage of national legislation creating a program is that a set of policy purposes, program design elements and fiscal arrangements cohere around the statute and resulting federal regulations. These then set the conditions of policy adoption and diffusion by placing limits on state discretion. As the SCHIP experience illustrates, for example (Brandon et al., 2001; Plein, 2004; Vogen, 2006; McGrath, 2009), considerable variation in implementation can still occur within such frameworks. But to participate in these new arrangements, states must follow templates and adhere to a pace of diffusion that is set largely by the federal government.

The experience with high-risk insurance pools is altogether different. Federal involvement has been minimal and policy diffusion has happened gradually. Two factors likely account for this. First, the origins of high risk pools are found in self-governing alliances of insurers operating under nominal state control. Thus, their origins are market-based rather than the product of public policy. Second, regulation of the private health insurance market has traditionally been the domain of the states. This has long been a complicating factor in efforts to push for health reform at the national level and helps to account for the fragmented health insurance system in the United States.

The lack of federal direction and the slow evolution and diffusion of high-risk pools might lead one to conclude that these home-grown plans are highly variable and diverse. Yet the opposite seems to be the case. While there is some significant variation in the manner in which these programs are funded, their basic design elements in terms of governance, administration, and the benefits provided are very similar (Gruber, 2007). This coherence can be accounted for, in part, by the presence of a strong national association of high risk plans that has provided model legislation and policy guidance to the states.

The organization of state interests around professional or program themes affords such groups a level of shared knowledge, legitimacy, visibility, and authority in the policy arena (Gormley and Balla, 2004: 106-107). The National Association of State Comprehensive Health Insurance Plans (NASCHIP) was formed in 1993 and represents high risk pool plans across the United States. Comprised mainly of executive directors of state-sponsored high-risk pools, it has forged alliances with other stakeholders, most notably another public officials group, the National Association of Insurance Commissioners.

One of the key roles that professional organizations play is to offer and refine model legislation that can assist states in policy development. NASCHIP promotes model legislation for high-risk pools that has been developed by the National Association of Insurance Commissioners (NAIC). As amended and revised over time, it has become the "gold standard" by which plans are judged and endorsed by other key players in the health policy arena. This model act is recognized by leading trade groups in the insurance industry (see, for example, America's Health Insurance Plans, 2004; Communicating for Agriculture, 2004). Perhaps most significantly, standards and specifications spelled out in the model legislation are now identified by federal law as key criteria for designating and qualifying high risk pools for federal support and for their use in implementing new federal initiatives.

Other factors reinforce program consistency across the United States. National level consulting firms have helped a number of states design their programs. In many states, non-governmental, third party administrators are contracted to take care of the day-to-day and technical aspects of program implementation. The model legislation actually calls for the selection of "a plan administrator through a competitive bidding process to administer the plan" (Communicating for Agriculture, 2004: 278). In every state except South Dakota and West Virginia, third-party administrators operate high-risk pool programs. And even in these two states, key support services are provided by contractors. Firms have emerged to specialize in high-risk pool administration and have multiple states as clients (NASCHIP, 2007: 10). Thus, consultants and contractors have helped to harmonize plan structures across the United States.

While plans are similar, they are also different. The greatest variation is found in the way that plans are funded. All plans require that members pay a premium--but this is subsidized or off-set by other sources of funding. By design, high-risk pools cannot sustain themselves on premiums alone. Doing so would make them unaffordable for members and would defeat their purpose. Thus premiums do not reflect "true" actuarial costs. Setting premiums too high will limit enrollment, while setting premiums too low will cut into the private insurance market and will pose the threat of debilitating program losses. The model act suggests that premiums be set between 125 and 150 percent of the prevailing average premium or "standard risk" rate in the individual insurance market. This provision has been incorporated into statute in many states.

In 2007, on average, the premium loss ratio was 161 percent in state high risk pools (NASCHIP, 2008: 39). There are three basic supplementary funding mechanisms used by states to offset losses. Their use highlights state variability in high-risk pool operation. The first mechanism is to assess insurance companies operating within the state. This is by far the most common approach and is found especially in those states that were early adopters of high-risk pools. Seventeen states utilize this approach exclusively and others use this as one source of funds in a mixed revenue system. The second approach is to allocate revenue from state general revenue and special funds, such as tobacco taxes and premium taxes. Three states rely exclusively on this type of funding. A third approach is to levy assessments on health care providers, and only two states do so exclusively. It is now common for states to use a blended approach utilizing two or more funding streams. A total of thirteen states use the blended approach (NASCHIP, 2008: 16-17). Regardless of funding mechanisms, some states have found it difficult to maintain fiscal stability and as a result have had to place caps on enrollment or benefits.

Choice of funding mechanisms is no doubt a function of politics, economic capacity, and the structure of the health and insurance industry. In the states that first adopted high-risk pools, such as Minnesota and Connecticut, plans built on funding mechanisms already in place with reinsurance pools. The practice followed a traditional pattern of self-regulation within the insurance market. As the concept evolved as a means of addressing the needs of the uninsurable, traction gained for shared burden. Thus, states like Illinois, California, Colorado, Tennessee, and Louisiana have looked to multiple funding mechanisms to share responsibility and accountability across the health system and taxpayers.


Scholars have long noted that policy development in the United States often involves incorporating new policies into existing program and administrative structures. This practice helps make policymaking incremental and helps define the role of intergovernmental relations in policy design and implementation (Robertson and Judd, 1989; Stephens and Wikstrom, 2007). This dynamic is characteristic of health policy in the United States--especially as it relates to the development of publicly-funded health insurance programs. For example, Medicaid was created in 1965 as an amendment to the Social Security Act of 1935. Its implementation was delegated to existing state welfare and human services programs (Brown and Sparer, 2003). More recently, the State Children's Health Insurance Program (SCHIP), another amendment to the Social Security Act, increased insurance coverage to children in low-income and working families largely through the auspices of existing state administrative structures (Plein, 2004).

In recent years, there has been a move to use state high-risk pools as platforms for implementing new federal initiatives. This is a major development in the evolution of high-risk pools. In this regard, two of the most important developments involve the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Coverage Tax Credit (HCTC) established in the Trade Adjustment Assistance Reform Act of 2002.

The Health Insurance Portability and Accountability Act sought to tighten-up protections for those receiving insurance through group or employer-based insurance programs. In a more limited way it was also aimed at addressing concerns about underwriting practices in the individual insurance market. The Act sought to mitigate discrimination, unfair pricing, or denial of insurance to those currently or recently enrolled in an insurance program. Specifically, the purpose was to protect individuals from losing insurance as they moved from one job to another, or when they could no longer access group or employer-based coverage due to a change in employment status (Health Care Financing Administration, 2000: 6-7). To ensure insurance "portability" from one plan to another, states were mandated to establish "guaranteed issue" protections requiring individual insurance providers to offer access to their products. In the parlance of the Act, those offered such protection were known as "HIPAA eligibles."

While some states opted to regulate insurers under the guaranteed issue provision, others elected to utilize a federal option allowing for "state alternative mechanisms" as substitutes. High-risk insurance pools were quickly identified as such an alternative. Under HIPAA requirements, these plans had to meet key provisions of the NAIC model legislation to qualify (NASCHIP, 2007: 8). Not only did this validate the importance of the model legislation, it also signaled federal recognition that high risk pools could be used to advance national policy goals at the state level.

By 1996, there were 23 state pools in operation. Initially all but five states elected to use their plans as the alternative mechanism. Since then, almost all plans have incorporated provisions to allow for HIPAA eligible enrollment. By 2008, thirty-four state pools were designated as alternative mechanisms (NASCHIP, 2008: 45). While HIPAA did not necessarily lead to an acceleration of plan adoption, it did motivate the development of plans in Texas and Alabama (Frakt et al., 2004: 75; NASCHIP, 2007: 50-51). Indeed, Alabama is the extreme case in that its plan exists solely for HIPAA eligibles.

States had two incentives for relying on high risk pools to meet the federal guaranteed issue mandate. First, regulating the individual insurance market posed practical challenges. While HIPAA mandated guaranteed issue it did not impose any controls or limits on premium setting or underwriting practices in the individual insurance market. Thus, HIPAA eligibles might have nominal access to insurance, but there was no guarantee that policies would either be affordable or comprehensive. Second, for actuarial and economic reasons, HIPAA eligibles were seen as beneficial to the pools. This group does not fit the traditional profile of high-risk pool enrollees. They are seen as good risks and as premium paying customers, they help to minimize overall risk to the pool and enhance revenue bases.

While many states used high-risk pools as the alternative mechanism, overall participation by HIPAA eligibles has varied. The high premiums charged by state plans pose a barrier to participation. This has led to recommendations that states consider lowering premiums to bolster enrollment (Frakt et al., 2004). To date, six states have pursued this approach (NASCHIP, 2008: 33). Available data from two of these states illustrate that HIPAA eligibles now make up a considerable part of the enrollment base. In Illinois, HIPAA eligibles make up 65 percent of the state's pool (NASCHIP, 2008: 105). In Montana, HIPAA eligibles make up 47 percent of the state's pool (Montana Comprehensive Health Association, 2008: 5).

Over the past decade, federal interest in high-risk pools has deepened. In 2002 and again in 2006, states were further encouraged to accommodate HIPAA eligibles in their high risk pools when federal monies were provided to assist in off-setting program losses. Federal funds were also appropriated to encourage proactive enrollment efforts. In 2002, the Trade Adjustment Assistance Reform Act established a new Health Care Tax Credit (HCTC) that could be applied to high-risk insurance premiums by qualified individuals.

The HCTC is offered to those who have lost their jobs due to foreign competition or whose failed pension plans and health benefits have been taken over by the Federal Pension Guarantee Benefit Corporation. Those who have lost pension benefits are the most likely candidates for high-risk pool enrollment. They tend to be older and more likely to have preexisting conditions. In addition, they are likely looking for a "bridge" to Medicare coverage which starts at age sixty-five. The HCTC is quite generous. It provides a 65 percent tax credit on every dollar spent on a health insurance premium. Unlike many other tax credits, the benefit can be applied prospectively so that the up-front costs to policy holders is 35 percent of the premium--the IRS pays the difference (Communicating for Agriculture, 2004: 21).

Although now in operation for close to seven years, the HCTC remains largely a niche segment for state high-risk pools. Twenty-three states have designated their high-risk pools as eligible for HCTC participation (NASCHIP, 2008: 41). Doing so requires states to ensure that they will not discriminate in premium rates between HCTC and non-HCTC participants. This provision is in place due to concerns that states might "cost shift." That is, they would adjust upward the premiums for HCTC eligibles--knowing that 65 percent of the cost would be borne by the federal government--while holding down premiums for non-HCTC eligibles. Because some states seek flexibility in rating differently among eligibility groups, twelve states have opted not to enroll HCTC eligibles.

Until recently, state high-risk pools operated largely outside of the dynamics of the intergovernmental health policy arena. The past decade has seen greater federal interest and involvement in the affairs of these programs. With 35 states now participating, high-risk pools are prevalent enough to be used as a tool for federal program implementation. They have come to be seen as platforms to operate new health policy reforms aimed at addressing issues of insurance portability and affordability among select groups of individuals. In turn, these initiatives have helped to further shape state high-risk pools.


The evolution of high risk pools has been a state-centered phenomenon. This stands in contrast to the development and evolution of other publicly-sponsored programs, such as Medicaid and SCHIP, that coalesced around federal priorities and funding. With minimal federal involvement, high risk programs have evolved largely within and among the states. Model legislation and national associations have helped to guide state action. At the same time, individual states have grappled with funding issues associated with high-risk pool operations. Recent federal interest in using high-risk pools as platforms for policy implementation has also led to new intergovernmental dynamics.

Demand for coverage and fiscal constraints makes it increasingly difficult for states to maintain high-risk pools. Some states have capped or closed enrollment due to fiscal stress, including Florida and California (NASCHIP, 2008: 14, 68). While all plans rely on premium revenue, each also is dependent on other sources of funding. It is in the mix of funding sources that we find the greatest variation among the states. Politics, markets, and state fiscal capacity come to bear on the type of funding mechanisms used in the respective states. All programs now rely on some level of public funding thus making them more accountable to public authority.

States also face the practical concern of program affordability. A common criticism leveled against high risk pools is that premiums are too expense and are thus poor public policy (Sumner et al., 1997; Achman and Chollet, 2001; Chollet 2002; Pollitz and Bangit 2005). Typical of this long-standing criticism is an early analysis of high-risk plans that noted, "low enrollment and high costs are the main problem of pools" (Bovbjerg and Koller, 1986: 118). As health costs increase, so too do private insurance premiums. Since high risk pool premiums are indexed to the standard risk rate in the individual insurance market, they are legally mandated to follow these benchmarks that have risen over time. In order to address this, some states discount or subsidize premiums. Currently 13 states have means-tested premium schedules that help hold down individual cost (Sack, 2008). In addition, NASCHIP and its allies have largely embraced and welcomed consideration of how premium subsidies, more integrated models of health care delivery and case management, and broader funding mechanisms that tap into general revenue pools to share program costs across society and economy can be adopted (Gruber, 2007; America's Health Insurance Plans, 2004).

Recent federal interest in high-risk pools has helped change the intergovernmental dynamic. Fiscal federalism plays a role in this change. To date, direct federal funding has played a minimum role in the operation of high-risk pools. Since 2002, the federal government has allocated approximately $45 to $50 million a year to help off-set program losses in the states. This is only a small portion of total program costs across the states which in 2006 totaled over $1.73 billion (NASCHIP, 2007: 34). However, when combined with the influence of HCTC and HIPPA provisions on high-risk pool operations, the presence of the federal government becomes more apparent. As such, federal regulatory authority has begun to extend its reach into program operations by mandating that certain services, premium pricing structures, and other attributes conform to federal standards associated with these laws. By extension, this has an economic effect by creating new eligibility groups to enroll in high-risk pools.

Most significantly, there is growing interest in using high-risk programs as platforms for federal policy implementation. For example, in July 2003, the National Conference of State Legislatures (NCSL) issued a position statement on "State Health Care Cost Containment Ideas." Among it recommendations was a reinvention of high-risk pools to allow costs to be more evenly spread across stakeholders while at the same time expanding coverage to the uninsured. The statement further noted that expanding eligibility and coverage would broaden the base of political support for such plans which in turn would lead to lower premiums, a more actuarially sound enrollment base, and public support for subsidy programs for low-income individuals (NCSL, 2003: 22).

During the 2008 presidential campaign, Republican nominee John McCain's health care reform plan gave high risk pools a prominent role in remedying the problem of the uninsured (Sack, 2008). In 2009, President Obama identified high risk pools as part of the solution as well. He gave Senator McCain credit for this idea in a bid to win bipartisan support for the White House's healthcare reform initiative. Through the summer and fall of 2009, high-risk pools were incorporated into both the major Senate and House bills focusing on health insurance reform. Proposed legislation calls for high risk pools to be used as bridge to new insurance system that would prohibit pre-existing exclusions, discriminatory underwriting, and other practices that have given rise to the medically-uninsured. Both bills call for five billion dollars to be set aside to fund high-risk pools. The legislation also provides for existing state pools to carry out this new federal initiative (Senate Finance Committee, 2009; "Affordable Health Care for America Act," 2009). The final health care legislation passed into law in 2010 incorporates these provisions.

Beyond the practical and immediate questions and issues raised by the place of high risk insurance pools in health and human services administration in the United States, their presence offers opportunity for further analysis and theory building regarding intergovernmental relations and program management. The high risk insurance pool experience may shed new light on the manner in which health and human services policies are diffused and adopted throughout the United States--especially where the federal government has played a minimal role in program development and diffusion. The largely decentralized and autonomous nature of high risk pool development and evolution reflects how program design and purpose can cohere around a set of principles and practices that are shared by the states.

Recent experience also reveals how dynamics can begin to change once the federal government takes an interest in established state plans as platforms for new policy innovation. Given the current policy context where health care reform figures prominently, this interest and relationship may further intensify and make high-risk pools a more prominent feature in the health policy landscape. The politics, policy, and administrative structures that surround high-risk pools are worthy of our attention in political science and public administration. In their own right, they highlight the importance of niche programs that provide incremental responses to larger policy concerns. They also highlight subtleties in American federalism and intergovernmental relations that warrant further review and investigation.


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West Virginia University
States with High Risk Insurance Pools (As of 2009)

New Hampshire
New Mexico
North Carolina
North Dakota
South Carolina
South Dakota
West Virginia

Source: NASCHIP, 2008, pp. 14-15.
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