Nebraska's Insurance Purchasing Group Project

The proportion of United States citizens without health care coverage continues to increase. By 1997, more than 16% of the population, or 43 million people, were without coverage. Persons least likely to have health coverage are persons employed in small businesses, the self-employed, and/or low-wage workers (Monheit & Vistness, 1997).

In 1994, Nebraska enacted the Small Employer Health Insurance Availability Act (LB 1222), which allows at least 25 individuals to voluntarily band together for the sole purpose of purchasing insurance. The formation process requires the group to meet certain legal requirements before soliciting a bid from a health insurance company or health care provider.

The initial response to LB 1222 was somewhat disappointing in that no groups had formed by late 1995. Those closest to the legislation felt an education and outreach effort was needed to help establish one or more groups that could be used as a "model" for others. Nebraska Cooperative Extension, in partnership with the University of Nebraska Medical Center (UNMC) and the Nebraska Departments of Health and Insurance, took the lead in developing and implementing such a strategy.

Phase One of the Project

Cooperative Extension and the Nebraska Department of Health provided $5000 each to initiate the project. A seven-person steering committee was established and began meeting in the summer of 1996. This committee included representatives from the four sponsoring agencies plus two Nebraskans who had been active in health issues at local and state levels and had worked closely with the University of Nebraska. Cooperative Extension's representative convened the committee and implemented the resulting plan. Committee deliberations focused on various educational, promotional, outreach, and technical assistance strategies.

The educational and outreach strategy developed by the committee involved three components: awareness, educational follow up, and organizational development.

Funds were used to develop and pay for "advertisements" with radio stations whose aggregate coverage area included much of rural Nebraska. Initial airing of these advertisements was for two days per week over a three-week period. These ads included an 800 number that interested persons could call. A second round of radio advertisements focused on those areas and stations from which relatively few calls had been received in the initial blitz.

Although these paid radio advertisements were the primary vehicle used for the awareness phase, "gratis" radio and television programming produced by Extension and UNMC were also used. Additionally, a 13-minute videotape containing the 800 number was developed by Cooperative Extension for use with civic organizations and for other opportunities that might arise to heighten the awareness of LB 1222.

The 800 number that interested persons could call was answered by a recorded message asking the caller to leave his or her name, address, and phone number. Within one week of each call, a follow-up mailing was sent that included a personally addressed letter and an Extension publication focusing on general information about LB 1222, how to form groups, etc.

Each call received was logged onto a map of Nebraska to determine which geographical locations would likely have the needed critical mass of interest to generate an insurance purchasing group. An area in Northeast Nebraska was selected in fall 1996. The local Extension Educator took responsibility for bringing together those interested in forming an insurance purchasing group. An Extension Specialist and personnel from the Nebraska Department of Health supported the Educator's efforts.

Project Transition

Unfortunately, the retirement of the local Educator, coupled with the resignation of the resource person provided by the Department of Health, occurred at a critical time, and the momentum for the project slowed. Fortunately, the basic value of the three-part strategy had already been validated.

The leadership for the project then migrated to one of the citizen advocates on the initial steering committee. In late 1997, this person secured $50,000 for follow up and expansion of the initial effort. Two groups, one in Western Nebraska and another in Central Nebraska, began to work toward the formation of insurance purchasing groups. Merging into one group for purposes of obtaining a lower bid with a larger group remained a possibility. Extension continued to be involved in an educational support role and in evaluating the first phase of the project.

Successes and Implications

The project provided an example of the role Extension can play in health policy issues. Other lessons learned included the following.