GET "HIP" AMERICA: USING THE "HEALTHY INDIANA 
PLAN" AS A MODEL FOR DECREASING THE NUMBER OF 

UNINSURED AMERICANS ONE STATE AT A TIME 

Barbara E. Molargik:-Fitch * 

I. INJR.ODUCTION ................................................................................. 58 
A. The Issue .................................................................................... 59 
B. The Roadmap ........... .................................................................. 60 

11. BACKGROUND AND FEATURES OF THE HEAL THY INDIANA PLAN ... 60 
A. The Passage and Objectives of HEA 1678 ....... .......................... 60 
B. Details of HIP ............................................................................ 62 

1. Qualif.yingfor HIP ............................................................... 62 
2. Funding HIP ........................................................................ 63 
3. HIP'S Coverage .................................................................. 65 

a. High-Deductible coverage ............................................ 65 
b. PO'WER Account ........................................................... 66 
c. Preventative health care ............................................... 66 

4. HIP's Insurers ..................................................................... 67 
5. The Buy-In Option ............................................................... 68 

III. HIP'S MODEL OFFERS A MORE SUSTAINABLE ROUTE THAN 

NATIONAL HEALTH CARE PROPOSALS TO ACHIEVE THE GoAL OF 

INSURING MORE AMERICANS ........................................................... 69 
A. The National Health Care Plans ................................................ 69 

1. The United States Insurance Act of 2008 ............................ 69 
2. The Obama Reform Bill ....................................................... 70 

B. HIP's Unique, Realistic and Sustainable Nature ....................... 72 
IV. HIP IS A MODEL FOR MANY OTHER STATES STRUGGLING TO 

INSURE THEIR CITIZENS ................................................................... 73 
A. HIP is a Model for Other States ................................................ 73 
B. Unsuccessful State Plans ........................................................... 74 

1. The California Plan ............................................................. 74 
2. The Wisconsin Plan ............................................................. 75 
3. The Massachusetts Plan ...................................................... 75 
4. The Washington Plan .......................................................... 77 
5. The Maine Plan ................................................................... 78 

C. Plans Similar to HIP and Based on Individual Choice and 
Market Competition ................................................................... 79 
1. The Florida Plan ................................................................. 79 
2. The Georgia Plan ................................................................ 80 

D. HIP Offers Something to Build On ............................................ 81 

* J.D. candidate, 2010, Indiana University School of Law-Indianapolis; B.A., 2007, 
Indiana University-Bloomington. 



58 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

V. ON-SITE HEALTH CARE CLINICS OFFER ADDITIONAL MEANS FOR 

INSURING MORE AMERICANS BY DECREASING THE COSTS STATE 

GoVERNMENTS MUST PAY IN HEALTH CARE EXPENSES ................. 82 
A. Novia Careclinics,LLC. ("Novia''), Indianapolis, Indiana ....... 83 
B. CareHere, UC., Central Tennessee .......................................... 85 

VI. CONCLUSION ..................................................................................... 86 

"I ... hope other states will follow Indiana's model 
of combining personal responsibility with public sup­
port to help those who are truly in need gain health 
coverage. "1 

-U.S. Department of Health and 
Human Services Secretary Mike Leavitt 

I. INTRODUCTION 

One August afternoon Ms. Tammy Chandler carried her fifteen-day­
old son to the Ambulatory Care Center in Huntsville, Alabama for a check­
up.2 While at the care center, Ms. Chandler was instructed to take her new­
born infant to the hospital for emergency care immediately.3 Upon arriving 
at the hospital, the uninsured, distressed mother "was asked if she had either 
insurance or $54 for the emergency room admission fee.'"' Ms. Chandler 
had neither. As a result of her indigence, Ms. Chandler was told that her 
son could not be seen. 5 A nurse at the hospital instructed her to go home 
and to give her sick infant Tylenol and a warm bath. 6 Later that evening, 
however, Ms. Chandler returned to the hospital, once again, with her se­
riously ill child.7 Three hours later the infant was finally seen by a doctor. 
Unfortunately, because of the delayed medical treatment, the infant died 
from spinal meningitis the next day.8 Spinal meningitis, "an inflammation 
of the membranes that cover the brain and spinal cord," is a potentially fatal 
disease if not immediately treated with ingestion of antibiotics.9 

1. Press Release, U.S. Dept. of Health & Human Services, HHS Approves Medicaid 
Waiver to Create New Indiana Health Plan for Uninsured Hoosiers (Dec. 14, 2007), availa­
ble at http://www.dhhs.gov/news/press/2007pres/12/20071214a.html (hereinafter "Press 
Release") 

1989). 
2. Chandler v. Hospital Authority of City of Huntsville, 548 So. 2d 1384, 1385 (Ala. 

3. !d. 
4. 1d 
5. ld 
6.·ld. 
7. Id. 
8. Chandler, 548 So.2d at 1385. 
9. U.S. Dept. of Health & Human Services, Centers for Disease Control & Preven­

tion, Meningitis Questions & Answers, http://www.cdc.gov/meningitis/about/faq.html (last 



2010] GET "HIP" AMERICA 59 

A. Thelssue 

The issue of health care coverage locally and nationally is not new. In 
2007, over 717,000 of Indiana's 6.26 million Hoosiers were without health 
insurance.10 The Healthy Indiana Plan (''IllP") was created to address the 
issue of health care coverage in Indiana, especially with regard to low in.;. 
come individuals like Ms. Chandler. IllP is vital for Indiana citizens, espe­
cially during times of economic downturn when Indiana citizens are losing 
health care coverage, particularly employer-sponsored health insurance. 
The percentage of Hoosiers covered by their employers'. health care plans is 
dropping substantially. In fact, employer-sponsored health care plans "cov­
ered 70.5 percent of Indiana's under 65 population'' in 2007.11 That was a 
substantial drop from the 75.7 percent employer-sponsored health care in 
2001.12 Moreover, in the past few years, the entire country has been expe­
riencing economic hardship. The number of people covered by employer­
sponsored health care in 2007 was 59.3 percent, which was a decrease from 
59.7 percent in 2006.13 "This continues a trend of decreasing employer 
sponsored coverage since 2000."14 Furthermore, many states are expe­
riencing a similar situation as in Indiana, where employers are eliminating 
health care plans. For example, in Minnesota fewer businesses provided 
health care coverage from 2001 to 2004, thus increasing the rate of unin­
sured residents from 5.4 percent in 2001 to 6.7 percent in 2004.15 Addition­
ally, looking at health care coverage overall, ten states had lower 2-year­
average uninsured rates for 2006-2007 than their 2-year-average rates for 
2004-2005.16 These states, along with their increase in uninsured,:include~ 
Kansas (+2.0), Kentucky (+1.6), Louisiana (+3.3), Mississippi (+3.0), Ne­
braska (+2.3), New Jersey (+1.4), New Mexico (+2.6), New York (+0.8), 
North Carolina (+2.1), and Texas (+0.9)!7 Many states could use IllP as a 
model to develop an affordable health care plan that will help insure niore 
of their citizens during this time of recession. 

visited Jan. 6, 2010). 
10. Daniel Lee, Fewer Hoosiers were Uninsured in 2007: Numbers Down Nationally, 

too; Experts Cite Expansion of Government Programs, THE INDIANAPOLIS STAR, August 27, 
2008, at B08. 

11. Report: Hoosiers Losing Health Insurance, GosHEN NEWS, Oct. 14, 2008, 
http://www.goshennews.com/archivesearcMocal_story_287105844.html (hereinafter "Los­
ing Health Insurance"). 

12. /d. 
13. Carman DeNavas-Walt, Bernadette D. Proctor & Jessica Smith, Income, Poverty, 

and Health Insurance Coverage in the United States: 2007, U.S. Census Bureau at 19 (2008}, 
available at http:/ /www.census.gov/prod/2008pubs/p60-235.pdf. 

14. Robert Wood Johnson Foundation, State Coverage Initiatives: Who's Uninsured? 
http:/ /www.statecoverage.org/node/18# _ ftn1. 

15. State's uninsured rate rises, m employers drop coverage, MlNNEAPousiST. PAUL 
Bus. J., Feb. 25, 2005, http://twincities.bizjoumals.com/twincitieslstories/2005/02/21 
/daily49.html. ' 

16. DeNavas-Walt, supra, note l3 at 26. 
17. ld. 



60 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

As explained herein, a realistic approach to substantially reducing the 
number of uninsured Americans nationwide is to offer health insurance 
coverage on a state-by-state basis which is based on market competition, 
personal responsibility, wellness, and public support, while also demanding 
a modest income-based premium. Such a plan makes it possible to insure 
more Americans while also being cost-efficient. If each state raises money 
to support its plan and crafts the plan to the very needs of its own citizens, 
like HIP, health care coverage for more Americans will be a more sustaina­
ble and affordable goal. Additionally, if each year states add new innova­
tive aspects to their state plans to save money each year, and if those states 
continue to build on their plans annually to make them better, more Ameri­
cans will be insured each year. On-site health care clinics, discussed in Par­
ty V of this note, exemplify an innovative feature which states may add to 
their health care plans and to their government agencies to save on health 
care costs. 

B. The Roadmap 

This Note discusses how HIP offers a health care model for other 
states struggling to provide health insurance for their citizens. In order to 
fully understand HIP's makeup and coverage, Section II of this Note dis­
cusses the background of HIP. Section III focuses on why HIP is a more 
sustainable model for decreasing the number of uninsured Americans than 
other federal health care plans that have been proposed or are currently be­
ing enacted. Section IV argues that HIP is a model for many other states 
that are struggling to insure their citizens by comparing HIP to state plans 
that have failed as well as state plans similar to HIP that are currently expe­
riencing success. Finally, Section V takes a step into the future and dis­
cusses how adding "on-site" health care clinics to state health care plans and 
state governments may offer additional means for insuring more Americans 
by decreasing the overhead costs state governments must pay out in medi­
cal-related expenses. 

II. BACKGROUND AND FEATURES OF TilE HEALTHY INDIANA PLAN 

A. The Passage and Objectives of HEA 1678 

HIP, also known as the Indiana Check Up Plan, was introduced and 
passed by the Indiana General Assembly in April 2007 as part of the House 
Enrolled Act No. 1678, Public Law 218-2007 ("HEA 1678").18 The stated 

18. Family and Social Services Administration, A Check Up on the Indiana Check-Up 
Plan: HEA 1678, slide 16 (Sept. 30, 2008) http://www.in.gov/fssalhip/files 
/IndianaCheckUpPlan.pdf (last visited April 8, 2010) (hereinafter "A Check Up"); Indiana 
House of Representatives House Democrats, Indiana Check Up Plan, http://www.ai.org 



2010] GET "HIP" AMERICA 61 

objective behind enacting HEA 1678 was to "advance health care policy in 
Indiana ... and [to] reduce the state's high rate of smoking."19 When con­
sidering the passage of HEA 1678, the Indiana legislature was encouraged 
to reform its health care policy because of the alarming fact that Indiana had 
the second highest drop in employer-sponsored health insurance between 
1999 and 2004.20 Since 1990, the uninsured population has increased by 
approximately 30 percent in Indiana.21 Additionally, Hoosiers had the 
second highest rate of smoking in 2008 (26% ), 22 eighteenth highest rate of 
obesity in 2008 (63.5%),23 and fourteenth highest rate of stroke and other 
cerebrovascular diseases in 2006 (49.0%).24 To address these problems, the 
legislature enacted HEA 1678 to provide for various health care policy im­
provements. 

Some of the health care highlights ofHEA include: 25 

• tax credits related to small employer qualified wellness pro­
grams; 

• an increase in cigarette tax by 44 cents per pack to fund vari­
ous health related expenses; 

• tax credits for employers for making a health benefit plan 
available to employees for the first two taxable years the 
health benefit plan available; 

• an increase in the income limit for Medicaid eligibility for 
pregnant women; 

• continuous eligibility of a child under Medicaid and the 
children's health insurance program (CHIP) until the child 

/legislativelhouse_democrats/indiana_checkup_plan.html (last visited Feb. 9, 2009). 
19. Governor Signs Healthy Indiana Bill, INSIDE INDIANA Bus., May 11, 2007, 

http://www.insideindianabusiness.com/newsitem.asp?id=23285. 
20. The Iowa Legislature General Assembly, The Healthy Indiana Plan House 

Enrolled Act 1678, slide 9 (2007) http://www.in.gov/fssa/hip/filesllndianaCheckUpPlan.pdf. 
21. Id. 
22. Kaiser Family Foundation-Statehealthfacts.org, Percent of Adults Who Smoke 

(2008) http://www.statehealthfacts.org/comparemaptable.jsp?ind=80&cat=2&sort=a (last 
visited Jan. 8, 2010). The Kaiser Family Foundation is a non-profit and private operating 
foundation that focuses primarily on the major health care issues facing the U.S. and abroad. 
"Kaiser develops and runs its own research and communications programs, sometimes in 
partnership with other non-profit research organizations or major media companies," such as 
NPR or the Harvard School of Public Health. Additionally, Kaiser "serves as a non-partisan 
source of facts, information, and analysis for policymakers, the media, the health care com­
munity, and the public." Kaiser Family Foundation, About Us, http://www.kff.org/about 
/index2.cfm (last visited Jan. 8, 2010). 

23. Kaiser Family Foundation-Statehealthfacts.org, Percent of Adults Who are Over­
weight or Obese (2009) http://www.statehealthfacts.org/comparemaptable.jsp?ind=89&cat= 
2&sort=a (last visited Jan. 8, 2010). 

24. Kaiser Family Foundation-Statehealthfacts.org, Number of Deaths Caused by 
Stroke and other Cerebrovascular Diseases (2006), http://www.statehealthfacts.org 
/comparemaptable.jsp?ind= 122&cat=2&sort=a. 

25. Legislative Services Agency, DIGEST OF HB 1678 (2007}, http://www.in.gov 
/appsllsalsessionlbillwatchlbillinfo?year=2007&request--getBill&docno=1678. 



62 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

becomes three years of age; 
.,. establishment of the Indiana check-up plan (plan) [aka 

Healthy Indiana Plan] and the Indiana check-up plan trust 
fund; 

• requirements for· the state department of health to establish 
· standards for and certify a small employer qualified wellness 
program; 

• · requirements for health insurers and health maintenance or­
ganizations to cover children up to 24 years old upon request; 

·• provisions· certain small employers to join together to pur­
chase group health insurance and allows the insurance com­
missioner and the office of the secretary of family and social 
services to develop a program to provide for such purchases; 

• requirements that the Indiana comprehensive health insurance 
association administer plan benefits for high risk individuals 

· · insured under the plan; 
., requirements for applications for necessary federal Medicaid 

approvals, including approval for presumptive eligibility for 
certain pregnant women and implementation of the plan; 

• establishments of a plan task force; requirements for the 
health finance commission to study and report concerning 
several issues; 

•· and an allowance of appropriations for the act. 

HIP is one of the many health care highlights included in HEA 1678. 
After HIP was passed in April 2007, the plan was quickly implemented. In 
August 2007, health insurance plans were selected for HIP (Anthem and 
MD Wise), and in November 2007, a contract was signed with the health 
plan carriers. 26 In December 2007, insurance carriers began accepting ap­
plications for HIP.27 Finally, on January 1, 2008 HIP was fully imple­
mented. 28 At that time, almost 7,000 applications have been received. 29 

B. Details of HIP 

1~ Qualifying/or HIP 

To qualify for HIP, individuals must be uninsured for at least 6 
months and cannot be eligible for employer-sponsored health insurance, 

26. Nat'l Governor's Association. Healthy Indiana Plan, slide 22, (2008) http:// 
WW'W.nga.org!Fileslpdf70803HEALTHREFORMCOLLISI.PDF . 

. 27 . . .Jd . . 
28. /d. 
29. Id 



2010] GET "IDP" AMERICA 63 

Medicare, or regular Medicaid. 30 HIP offers insurance to uninsured adult 
Hoosiers who are between the ages of 19 and 64 whose household incomes 
are between 22 and 2000/o of the Federal Poverty Level ("FPL").31 This 
range is equivalent to approximately "$3,872 to $35,200 per year for a fam­
ily of three in 2008."32 Hoosiers with incomes above 200% of the FPL are 
not eligible for HIP. They may, however, be eligible for the buy-in option 
explained in Section II(B)(5) of this Note. These requirements are intended 
to discourage insured Hoosiers from dropping their plans to join HIP, in the 
hope of preventing the plan from being overburdened with applicants. 
They also serve to discourage employers from dropping their plans so that 
their employees will join HIP. HIP cannot support every Hoosier; it was 
not built for universal-type coverage. 

2. Funding HIP 

One provision ofHEA 1678 provides for an increase in cigarette taxes 
by 44 cents per pack to help finance HIP.33 Consequently, the cigarette tax 
increased from $.555 to $.995 per pack as of July 2, 2007.34 Since August 
1, 2007, 27.05% of the money made from the cigarette tax has been dis­
persed to the HIP trust fund. 35 This increase in cigarette tax is expected to 
lower the number of young smokers by approximately 40,000, and the 
number of adult smokers by approximately 23,400.36 In states that have 
high numbers of cigarette smokers, increasing the cigarette tax is one way 
to decrease the number of smokers, especially young smokers, while simul­
taneously funding a health care plan. 

Moreover, those individuals who smoke less or quit smoking altogeth­
er will be healthier and will require less medical attention and treatment. 
Less overall treatment decreases total medical expenses and opens up addi­
tional funds for insuring more people. After all, in 1998, smoking-related 

30. Family & Social Services Administration., HIP: About the Plan, http://www.in.gov 
/fssalhip/2344.htm (last visited Sept. 10, 2008) (hereinafter" About the Plan"). 

31. Family & Social Services Administration, Healthy Indiana Plan: Frequently Asked 
Questions, http://www.in.gov/fssalhip/ (last visited Oct. 25, 2008) (hereinafter "FAQs"). 

32. Kaiser Commission on Medicaid Facts, Summary of Healthy Indiana Plan: Key 
Facts and Issues (2008),at 2, http://www.kff.org/medicaid/upload/7786.pdf. 

33. Healthy Indiana Plan Th,e Issue: State launches coverage for low-income Hoosi­
ers. Our View: Program could bring improved health to thousands, Ev ANSVU..LE CoURIER & 
PREss, January 2, 2008, ·available at http://www.courierpress.com/news/2008/jan/02 
/healthy-indiana-plan-the-issue-state-launches-to/. 

34. Lawrence Jegen, Recent Developments in Indiana Taxation, 41 IND. L. REv. 1271, 
1291 (2008). 

35. /d. 
36. "Healthy Indiana Plan" to go live in January, HEALTH CARE FINANCIAL 

MANAGEMENT, October 2007, available at http://findarticles.com/p/articleslmi_m3257 
/is_l0_6llai_n21040136/. (Health care Financial Management is the "[o]fficial magazine of 
the Health care Financial Management Association. Features the latest industry news for 
~cial managers in all segments of the health care industry.) 



64 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

health care costs in the United States were approximately $75.5 billion.37 

"For each of the approximately 46.5 million adult smokers in 1999[,] these 
costs represented an annual cost of ... $1 [,]623 in excess medical expendi­
tures in addition to the ... $ 1[,]760 in lost productivity."38 Decreasing the 
number of smokers would substantially trim this number especially consi­
dering "[h ]ealth care costs for smokers at a given age are as much as 40 per­
cent higher than those for nonsmokers."39 

In addition, HIP collects low premiums from those insured by HIP. 
For example, a single adult with no children and an income ranging from $0 
to $10,200 would pay $0 to $204 a year.40 A family of four with an income 
of $0 to $20,650 would pay $0 to $413 annually.41 Collecting these low 
premiums helps make the funding of HIP more manageable. Furthermore, 
the sliding scale used to determine the premiums is appropriate because 
those individuals who do not have jobs, such as students, can still obtain 
health care coverage without paying premiums they cannot afford. Some 
Hoosiers who do have an income, however, must contribute not more than 
5 percent of their income to the plan to help offset expenses. 42 This helps 
make HIP affordable and possible. 

Furthermore, HIP is operated under § 1115 of the Medicaid waiver 
program and, thus, must be budget-neutral to the federal government. 43 The 
details of this waiver, which have been approved by the Department of 
Health & Human Services, are as follows: 

In December 2007, Indiana received federal approval 
for a Medicaid waiver to implement the Healthy Indi­
ana Plan. Under the plan, Indiana is using Medicaid 
funds to provide a benefit package modeled after a 
high-deductible heath plan and health savings account 
to previously uninsured very poor and low-income 
adults. Most enrollees are covered through managed 
care plans; those with certain high-risk medical condi­
tions are covered through a separate fee-for-service 
plan. The waiver was approved for five years, from 

37. World Health Organization, Tobacco and Poverty A Vicious Circle (2004), at 5, 
available at http://www.ingcat.org/linked%20files/Poverty_en.pdf (citing Dept. of Health & 
Human Services, Centers for Disease Control and Prevention, Annual smoking-attributable . 
mortality, years of potential life lost, and economic costs-United States, 1995-1999,51 
MORBIDITY AND MORTALITY WEEKLY REPoRT, 300-3 (2002)). 

38. World Health Organization. supra note 37, at 5. 
39. Jan J. Barendregt, Luc Bonneux, & Paul J. van der Maas, The Health Care Costs 

of Smoking, 337 THENEWENG.J. MED.1052, 1052 (1997). 
40. FAQs, supra note 31, at 10. 
41. /d. at 11. According to FSSA data, a family of four consists of two adults and two 

children. Id. 
42. FAQs, supra note 31, at 3. 
43. Kaiser Commission on Medicaid Facts, supra note 32, at 6. 



2010] GET "HIP" AMERICA 65 

January 1, 2008-December 31,2012.44 

During the five-year waiver period, HIP "cannot cost the federal govern­
ment more than would have been spent without the waiver.'"'5 To assure 
this requirement is met, a per capita cap on federal funds was established, 
"which limits the amount of federal funds the state can receive for people 
covered under the waiver based on pre-set per person costs and annual 
growth rate.'M 

Indiana plans to offset the costs of expanding coverage by using a por­
tion of its Disproportionate Share Hospital funds.47 Also, the state plans to 
save "in its existing Medicaid coverage for pregnant women, children, and 
parents. '"'8 To ensure budget neutrality is achieved, "the federal govern­
ment established a per capita cap on federal funds for Healthy Indiana Plan 
expansion enrollees as well as pregnant women, children, and parents cov­
ered through Medicaid.'"'9 Additionally, Indiana has agreed to achieve fur­
ther savings of $15 million over the five-year waiver period for which HIP 
was approved. 50 This feature of HIP aids Indiana in maintaining a budget 
and prevents the risk of serious financial harm to the State Treasury. 

3. HIP'S Coverage 

HIP's benefits basically consist of three parts provided through ma­
naged care plans.51 These three components include: high-deductible cov­
erage, a POWER account, and preventative health care. 

a. High-Deductible coverage 

First, HIP provides high-deductible coverage. 52 After meeting a 
$1,100 deductible, individuals are covered up to $300,000 a year and up to 

44. Id 
45. Id 
46. Id 
47. Id. See also U.S. Dept. of Health & Human Services, Analysis of the Joint Distri­

bution of Disproportionate Share Hospital Payments, http://aspe.hhs.gov/health/reports/02 
/DSH/execsum.htm#Introduction, ("The Medicare and Medicaid programs distribute extra 
payments to hospitals that treat a disproportionate share of indigent patients. The dispropor­
tionate share hospital (DSH) payment policies differ substantially between the two programs 
and, under Medicaid, across states as well. Nevertheless, the general objectives of each pro-­
gram are the same: to support the hospitals that are crucial to the health care safety net, and 
to preserve access to these hospitals for the respective program's enrollees.") 

48. Kaiser Commission on Medicaid Facts, supra note 32, at 6. 
49. Id. at l. 
50. Id at6. 
51. Id. at 3. 
52. Id. 



66 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

$1 million in a lifetime for state-specified benefits. 53 Upon meeting this 
deductible, individuals receive coverage for state-specified benefits, which 
include "inpatient and outpatient care, physician care, prescription drugs, 
home health care, and mental health care up to the caps."54 HIP does not, 
however, cover dental or vision care nor does it cover long-term skilled 
nursing care or pregnancy-related services. 55 

b. POWER Account 

The second component of HIP is its Personal Wellness and Responsi­
bility (POWER) Account feature.56 This account is HIP's ''version of a 
Health Savings Account (HSA) and is used to cover the $1,100 deducti­
ble."57 The POWER Account is funded by the enrollee or enrollee's em­
ployer, the state government, and the federal government and is 
administered by the enrollee's managed care plan. 58 The POWER Account 
helps individuals pay for basic health services, such as regular doctor visits. 
Participants may make contributions to their POWER Accounts by check or 
money order, automatic bank draft, credit card, cash or through an employer 
contribution. 59 However, failure of an individual to make the POWER Ac­
count contribution within 60 days will result in one of the following: (1) 
losing the coverage from HIP; (2) losing the chance to see an individual's 
doctor; (3) being removed from the HIP plan and having a portion of one's 
contribution returned; or ( 4) waiting twelve months to reapply for the HIP 
plan.60 

c. Preventative health care 

Finally, HIP encourages preventative care.61 Indiana requires partici­
pating care plans to cover up to $500 in preventative care each year.62 Pre­
ventative care is "not subject to the deductible and does not draw from the 
POWER Account.'.63 Additionally, with HIP coverage, "[p ]arents are 

53. Kaiser Commission on Medicaid Facts, supra note 32, at 3. 
54. Id. 
55. /d. 
56. /d. 
57. Id. 
58. /d. 
59. Family & Social Services Administration, Healthy Indiana Plan: Health Plan 

Summary, http://www.in.gov/fssa/hip/files!MAXI542 _IN_ HIP-PlanChartDEC20.pdf (last 
visited February 8, 2009) (hereinafter "Health Plan Summary"). 

60. Kaiser Commission on Medicaid Facts, supra note 32, at 5; MDWise, Power Ac­
count, http://www.mdwise.org/HIP/members/poweraccount/ (last visited Feb. 19, 2009) 
[NT A: The MDWise website is not accessible. Consider eliminating this citation]. 

61. Kaiser Commission on Medicaid Facts, supra note 32, at 3. 
62. Id 
63. /d. 



2010] GET"HIP"AMER!CA 67 

charged between $3 and $25 for an· emergency room visit," emergency 
room fees being based on a parent's income.64 "[C]hildless adults are 
charged $25 per visit" without consideration of income. 65 

4. HIP's Insurers 

HIP has two health care insurers: MDWise (partnering with Amen­
Choice) and Anthem Blue Cross and Blue Shield ("Anthem").66 The 
MDWise coverage is an extension of its Hoosier Healthwise Participating 
Provider Agreement. 67 Characteristics of the MD Wise agreement with HIP 
include, but are not limited to the following: $25 co-pays for emergency 
room care for childless adults; emergency room care (for non-emergency 
services) based on family income level of adults with children; multiple 
POWER account methods of payment; care management services; disease 
management programs; enhanced services such as free unlimited preventa­
tive care services and free over-the-counter medicines; assistance with 
community resources and other needs; and educational programs. 68 

The Anthem agreement is an attachment to its Anthem Blue Cross and 
Blue Shield Provider· Agreement and an Amendment to the Anthem Blue 
Cross and Blue Shield Professional Provider Agreement.69 This plan in­
cludes the following characteristics: $25 co-pays for emergency room visits 
for childless adults; emergency room (for non-emergency services) visits 
for adults with children requiring a co-pay amount based on family income 
level; multiple POWER account methods of payment; care management 
services; disease management programs; 70 community resource centers; and 
educational programs.71 

Enrollees of HIP must select a health care plan at the time of applica-

64. Id at 3-4. 
65. Id. at4. 
66. Healthy Indiana Plan (HIP) Resource Center, http://www.ismanet.org/HIP.httn 

(last visited Sept. 10, 2008) (hereinafter "HIP Resource Center''). 
67. Id.; Welcome to the Hoosier Healthwise Website (2007) 

http://www.healthcareforhoosiers.com/index.html. (''The Hoosier Healthwise Program is a 
health ( )care program for low income families, pregnant women, and children. It is spon­
sored by the state of Indiana through Family and Social Services Administration. The pro­
gram covers such medical care as doctor visits, prescription drugs, mental health( )care, 
dental care, hospitalizations, surgeries, and family planning at little or no cost.") 

68. Health Plan Summary, supra note 59. 
69. HIP Resource Center, supra note 66. 
70. Health Plan Summary, supra note 59. 
71. Id. (HIP offers educational programs such as: ''New Member Education Meetings 

at locations throughout the state[;] Online Health Risk Assessments [that] help [] [individu­
als] improve [their] health and give[] [them] a $50 Gift Card for completion;;] Personalized 
Telephone Based Weight Management Program[s that] help[] [individuals] lose or gain 
weight, or stay at a healthy weight[;] Tobacco Treattnent Program[s that] help[] [individuals] 
learn new behaviors, offers nicotine replacement gum and patches[; and] Health Coach Pro­
grams [that] offer telephone coaching sessions for certain health conditions.") 



68 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

tion, otherwise the state will assign a plan upon approval. 72 Once enrollees 
are approved and are assigned a plan, they must stay on that plan for 12 
months.73 As of June 2008, approximately 74 percent of enrollees chose the 
Anthem plan and approximately 24 percent chose MDWise.74 

5. The Buy-In Option 

Another unique characteristic of HIP is that it further permits a buy-in 
option for individuals and families who earn over 200% of the FPL. 75 The 
buy-in option also allows for employers to pay for a portion of their em­
ployees' health insurance.76 In fact, "[e]mployers who do not currently of­
fer any health plans oftheir own can pay up to 50 percent of the premiums 
for their employees who enroll in HIP."77 Furthermore, "[a]s with the sub­
sidized HIP program, [Hoosiers] accepted for the buy-in" option must also 
be uninsured for 6 months or more with no access to employer-sponsored 
health benefits. 78 When determining the premium rate for the buy-in op­
tion, an individual's age, health status, and gender.79 The policy also looks 
at an individual's weight and overall health condition.80 By way of exam­
ple, "[m]onthly premiums for a 25-year-old male are around $125, while a 
60-year-old female would pay about $550 per month."81 

Additionally, the policy will cover some preexisting conditions. For 
example, it will cover diabetics who take pills only, but will not consider 
diabetics who take insulin.82 Also, to even apply for the buy-in option, ap­
plicants must have applied for and have been denied by HIP first. 83 Addi­
tionally, according to FSSA spokesperson Elizabeth Sergener, 
approximately "140,000 Hoosiers are eligible for the HIP expansion."84 As 
of August 2008, Anthem is the only insurer participating in the buy-in op­
tion.85 MDWise is expected to also participate in the option in the near fu­
ture.s6 

72. Kaiser Commission on Medicaid Facts, supra note 31, at 4 .. 
73. ld. 
74. /d. 
75. FAQs, supra note 31, at 2. 
76. Losing Health Insurance, supra note 11. 
77. /d. 
78. Bruce Goldfarb, Account-Based Healthy Indiana Program Expands With a Buy-in 

Option, AIS's HEALTH Bus. DAILY, Aug. 5, 2008, http://www.aishealth.com/Bnow 
/hbd080608.html (last visited 2009). 

79. !d. 
80. Interview with Sales Representative, Anthem Blue Cross & Blue Shield, Sales 

Hotline, at 1-800-622-4075 (Dec. 30, 2008) (hereinafter "Interview"). 
81. Goldfarb, supra note 78. 
82. Interview, supra note 80. 
83. Id 
84. Goldfarb, supra note 78. 
85. !d. 
86. /d. 



2010] GET ''HIP., AMERICA 69 

Individuals who would otherwise qualify for HIP may use the buy-in 
option if HIP reaches its maximum capacity of enrollees. 87 In these in­
stances, the HIP rates are available to such individuals, but the participants 
must pay the full costs. 88 The buy-in option has not been promoted as much 
as the other portions of HIP have. It is, however, a unique part of the HIP 
program that could prove very beneficial to many uninsured Hoosiers. 

III. HIP'S MODEL OFFERS A MORE SUSTAINABLE ROUTE THAN NATIONAL 
HEALTH CARE PROPOSALS TO ACHIEVE THE GoAL OF INSURING MORE 

AMERICANS 

Over 47 million Americans were uninsured in 2006.89 Furthermore, 
"[h]ealth care costs are predicted to increase from $1.6 trillion in 2002 to 
$3.4trillion in 2013."90 Many national health care plans have been pro­
posed to provide Americans with access to health insurance and to address 
rising health care costs. However, a universal health care plan in the United 
States would likely be unsuccessful and would likely create a great financial 
burden on the country. It is questionable as to whether our country could 
sustain such an expensive plan for a long duration of time before it failed. 
In the early 1990s, Congress rejected President Clinton's universal health 
care plan because it would be too expensive to implement.91 As 2004 
Health and Human Services Secretary Tommy Thompson stated, a univer­
sal health care plan is "'unrealistic. "'92 

A. The National Health Care Plans 

1. The United States Insurance Act of 2008 

The United States National Health Insurance Act of 2008 intro­
duced in the House as H.R. 676 ("H.R. 676")93 "[e]stablishe[d] the 
United States National Health Insurance (USNHI) Program (the Program) 
to provide all individuals residing in the United States and in U.S. territories 
with free health[ ]care that includes all medically necessary care, such as 
primary care and prevention, prescription drugs, emergency care, and men-

87. A Check Up, supra note 18, at slide 15. 
88. /d. 
89. Lee, supra note 10. 
90. Mark E. Douglas. Finally Moving Beyond the Fiction: An Overview of the Recent 

State Rally for Health Care Reform, 5 IND.IIEALm L. REv. 277, 280-1 (2008). 
91. Kristine Nwazota, Who Should Pay for Health Care, PBS, Jan. 19, 2004, 

http://www.pbs.org/newshour/extra/features/jan-june041uninsured _1-19 .html. 
92. /d. 
93. United States National Health Insurance Act (or the Expanded and Improved Med­

icare for All Act), H.R. 676, llOth Cong. (2008), available at http://www.govtrack.us 
/congresslbill.x.pd?bill=h11 0-676&tab=summary (hereinafter "H.R. 676j. 



70 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

tal health services."94 The plan allows a participant to choose a doctor or 
facility within the network.95 H.R. 676, however, prohibits private health 
care insurers from providing coverage duplicative of benefits it provides.96 

H.R. 676 allows private "insurers to sell benefits that are not medically ne­
cessary, such as cosmetic surgery benefits."97 Allowing private insurers to 
provide coverage only for specific medical care may diminish the health 
insurance industry and may reduce the overall quality of health care cover­
age that is available to individuals. 

To finance the plan, H.R. 676 seeks to establish the USNHI Trust 
Fund.98 This trust collects funds from the following: "(1) existing sources 
of Government revenues for health care; (2) [] increase[ ed] personal income 
taxes on the top 5% ofincome earners; (3) [] instituting a progressive excise 
tax on payroll and self-employment income; and (4) [] instituting a small 
tax on stock and bond transactions. "99 

2. The Obama Reform Bill 

Another national health care plan, of which was proposed by and 
signed into law100 by President Barack Obama on March 23, 2010,101 is 
known in short as the "Health Care Reform Bill" ("Reform Bill").102 The 
Reform Bill is ''the most far-reaching health legislation since the creation of 
the Medicare and Medicaid programs."103 While the Reform Bill has been 
signed, additional changes will occur if a reconciliation bill is passed at a 
later time in addition to the Reform Bill. 104 

The Reform Bill mandates that Americans obtain health insurance by 
2014 or they would be obligated to pay a penalty.105 For individuals, [t]he 
penalty would start at $95, or up to 1 percent of [one's] income, whichever 
is greater, and could rise to $695, or up to 2.5 percent of [one's] income, by 
2016."106 "[F]amilies have a limit of $2,085.' 107 Some individuals would 

94. Id 
95. Id. 
96. Id. 
97. Jd. 
98. Id 
99. H.R. 676, supra note 93. 

100. Reform bill was signed into law as Public Law No: 111-148. See Thomas (Library 
of Congress), H.R. 3590, Major Actions, http://thomas.Ioc.gov/cgi-bin/bdquery 
/z?dlll :HR03590:@@@R (last visited March 31, 201 0) (hereinafter "Major Actions"). 

101. Major Actions, supra note 100. 
102. Thomas (Library of Congress), H.R.3590, Titles, http://thomas.loc.gov/cgi-bin 

lbdquery/z?d111 :HR03590:@@@T (last visited March 31, 2010). 
103. Phil Galewitz, Consumers Guide to Health Reform, Kaiser Health News, March 

23, 2010, http:/ /www.kaiserhealthnews.org/Stories/20 1 0/March/22/consumers-guide--health­
reform.aspx =(hereinafter "Consumers Guide"). 

104. Id. 
105. Jd. 
106. Id. 



2010] GET "HIP" AMERICA 71 

be exempted from the individual mandate for financial hardship or religious 
beliefs or if they are American Indians. 108 

Beginning in 2014, the state-federal program for the poor and disabled 
would be substantially increased, so that individuals with income less than 
133 percent of the FPL, may be eligible for the Medicaid program.109 Indi­
viduals with income greater 133 percent of the FPL, may acquire govern­
ment subsidies to help pay for a private insurance plan 'that would be sold 
in the new state-based insurance marketplaces, called exchanges, slated to 
begin in 2014."110 These subsidies would be available for individuals and 
families making between 133 percent and 400 percent of the poverty lev­
el.tu 

Furthermore, individuals with preexisting conditions would be able to 
obtain health insurance easier because "insurers would be barred from re­
jecting applicants based on health status" beginning in 2014 when the ex­
changes are operating. 112 During the transition period, there would be "a 
temporary high-risk insurance pool for people with medical problems who 
have been previously rejected by insurers and have been uninsured for at 
least [6] months."113 Additionally, individuals younger than 26 would be 
able to stay on their parent's insurance plans as long as they are not offered 
health coverage at work.114 Individuals over 65 would notice an improve­
ment in the Medicare prescription-drug benefit.115 However, government 
funding of the Medicare Advantage, 116 "would be cut sharply starting in 
20 11."117 This means that the 10 million individuals enrolled in Medicare 
Advantage would "lose extra benefits that many of the plans offer, such as 
free eyeglasses, hearing aids[,] and gym memberships."118 

The Reform Bill would require firms with more than 50 employees to 
pay a fee of up to $2,000 per full-time employee if any of their workers got 
government-subsidized insurance coverage in the exchanges instead of from 
the employer. 119 The first 30 workers would not be included in the assess­
ment. 120 In contrast, companies with fewer than 50 workers would not face 
any penalties for not offering health insurance to its employees. 121 Addi­
tionally, tax credits could be available to companies to help them buy insur-

107. Jd. 
108. Id. 
109. Galewitz, supra note l 03. 
110. Id. 
111. Jd. 
112. Id. 
113. Id. 
114. Id. 
115. Galewitz, supra note 103. 
116. Jd. (Medicare Advantage is the private-plan part ofMedicare.) 
117. Galewitz,supranote 103. 
118. Jd. 
119. Jd. 
120. Jd. 
121. ld. 



72 INDIANA HEALm LAW REVIEW [Vol. 7:57 

ance if they have 25 or fewer employees and a workforce with an average 
wage up to $50,000.122 

The Reform Bill will cost approximately $938 billion over the next 10 
years123 and is expected to extend health care coverage to 32 million addi­
tional Americans by 2019.124 Those individuals with higher incomes will 
have to pay higher taxes.125 Individuals earning more than $200,000 a year 
and couples earning more than $250,000 will pay a 2 percent higher Medi­
care payroll tax which is up from the current 1.45% tax.126 Furthermore, 
the Reform Bill will impose "a 40 percent excise tax on the portion of em­
ployer-sponsored health coverage (excluding dental and vision) that ex­
ceeds $10,200 a year for individuals and $27,500 for families."127 Future 
health insurance premiums will be hard to predict are the subject of much 
debate in the passage of the Reform Bill.128 

B. HIP's Unique, Realistic and Sustainable Nature 

HIP is different and more realistic to implement than H.R. 676 and the 
Reform Bill. HIP is a more sustainable plan because it requires each par­
ticipant to make a modest income-based financial contribution and focuses 
on combining personal responsibility with public support. Also, it does not 
abolish employer-sponsored health care benefits nor does it mandate indi­
viduals to obtain health insurance as do the national plans mentioned in Part 
III(A)(1) and (2) ofthis Note. HIP recognizes that insuring all Indiana citi­
zens solely through HIP coverage is not a realistic goal. Gradually insuring 
Hoosiers who cannot obtain insurance elsewhere, while also encouraging 
employers to keep their health care plans for their employees, is a more sus­
tainable route to increasing access to medical care. HIP also "provides in­
centives for participants to stay healthy, be value and cost-conscious, and to 
utilize services in a cost-efficient manner."129 Additionally, by taxing aha­
bit that is very destructive to health, Indiana will be able to finance a health 
care plan while also discouraging smoking at the same time. Also, instead 
of increasing income taxes for residents, as does the Reform Bill, HIP re­
quires those insured by HIP to pay an income-based premium. 

National health care sounds ideal initially. However, the reality is that 
if the government insures the entire country, which included approximately 
307,212,123 people in 2009,130 the government may be forced to substitute 

122. !d. 
123. Galewitz, supra note 103. 
124. Id 
125. Id 
126. Id 
127. Id. 
128. Id 
129. FAQs, supra note 31, at 1. 
130. CIA-The World Factbook. The United States (July 2009), https://www.cia.gov 



2010] GET "HIP" AMERICA 73 

quality for quantity, and limit who and where citizens may choose to obtain 
health care. Also, by substituting quality for quantity, many health care 
professionals, such as specialists, may struggle to stay in business. Special­
ists are more expensive, and a national health care plan may wish to curtail 
spending for specialists even though specialist care is often critical for re­
ceiving proper health care. 

The Reform Bill has numerous positive aspects such as barring insur­
ance companies from denying coverage based on preexisting conditions. 
Nevertheless, the plan is expensive as it will cost approximately $938 bil­
lion over 10 years to make the health care reforms it projects to make. 131 

The Reform Bill also seeks to mandate the entire country to obtain health 
insurance, penalizing those who do not obtain insurance, rather than look­
ing at the various needs of individual states. Instead, the majority of health 
care decision making should be left to the states, because they are in a better 
place to individually address the issue of financing and creating health care 
programs within their borders. For example, if a state has a high rate of 
alcoholism, drunk drivers, and underage drinkers, it could increase the tax 
on alcohol. If a state has experienced a rapid increase in the number of ca­
sinos being built within its borders, it could capitalize on this expanding 
industry and increase the tax on the winnings at such casinos. Each state is 
different and has different needs. These innovative ideas allow for a more 
customized, stable, and effective health insurance plan, than does national 
health care, which is why this Note finds that HIP offers an excellent health 
care model for other states to follow to decrease the number of uninsured 
Americans. 

IV. HIP IS A MODEL FOR MANY OTHER STATES STRUGGLING TO INSURE 
THEIR CITIZENS 

A. HIP is a Model for Other States 

HIP offers a model for other states to follow to connect more citizens 
in each state to health care. According to U.S. Department of Health & 
Human Services Secretary Mike Leavitt, HIP "'is a forward-thinking plan 
to reduce the numbers of uninsured Indiana residents .... "'132 Secretary 
Leavitt went on to say, "'[HIP] is an excellent example of what can be done 
now in the states to advance this important objective."' '"[I] hope other 
states ·will follow Indiana's model of combining personal responsibility 
with public support to help those who are truly in need gain health cover­
age. "'133 HIP is a "forward-thinking plan" because it is different from plans 
such as Medicaid and Medicare, in part, because it has strictly limited bene-

/library/publications/the-world-factbooklprint/us.html. 
131. Consumers Guide, supra note 103. 
132. Press Release, supra note 1. 
133. !d. 



74 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

fits and services where recipients have the incentive to be responsible for 
their health status, to be mindful of costs, and to utilize health care services 
efficiently. 134 

B. Unsuccessful State Plans 

1. The California Plan 

California proposed a statewide health care plan in 2007 ("California 
Plan"). 135 This plan required all California residents "not on Medicare or 
MediCal (California's Medicaid program)" to acquire insurance. 136 Those 
who could not afford the insurance would be offered subsidies. 137 Howev­
er, it was debated whether the subsidies would be substantial enough to 
cover lower-income families. 138 Opponents of the plan argued that it 
"wasn't fair to penalize [low-income citizens] for coverage they couldn't 
afford.''139 As one California senator stated, the California Plan is "'a knife 
in the throat of the working poor."'140 The California Plan also placed a 
mandate on employers to do one of two things: either to provide health in­
surance for their employees, or to pay an additional business tax of 10 per­
cent to the state.141 This employer mandate was applicable to businesses 
with more than 9 employees. 142 Also, the California Plan required insurers 
to sell their product to anyone asking for it without consideration of an in­
dividual's medical condition.143 

The California Plan was funded by increasing payroll tax by 6 percent, 
implementing a 2 percent tax on physicians and a 4 percent tax on hospitals, 
and adding an additional $1.50 to $2.00 per pack tax on cigarettes.144 The 
total cost of the plan was predicted to be $14 billion annually.145 Although 

134. F AQs, supra note 31, at l. 
135. Robert Stark, What Works and What Doesn't: A Review of Health Care Reform in 

the States, Washington Policy Center for Health Care, August 2008, at 9, available at 
www.washingtonpolicy.org!Centers/healthcare/policybrief7StateHealthCareReforms.pdf 
(Dr. Roger Stark is a health care policy analyst with the Washington Policy Center ("WPC"). 
The WPC is an independent and non-partisan. research and education organization that pub­
lishes studies, sponsors events and conferences, and educates citizens on public policy is­
sues.) Washington Policy Center, About Us, http://www.washingtonpolicy.orglaboutus 
/missionstatement.html. 

136. Id. 
137. Op-Ed, Tenninated, WALL ST. J., Jan. 30. 2008, at Al6, available at 

hUp://online.wsj.com/article/SB120165320966126977.html?mod=opinionjoumal_main_stories. 
138. Id. 
139. Id 
140. Id 
141. Stark, supra note 135, at 6. 
142. Id 
143. Id. 
144. Id. 
145. Id. 



2010] GET "HIP" AMERICA 75 

California's increase on the cost of cigarettes .is a forward-:-thinkingiidea, 
requiring citizens to pay an augmented payroll tax is burdensome, especial­
ly in light of the current economic climate in which residents may not have 
additional funds to either pay higher taxes or purchase compulsory health 
insurance. 

2. The Wisconsin Plan 

Wisconsin proposed a health care plan ('Wisconsin Plan'') in 2008, 
but it failed to pass.146 If implemented, the plan would have required "cov­
erage for all [citizens] not enrolled in an existing government program· such 
as Medicare or Medicaid."147 The Wisconsin Plan's goal was to offer uni­
versal coverage while also lowering costs. The plan was funded by a new 
14.5 percent payroll tax, in addition to the "15.3 percent tax [that] workers 
already pay to fund Social Security and Medicare."148 In its first year after 
passage, Wisconsin legislators estimated that the Wisconsin Plan w,ould 
cost $15.2 billion.149 This would have doubled the state budget.150 

3. The Massachusetts Plan 

One state plan that has proved to be unsuccessful is the Massachu­
setts' "Connector Plan" ("Massachusetts Plan").151 This plan was passed in 
the spring of 2006 for the purpose of dealing with increased health care 
costs in Massachusetts. 152 The plan intended to cover the estimated 550,000 
uninsured Massachusetts residents.ts3 Proponents of the plan were deter­
mined that "the state's uninsured population would be reduced to zero .. ",154 

The Massachusetts Plan requires "every resident between the ages of 
18 and 64 to purchase a state-defined health insurance policy" beginning 
July 1, 2007.155 Those individuals who did not purchase a policy by De­
cember 2007 would be penalized $219 through tax filings.156 The penalty 
would increase in 2008 to 50 percent of the average cost of a health insur­
ance plan in the geographic region where the person lives.157 

146. !d. at 7. 
147. Id. 
148. !d. 
149. !d. 
150. !d. 
151. Idat5. 
152. Id 
153. Id 
154. Id 
155. !d. See also Kaiser Commission on Medicaid Facts. Massachusetts Health Care 

Reform: Two Years Later (2008) http://www.ldiorgluninsuredlupload/7777 .pdf. (berineafter 
"Kaiser on Massachusetts"). 

156. Kaiser on Massachusetts. supra note 155. 
157. Id 



76 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

Additionally, all employers with more than 11 workers were required 
to make a "fair and reasonable" contribution to their employees health in­
surance covemge or pay a "Fair Share" contribution of up to $295 per em­
ployee each year. 158 Massachusetts "provides subsidies for residents with 
incomes less than 300 percent of the [FPL]."159 Residents with an income 
below this percentage do not pay anything.160 Additionally, the Massachu­
setts Plan took over ''the role of private-sector insurance agents by matching 
individuals with state-approved health plans." 161 "[A]pproximately 
350,000 people who previously had no insumnce are covered by the" Mas­
sachusetts Plan. 162 A majority of the enrollees, however, are also in an en­
titlement progmm that is subsidized by the state. As a result, "[i]ndividual 
private plans are not selling well."163 

Furthermore, the Massachusetts Plan does not have any measures in 
place to deal with the state's mpidly increasing health care costs.164 Addi­
tionally, the plan has caused "a dmmatic increase in demand for medical 
services, to the point where primary care doctors are in short supply. Wait­
ing times to see a family physician are up to [1] year in parts of western 
Massachusetts."165 Already, there is an early budget overrun of 30 per­
cent.166 The Massachusetts governor asked for $869 million in additional 
funds for 2009.167 This amount is about $400 million more than 2008 and 
may still fall short.168 However, that number may "reach as high as $1.1 
billion."169 In the next ten years, the over-run cost of the Massachusetts 
Plan is estimated to reach $4 billion.170 Resultantly, there is a "proposed tax 
increase of $129 million."171 Additionally, to control costs, the legislature 
is "considering cutting payments to doctors, increasing the special tax on 
employers (currently $295 a year), increasing the state tobacco tax, and im­
posing additional regulations on insurers and drug companies."172 Current­
ly, there is no proposal to decrease mandates on individual insurance plans. 
As a result, Massachusetts insurance carriers are finding it difficult to offer 
low-cost plans.173 

158. Id 
159. Stark. supra note 135, at 6. 
160. Id. 
161. /d. 
162. ld. 
163. Id. 
164. Id 
165. Stark, supra note 135, at 6. 
166. Id. 
167. Id. SeealsoKaiseronMassachusetts,supranote 155. 
168. Id. 
169. Stark. supra note 135 at 6. 
170. Id. 
171. Id 
172. Id 
173. /d. 



2010] GET "HIP" AMERICA 77 

Initially, advocates of the Massachusetts Plan claimed it would lower 
health care costs to achieve universal coverage. It has instead "increased 
costs for individuals and the state, in addition to reducing revenues for doc­
tors and hospitals."174 Massachusetts officials are admitting that their 
"'universal coverage is not likely to be universal any time soon. "'175 Never­
theless, benefits are increasing for individuals because the state government 
is requiring all patients to purchase certain "benefits" that they will never 
use and would never have voluntarily chosen in a free market.176 "For ex­
ample, the Massachusetts Plan currently requires insurance ·plans 
to ... [cover] in vitro fertilization, blood lead poisoning treatment, and chiro­
practor services" even if these services are not needed by the insured .. 177 

The mandated benefits of the Massachusetts Plan have raised health care 
insurance costs by at least 23 percent.178 

4. The Washington Plan 

In 1993 the Washington state legislature passed health care reform 
legislation, which was known as the Washington State Health Plan ("Wash­
ington Plan") in response to Washington's 600,000 uninsured residents.179 

The plan would require all residents to join a managed competition plan if 
they were not receiving coverage through Medicare.180 The underlying goal 
of the Washington Plan was to provide universal coverage. The plan in­
cluded the following elements: "(1) Price controls in the form of state­
imposed caps on insurance premiums; (2) Statewide community ratings and 
universal access; (3) New mandates on employers and individuals; (4) A 
guaranteed issue law, and; (5) Increased emphasis on public health and pre­
vention."181 The Washington Plan added more mandates and restrictions on 
employers and individuals, gave state government more control over health 
care, and added a new powerful state bureaucracy.182 

The Washington Plan ultimately created overwhelmingly negative 
consequences.183 After the plan was enacted, 14 health insurance carriers 
left the state.184 Those carriers that remained were forced to raise their rates 

174. Paul Hseih. Mandatory Health Insurance: Wrong for MassachuseltS, Wrong for Ameri­
ca, 3 "DIE OBJECTIVE STANDARD: A JOURNAL OF CUL1URE AND Pouncs 3, (2008), available at 
http:llwww.theobjectivestandard.com/issues/2008-fulllmandatory-health-insurance.asp (last visited 
Apr. 8, 2010). 

175. /d. 
176. ld 
177. /d. 
178. Id 
179. Stark, supra note 135, at 2. 
180. !d. 
181. Id 
182. Id 
183. Id. at3. 
184. Id 



78 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

up to 40 percent. 185 The number of uninsured actually rose instead of de­
creasing.186 The guaranteed issue provision in the plan also caused severe 
consequences.187 This law required carriers to sell their product to anyone, 
regardless of their medical history.188 For instance, a woman who becomes 
pregnant could purchase an insurance plan, use it during her pregnancy and 
immediately after giving birth, then withdraw from coverage when it is no 
longer needed.189 The community rating law mandated "that premiums 
charged by [carriers] be an average of all premiums ... in a given region."190 

The community rating and guaranteed issue rules caused two events to hap­
pen.191 First, they encouraged people who were healthy to avoid buying 
health insurance. 192 Second, they encouraged people to avoid buying health 
insurance until they got sick. 193 These rules resulted in higher health insur­
ance costs for everyone.194 Therefore, by 1994, there was a citizen revolt at 
the voting booths.195 "The governing party lost its majority, and the gover­
nor who had signed the reform the plan was forced to approve a repeal of 
the program."196 The Washington health insurance market is still recuperat­
ing from the detrimental consequences results of the Washington Plan 197 

5. The Maine Plan 

In 2005, Maine passed a health care reform plan known as the Dirigo 
Health Plan ("Maine Plan"). 198 This plan provides coverage beyond Mai­
neCare, Maine's Medicaid Program.199 The plan's goals were to "expand 
access to care, contain costs, and quality" of health care.200 Initially the 
Maine Plan was ''available to uninsured individuals and to business owners 
with fewer than 50 employees."201 The Maine Plan includes a guaranteed 

185. !d. 
186. Id 
187. !d. 
188. Jd 
189. Stark, supra note 135, at 3. 
190. Id. 
191. Id 
192. Id. 
193. Id. 
194. Id. 
195. Stark, supra note 135, at 3. 
196. Id. 
197. Id. 
198. !d. at 7. 
199. Paul Saucier, MaineCare and Its Role in Maine's Healthcare System, The Kaiser 

Commission on Medicaid and the Uninsured, January 2005, at 5, available at 
http://www.lcff.org/medicaidlupload/MaineCare-and-Its-Role-in-Maine-s-Healthcare­
System-Report.pdf. 

200. !d. 
201. Stark, supra note 135, at 7. 



2010] GET "HIP" AMERICA 79 

issue requirement.202 Funding for the Maine Plan is provided by individuals 
who enroll in the program, "a one-time $53 million state 'grant,' and federal 
subsidies for people earning less than 200 percent of the [FPL].'.2°3 Also, 
insurance companies are taxed ''four percent on all health insurance policies 
sold in the state."204 The plan includes Certificate of Need restrictions, 
which makes it difficult. for doctors and clinics to provide medical services 
that are current and new. 205 

Unfortunately, the Maine Plan has not provided the health coverage 
that it initially promised, and has been unsuccessful at controlling health 
care costs. 206 Presently, "only 13,000 people are covered [under the Maine 
Plan] at a cost of over $50 million per year, and the program is also no 
longer accepting new enrollees.'' 207 

C. Plans Similar to HIP and Based on Individual Choice and Market Com­
petition 

In contrast, two plans that have been passed in states which are similar 
to HIP include Georgia's health care plan (''the Georgia Plan") and Flori­
da's health care plan (''the Florida Plan.'')208 Both of these plans use indi­
vidual choice and market competition to lower costs and are currently 
experiencing success.209 HIP, the Georgia Plan, and the Florida Plan take a 
different approach to health care reform. 210 These three plans "move deci­
sion-making about health care to the individual, work with market forces, 
and create voluntary incentives that increase choice and expand access· to 
health care coverage.'m1 Additionally, these plans do not promote univer­
sal coverage. "Instead, they direct reform policies toward people who need 
the most help in getting health coverage: low-income families, the chroni­
cally ill and the uninsured.'m2 

1. The Florida Plan 

The Florida Plan was enacted in 2008 to provide health care coverage 
for the 20 percent of uninsured Florida residents.213 The plan is voluntary 

202. Id 
203. /d. 
204. /d. 
205. Id 
206. /d. 
207. Stark, supra note 135, at 7. 
208. /d. at 1 0; 
209. Id at 10-11. 
210. /d. at 2. 
211. Id 
212. Id at 10. 
213. /d 



80 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

and available to residents earning less than 300 percent of the FPL who 
have, like HIP requires, been uninsured for more than 6 months?14 The 
Florida Plan helps lower costs by creating increased competition among 
private insurers, which encourages them "to offer attractively-priced 
plans .... "215 This contrasts plans that mandate coverage because such 
mandates actually add 15 to 25 percent to health care coverage costs.216 

The Florida Plan includes: ''preventative and primary care services, such 
as ... office visits, outpatient and inpatient surgery, urgent care, prescription 
drugs, durable medical equipment and diabetic supplies.'.z17 The Florida 
Plan, however, does "not cover prolonged hospital stays or specialty 
care.''218 As of 2008, 9 insurers submitted proposals to participate in the 
program, which has proven to be successful thus far.219 

2. The Georgia Plan 

The Georgia Plan was enacted in May 2008 as a voluntary plan which 
"encourages use of ... low-cost Health Savings Accounts (HSAs) to provide 
health care coverage.''220 Under this plan, residents are allowed to deduct 
their HSA-related insurance premiums from their income when they calcu­
late their state income tax liability.Z21 This feature results in a "[6] percent 
reduction in the cost of health care coverage for individuals.''222 Another 
attractive feature of the Georgia plan is that it provides a $250 tax credit per 
worker to small business owners with 50 or fewer employees who offer 
HSA coverage to their employees. 223 Georgia legislators "repealed state 
and local taxes on HSA-based insurance premiums," which further lowers 
the market price ofHSA plans.224 Legislators also predict that its new plan 
''will reduce the cost ofHSA-based insurance plans by $146 million a year, 
lower taxes for employees by $64.8 million a year, and save workers $6.7 
million a year.'ms Georgia is expecting to expand health care coverage to 
approximately 500,000 uninsured residents.226 

214. Id. 
215. !d. 
216. Id. 
217. Id 
218. Stark, supra note 135, at 10. 
219. Stark, supra note 135, at II. 
220. /d. 
221. Id. 
222. /d. 
223. Id 
224. Id 
225. Stark, supra note 135, at II (citing Ron Bachritan, Senior Fellow, Impact of Insur­

ing 500,000 Georgians Previously Uninsured, CENTER FOR HEAL Til TRANSFORMATION, May 
9, 2008, available at http://www.bealthtransformation.net/galleries/wp-consurnerism 
!TheEconomiclmpactofHB977.pdf. 

226. Stark, supra note 135, at 11. 



2010] GET "HIP" AMERICA 81 

D. HIP Offers Something to Build On 

HIP, along with the Georgia and Florida plans, does not require much 
expanded government control. After all, health care problems do not neces­
sarily improve with more control from the govemment.227 Furthermore, 
mandates for health insurance coverage cause severe problems as well.228 

Mandates "restrict choice in type and amount of insurance" that an individ­
ual needs or can afford without taking into account each individual's situa­
tion.229 

Moreover, another problem faced by some states is price control.230 

"Community rating, guaranteed issue, and insurance premium caps are ef­
forts by policymakers to limit rising costs by simply banning price increas­
es.'.n1 However, these types of price controls are generally unsuccessful 
because "prices are set by the supply and demand" of the market.232 

Specifically, the Massachusetts Plan does nothing to help those who 
lose their insurance coverage when they become unemployed. Likewise, 
the Wisconsin Plan has its shortcomings, evidenced by the resulting ex­
treme amount of debt that the state has incurred. HIP starts out with a ca­
pacity that can be built on over time, instead of a plan that covers everyone 
all at once. Also, HIP neither increases personal income taxes to pay for the 
plan nor places a mandate on citizens to purchase health care regardless of 
whether or not they can afford it. Thus, universal plans, both state and na­
tional, are not the answer. 

Residents should have the ability to choose which plan they want. 
HIP has been in existence only since January 2008, but it is currently a 
leading model for state health care plans. Furthermore, 

[t]he implementation of the Healthy Indiana Plan in 
2007 offers something to build on. It extends insur­
ance to some low-income Hoosiers, offers tax credits 
for businesses with qualified wellness programs and 
encourages smokers to quit. But with many still un­
insured, there's more left to do. In 2009, the governor 
must explore options to go further. 233 

Indiana is doing its part in decreasing the number of uninsured Ameri-

227. ld. 
228. ld. at 12. 
229. !d. 
230. /d. 
231. /d. 
232. !d. 
233. Kevin M. Brinegar, Letters to the Editor, State Should Help with Health 

Care, JOURNAL GAZETTE, August 27,2008, at 15A, available at 2008 WLNR 16202790. 



82 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

cans by insuring Hoosiers through HIP, but it too has room for improve­
ment. According to FSSA Secretary Mitch Roob, '"[t]he program is 
signed for people who don't have access to employer-sponsored health 
care. "'234 In fact, HIP obtains "enough funding to cover about 130,000 
needy Hoosiers."235 HIP is still flawed in that it does not address em­
ployees who cannot afford the health care benefits offered by their employ­
ers. Additionally, approximately half of the 41,948 people enrolled in HIP 
as of December 2008 are Hoosiers without dependent children.236 This is 
problematic because the cap on enrollees without dependent children is 
34,000, while there is not a cap for adults with dependent children.237 

Nonetheless, even with its imperfections, HIP is making history. 
FSSA Secretary Mitch Roob is pleased with the results of HIP in its first 
year.238 He stated, '"[t]o go from a standing start to 40,000 insured Hoosi­
ers is pretty good, and we're still going, we're still growing. '"239 Secretary 
Roob further stated, '"HIP was never designed to be the end-all and be­
ali ... It was a large and important step out onto the ice, but it was the first 
step.'" 240 As of December 2008, the state of Indiana has received 100,657 
applications since beginning the program in January 2008.241 Even though 
HIP does not insure every Hoosier, or even every applicant, the program is 
setting an example for other states to follow.242 No other state has formed a 
plan quite like HIP. 243 HIP is a first step upon which it can be expanded 
like the Georgia Plan, which is expected to increase its coverage to 500,000 
people.244 HIP is a realistic model for other states struggling to insure their 
citizens, is superior to many other state health care plans, and is taking a 
vital step, along with states that have enacted plans similar to HIP, towards 
decreasing the number of uninsured Americans. 

V. ON-SITE HEALTH CARE CLINICS OFFER ADDITIONAL MEANS FOR 

INSURING MORE AMERICANS BY DECREASING THE COSTS STATE 

GOVERNMENTS MUST PAY IN HEALTH CARE EXPENSES 

An additional creative proposition that could decrease the amount of 

234. Brandi Watters, FSSA Admits Problems with HIP: State Confident in Most of the 
Progress Being Made, THE HERALD BULLETIN, May 26, 2008, available at http:// 
www .heraldbulletin.com/archivesearcbllocal_ story _147 I 93929.html. 

235. Id 
236. Shari Rudaysky, State health plan for uninsured nearing capacity for some adults, 

THE INDIANAPOLIS STAR, Dec. 29, 2008, 2008 WLNR 24894034. 
237. !d. 
238. !d. 
239. Id. 
240. !d. 
241. !d. 
242. Watters, supra note 234. 
243. Id 
244. Stark, supra note 135, at 11. 



2010] GET "IDP" AMERICA 83 

health care costs that state governments pay out for their health care plans 
includes implementing health care clinics, which offer preventative health 
care, into government agencies and into state sponsored health care plans. 
These on-site health care clinics would allow for an increase in the capacity 
to insure more Americans by decreasing health care costs. A growing 
number of companies are providing on-site health care clinics with services 
such as free check-ups, screenings, and prescription drugs.245 Some com­
panies, "such as Intel Corp., Walt Disney Co., and Toyota Motor Corp., are 
opening ... on-site" clinics for their employees that are "staffed by physi­
cians and nurses that offer primary-care services."246 Novia CareClinics, 
LLC (''Novia"), based in Indianapolis, Indiana and CareHere, LLC ("Care­
Here"), based in central Tennessee, are two companies that manage and 
implement these type of on-site clinics into businesses and government 
agencies. 

A. Novia Careclinics,LLC. ("Novia"), Indianapolis, Indiana 

Novia manages and creates on-site health care clinics for employers. 
These on-site clinics provide primary health care services to employees and 
their dependents.247 ·Novia's management services allow employers tore­
duce the costs of insurance coverage while also providing excellent insur­
ance benefits to employees.248 Some of the services Novia provides 
include: "[ c ]linic operations management, including inventory maintenance 
and staffing[; o]n.;line scheduling and electronic medical records systems[;] 
Individual Health Risk Assessments[; p ]re-disease management and educa­
tional reach-out programs[; h]ealth coaching[; a]ssistance in chronic disease 
management[; and] ... [e]mployee population health management and ac­
countability. "249 

Novia decreases health care costs for employers by providing on-the­
job care. The clinics are wellness-based, and the goal is to encourage em­
ployees to stay healthy while also decreasing health care costs. The clinics 
are staffed by physicians recruited from the employer's local community.250 

Employees and their families have access to the clinics at no additional 
cost.251 The idea of such health care clinics is to help decrease the amount 

245. M.P. McQueen, Workers Get Health Care at the Office, WALL ST. J., Nov. 18, 
2008, available at http://online.wsj.com/article/SB122696833222435529.html. 

246. /d 
247. Welcome to Novia Care Clinics, http://www.noviacareclinics.com (lasted visited 

Dec. 31, 2008). 
248. Id 
249. Id 
250. Leslie Condre and Floyd Hindbaugh, Novia CareCiinics Opens Offices for Elkhart 

County Government, www.noviacareclinics.com/news.cfin/ID/1 (lasted visited Dec. 31, 
2008). 

251. Id 



84 INDIANA HEA.Lm LAW REVIEW [Vol. 7:57 

which governments pay out in health care related expenses. States may 
save by implementing clinics into government agencies for employees to 
utilize as well as implementing them throughout the state for citizens who 
are insured by state health insurance plans, such as HIP, to use. Such clin­
ics help cut overhead medical costs. 

For example, the Elkhart County Government, the first government 
entity to contract for and provide Novia's on-site health care services in 
Indiana, has utilized the services by building an on-:site clinic for its em­
ployees to use.252 Novia's services offer ''the 880 employees and retirees on 
the Eklhart County medical plan[] a full range of health and wellness bene­
fit services."253 Employees receiving coverage from the county's health 
insurance plan will receive the following benefits: "[ c ]onvenient access to 
primary care physician services with no co-pays or deductibles[; t]he ability 
to receive commonly used generic prescription drugs[; and a ]ccess to health 
risk assessments, educational programs, and wellness initiatives which are 
intended to improve long term health of participating employees.'.254 As a 
result of the on-site clinic, employees of Elkhart County Government will 
be healthier and, in the long run, medical expenses are expected to decrease. 

Another on-site health care clinic implemented by Novia is in Fishers, 
Indiana. Faced with escalating health care costs growing about 14 percent 
annually, the Town of Fishers needed to take immediate action.255 Thus, 
Fishers is erecting a health care clinic in part of its train station for us.e by 
town employees. 256 Officials are hoping the town will save approximately 
"$1 million in health-care costs over the next three years.'.257 The clinic 
will allow town employees to visit the clinic for regu]ar check-ups and ob­
tain prescriptions at no cost.258 Not only do the employees benefit, but the 
town saves because the employee visits will cost much less than visits to a 
doctor's office.259 Furthermore, Fishers will be able to purchase medica­
tions at wholesale prices, which will save in prescription costs.260 Fishers 
Town Manager Gary Huff opined about Novia's health care clinics by stat­
ing, "'[I]t's a very innovative approach, and I think it's where a lot of muni­
cipalities will end up ... If you don't look at doing some of those things, the 
health care costs are going to eat you up."' 261 

Statistically, from July 2007 to July 2008, Fishers paid about $3.4 mil-

252. Id 
253. /d. 
254. Id. 
255. Carrie Ritchie, Town Plans Clinic to Cut Costs," FISHERS STAR, December 18, 

2008,http://www.indystar.com/article/20081218/LOCAL0102/812180324/1015/LOCALOl. 
256. Id 
257. Id 
258. /d. 
259. /d. 
260. /d. 
261. Ritchie, supra note 255. 



2010] GET ''HIP" AMERICA 85 

lion for health care related expenses for its employees.262 The town is hop­
ing that health care expenses will decrease by about "$166,000 in 2009; 
$324,000 in 2010; and $461,000 in 2011."263 Further, Fishers anticipates 
paying approximately $25 per month per employee, and incurring minimal 
expenses for the renovations at the train station?64 According to Scott Fad­
ness, co-chairman of the committee that recommended the clinic, '"[t]here 
are very few times in government where you can provide an additional ben­
efit to your employees and also save the town and taxpayers money ... and 
when you find those opportunities, you need to jump on them right away.'" 
265 

B. CareHere, LLC., Central Tennessee 

CareHere is another on-site clinic management company. As of2008, 
CareHere manages more than 60 clinics nationwide.266 CareHere integrates 
wellness and case management with on-site physicians to impact employers 
that are self-funded with large health care savings.267 The Town of Smyrna, 
Tennessee implemented one of CareHere's on-site health care clinics. 
Smyrna employees receive health care from a physician and/or a nurse prac­
titioner at no additional cost, and certain prescriptions are available for 
free.268 

Galveston County and the City of Galveston have implemented two of 
CareHere's health care clinics.269 These on-site clinics are expected to have 
numerous positive effects. In fact, ''the clinics are expected to have a posi­
tive impact for local taxpayers by trimming government employee health 
care costs.'mo The expectation is that on-site health care clinics offer a 
healthier workforce, reduce medical costs to the employer over time, and 
allow employees to spend more time at work and less time at the doctor's 
office. 

The same savings could be acquired by the Indiana and other state 
governments if such health care clinics are implemented in states through­
out the country as part of state health care plans as well as in state govern­
ment agencies themselves. Establishing on-site health care clinics in 
addition to or as a part of HIP could save the state of Indiana millions of 

262. /d. 
263. /d. 
264. /d. 
265. /d. 
266. About Us, www.carehere.com/about.asp (last visited Dec. 31, 2008). 
267. /d. 
268. Town of Smymo cuts ribbon for on-site medical clinic, http://www.carehere.com/ 

includes/downloads/20080828 _smyrna. pdf (lasted visited Dec. 31, 2008). 
269. Galveston County Employees HealthCare Center, Guidry News. May 8, 2008, 

http://carehere.com/includesldownloads/05092008 _galveston. pdf. 
270. /d. 



86 INDIANA HEALTH LAW REVIEW [Vol. 7:57 

dollars in health care related costs.271 After all, the Town of Fishers alone is 
expected to save approximately a million dollars in three years. 

VI. CONCLUSION 

In conclusion, HIP offers an excellent health insurance model for the 
states, especially those states struggling to connect their citizens with health 
care. HIP's model is especially needed during this time of economic down­
fall when employers are increasingly dropping health care plans for their 
employees. HIP offers health insurance coverage to Indiana Hoosiers based 
on market competition, personal responsibility, wellness, and public support 
while also demanding a modest payment of premiums by the insured based 
on income.272 HIP makes it possible to insure more Hoosiers, but will not 
deplete the Indiana treasury. HIP supplements employer-sponsored health 
care insurance, Medicaid/Medicare, Hoosier Healthwise, and other already 
implemented plans to collectively help decrease the number of uninsured 
Hoosiers. HIP encourages people to maintain employer-sponsored health 
care policies, and then works to provide quality and affordable health care 
to the uninsured. 

Furthermore, taking a statewide universal health care coverage ap­
proach is not HIP's purpose because that route, like a national universal 
health care plan, is not currently affordable and/or sustainable. Considering 
many employers currently offer excellent health care benefits, switching to 
a statewide universal health care plan may lessen the quality of health care 
for many individuals because universal coverage would be more expensive 
and possibly sacrifice quality of care for quantity of persons insured. 273 HIP 
is a plan on which expansion is possible. It does not insure everyone all at 
once, but starts with a capacity to insure 130,000 people. Through addi­
tional innovative practices, however, such as increasing cigarette taxes and 
inserting on-site health care clinics into the plan, HIP will be able to insure 
more and more Hoosiers in each year to come.274 If other states use HIP as 
a model and narrowly tailor their health care plans to meet the individual 
needs of their citizens, as HIP has, the number of uninsured Americans na­
tionwide will likely decrease substantially. 

Overall, HIP offers regular and sufficient health care coverage with 
"name brand" health care insurers.275 HIP, along with the buy-in option, 
takes into account people with different needs and different income levels. 
HIP does not cover everyone, but is a novel and well-designed plan that has 

271. See e.g, Town of Smyrna, supra note 254 and Galveston County Employees, supra 
note 255 (providing examples of savings in health care costs by establishing on-site clinics). 

272. See supra §II (details on HIP). 
273. See supra §III (comparison of HIP to national universal health care plans). 
274. See supra §V (details on on-site health care clinics). 
275. See supra §II (details on HIP insurance carriers). 



2010] GET ''HIP" AMERICA 87 

promising potential and is a first step in the right direction to insuring more 
Americans. If the HIP framework is more widely adopted, the goal for 
every American to have health insurance coverage may be more realistical­
ly achieved. 



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