Most states had adopted small group market reforms prior to HIPAA that met or exceeded the provisions of the HIPAA legislation. Thus, we expect limited effects nationally on access, coverage, and premiums in the group market. There may be greater effects in the few states that had not adopted market reforms. But even in these states, the literature suggests that the effects of guaranteed coverage are likely to be small without price reforms. The implication for evaluation design is to focus on selected states and populations within them that are most likely to benefit from the reform, such as persons in high risk industries or occupations and employers with a larger share of older workers. The key outcomes to monitor include the availability of group coverage, enrollment in group coverage, the cost of group coverage, and job mobility.
Evaluation requires a comparison group as well to control for secular change. This is especially difficult because we would like to compare what would have happened over time without reforms to the changes that we observe in states in which the HIPPA provisions lead to new group reforms. We cannot observe the former, but must rely on change over time in states that had implemented reforms prior to the HIPAA legislation as control groups. However, reforms are likely to affect premium growth and the stability of the market, and thus the change we observe in reform states is only an imperfect proxy for the control measure that we would like to have.
While the individual market reform provisions of HIPAA were much more controversial than the group market reforms, the evidence also suggests that these reforms are likely to have limited effect on the number of uninsured and the premiums they would have to pay for care. Many states already have high risk pools that will, with minor changes, meet the group-to-individual portability provisions of the law. A number of other states already had individual market reforms that provide portability. Again, careful selection of states and subpopulations is indicated for the evaluation. For example, one would want to include states that modified existing risk pools, states that have adopted new risk pools, states with new guaranteed issue provisions, and states that had prior individual market reforms. Focusing on access, coverage, and premiums for high risk individuals leaving the group market (e.g., early retirees, those in poor or fair health) would increase the likelihood of finding possible effects.
It is not surprising that we expect limited quantifiable effects. HIPAA was targeted to address the most important insurance abuses and not to ensure affordable coverage (Lieberman, 1997). But, there are many implementation issues and problems facing employers, insurers, and regulators that also need to be addressed in the evaluation. One observer notes that HIPAA "may appear modest in scope to public policy makers, but it is anything but simple for the private sector" (Findlay, 1997). Monitoring employer and insurer efforts to document creditable coverage, insurer benefit design practices and the characteristics of products available to HIPAA eligibles, and state practices to insure compliance with HIPAA requirements, are all important issues that will need to be addressed as a part of a qualitative assessment of HIPAA.