Artists and Health Insurance Existing Data and Implications for by ijk77032

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									 Artists and Health Insurance:
  Existing Data and Implications for the
Washington Artists Health Insurance Project

                      March 2005
            Richard Minifie, The Sonata Group,
          with Claudia Bach, AdvisArts Consulting




   A Leveraging Investments in Creativity (LINC) Project
             in Partnership with Artist Trust




                    The Sonata Group, LLC
April 1, 2005

Dear Reader:

Artist Trust and Leveraging Investments in Creativity were both founded on the belief
that the contributions artists make to our communities and our lives are necessary to a
healthy society. Our work focuses on providing support, validation and career
development to individual artists, on building policies that are equitable to artists and on
increasing the demand and markets for their work. Dedication to a professional artistic
practice is not an easy life choice, yet it is a choice made by approximately 2 million
people in the United States. Our culture is richer because of that choice.

Through anecdotal evidence, we have long known that artists often go without many
amenities that come with financial security – steady income, home ownership, retirement
funding, adequate medical insurance coverage for themselves and their families. The
Washington Artists Health Insurance Project (WAHIP), with the help of our funders,
advisors and numerous supporters, is offering us the opportunity to tackle the issue of
health insurance with new focus.

This Sonata Group report, “Artists and Health Insurance: Existing Data and Implications
for the Washington Artists Health Insurance Project,” collects and analyzes the limited
research available about artists and their insurance coverage and needs, focusing on
Washington State artists. It is the first phase of WAHIP’s work. The report dovetails with
the next phase of WAHIP during which we will collect statistically-accurate data about
the health insurance issues facing artists through a statewide artist survey, and then work
to develop some realistic solutions to those issues.

We hope that WAHIP, a fairly modest endeavor that is focused on a very specific
population of largely self-employed people, may eventually contribute to increased
access to quality health care among 45 million uninsured Americans.

 Art and artists change lives every day, often in surprising ways. The WAHIP effort
represents the linkage of rigorous research, expertise, optimism and boundless creativity.

Sincerely,




Barbara Courtney           Sam Miller                     Claudia Bach
Artist Trust               LINC                           WAHIP Consultant
                                       Table of Contents


Table of Contents .................................................................................. 1
Executive Summary ................................................................................ 2
  Population Characteristics of Artists ......................................................... 2
  Healthcare Needs of Artists.................................................................... 4
  Health Insurance and Artists................................................................... 4
Main Report ......................................................................................... 6
  Background ....................................................................................... 6
  Purpose ........................................................................................... 7
  Report Layout.................................................................................... 8
  Population Characteristics of Artists ......................................................... 9
     Nature and Scope of Population ............................................................ 9
     Type of Artists and Number of Artists ..................................................... 9
     Personal Characteristics ....................................................................13
     Employment Characteristics ...............................................................21
     Attitude Characteristics ....................................................................25
     Summary ......................................................................................25
  Healthcare Needs of Artists...................................................................26
     Health Information on Artists ..............................................................26
     Other Information ...........................................................................27
  Access to Health Insurance of Artists........................................................29
     Artists and Health Insurance ...............................................................29
     Other Populations ...........................................................................30
     Increasing Costs..............................................................................32
     Summary......................................................................................32
  Implications for Health Insurance............................................................33
     Healthcare Needs............................................................................33
     Access to Healthcare Insurance ...........................................................34
     Cost of Health Insurance ...................................................................35
  Gaps in Data ....................................................................................37
  Alternative Insurance Models .................................................................37
  Conclusion and Key Findings ..................................................................38
     Key Findings ..................................................................................38
     Conclusions ...................................................................................39
     Recommendations ...........................................................................40
Appendices.........................................................................................41
  Appendix A – Gaps in Data ....................................................................42
  Appendix B - Alternative Health Models ....................................................44
  Appendix C - Washington State Access to Health Insurance Project....................47
  Appendix D - Glossary of Terms ..............................................................49
  Appendix E – Advisory Group Members ......................................................56
Bibliography........................................................................................57




Artists and Health Insurance Report                                                                  1
                                      Executive Summary


Artist and non-artist communities alike are facing increased risks and costs associated
with healthcare services and insurance. This report prepared for the Washington
Artists Health Insurance Project (WAHIP), a program of Leveraging Investments in
Creativity (LINC) and Artist Trust, summarizes the findings of numerous analyses in
order to draw conclusions on the artist population in Washington State, their
demographic characteristics, healthcare needs and insurance coverage.

This report looks closely at the artist population as an important step in WAHIP’s goal
to expand health insurance coverage to artists. A clear picture of the demographic
profile and the current healthcare status and needs of the artist population is essential
in the development of new coverage opportunities or approaches. The information
here is designed to provide a foundation for arts service organizations, health
policymakers and insurance providers to work together on insurance issues.
Additionally, the information garnered from the artist population is likely to be useful
regarding other populations or industries where there is limited employer based health
insurance.

Our analysis relied on a large number of existing research efforts, surveys and
available public information of varying degrees of depth and relevance. Generally
speaking we found reasonably reliable sources for demographic characteristics of artist
populations, with less useful information and weaker data regarding healthcare needs
and health insurance. Further research, such as the WAHIP Survey, scheduled for
spring 2005, will help supplement the information discovered and summarized in this
report and the gaps identified in the data.

Our review of available research concentrated on three primary areas of interest
related to artists: Population Characteristics; Healthcare Needs; and Health Insurance.
Based on our findings we are able to draw conclusions on the implications for health
insurance of artists.


Population Characteristics of Artists
Our desire in reviewing population characteristics of artists is to determine similarities
or differences between Washington artists and nationwide artists, as well as compare
the artists to general workforce populations. These comparisons allow us to draw
conclusions on the relative healthcare needs and health insurance implications of
Washington artists.

Type of Artists and Number of Artists

In general the density and mix of artists in Washington and Seattle seem to indicate
the region is a valid one for purposes of considering alternative non-employer based
insurance solutions. Washington and Seattle have a high concentration of artists as
compared to nationwide averages. The distribution of artists by artistic discipline is
relatively consistent with nationwide findings although Washington exhibits a
somewhat greater distribution of fine artists/art directors and writers, with fewer
actors, producers and musicians.


Artists and Health Insurance Report                                                     2
Personal Characteristics

Typically Washington artists have similar personal characteristics to nationwide artists.
Often the characteristics are similar to an average workforce as well. Some of the
findings by characteristic include:

Age, gender, race and marital status
The average age of primary occupation artists in Washington is nearly 7% higher than
the average age of the employed populations in the State. The proportion of males
among primary occupation artists is only slightly higher than the overall employed
population in Washington as well as in Seattle and the US as a whole. Primary
occupation artists in Washington State and the Seattle region tend to have a higher
proportion of whites than that for the total workforce. The available information is
limited but it appears that the percent married among artists (about 40%) is lower
than for the national workforce (45% to 50%).

Regional density and migration
A higher proportion of artists (48%) live in King County compared to other workers in
the labor force (33%). Within King County, Seattle has over three times the rate of
artists per employed person as compared to the rest of the county. Artists are more
likely to move from place to place and across state lines than the total workforce.

Education and income
Artists have higher education levels than the entire workforce. In Washington 60% of
artists have an associates or higher degree compared to 39% for the overall workforce.
This is similar to national education levels for artists and non-artists. Family income of
artists is somewhat lower than that for the total workforce in Washington. The
median family income of artists is $50,800 in Washington compared to $54,600 for all
employed families. However, there are a greater proportion of artists who fall below
or are above 500% of the federal poverty line compared to all employed persons,
indicating a skewing of economic success among artists.

Employment Characteristics

Employment characteristics is one area where artists as a group differ substantially
from a standard workforce population. These differences may have deep and long-
lasting impacts on the health status and health insurance costs to artists.

More artists are self-employed compared to other workers. In Washington 46% of the
employed artists are self-employed compared to 10.5% for the general workforce.
The unemployment rate among artists is higher than the overall unemployment rate of
the labor force by about 2 percentage points. This is true for Washington and the
nation as a whole. Artists are three times more likely to work for non-profit
organizations than the general workforce. Artists are far more likely to have second
jobs than most other professions. This tends to result in artists being undercounted in
surveys that use primary income generating occupation as the means of determining a
profession.




Artists and Health Insurance Report                                                     3
Healthcare Needs of Artists
Based on available information, artists appear to be approximately average in terms of
health status as compared to other populations. Further research is needed to
validate this finding.


Health Insurance and Artists
Available research indicates that artists have similar insured rates as for other
populations. Artists indicate that affordability of healthcare and insurance is a major
concern.

   •   It appears 70% to 85% of artists have some level of health insurance coverage,
       dispelling the belief that artists face considerably higher uninsured levels than
       other populations.
   •   Artists, however, in some cases indicate that high costs are a barrier to
       obtaining healthcare coverage.
   •   Certain employment characteristics of artists have an impact on health
       insurance. These include self-employment, unemployment, second occupation
       frequency and working for non-profit organizations.


Recommendations for further research
We believe further research is warranted to better understand the specific issues
facing artists in regards to healthcare related issues and health insurance. Efforts are
needed to fill in the gaps from available research including demographic information,
type of insurance coverage, employer size, premium costs, direct medical costs,
benefit cost-sharing, family size and covered lives, association memberships and other
factors. In particular, research is needed on direct medical expenses, health status,
avoided medical care, individual insurance and group insurance premium sharing, and
gaps in coverage.

A more definitive study of insurance coverage percentages and costs should be
performed by employment status (self-employment, large employer, small employer,
non-profit, and public employer). We recommend that analysis be performed for
different artistic professions. Substantial differences were found between some artist
professions in our analysis. A study on the impact of second occupations is desirable to
better understand how many artists receive coverage through their non-art related
occupation. A study on the number of artists obtaining coverage through their spouse
may also prove informative.

It is the goal of the 2005 WAHIP Survey to answer many of the questions raised by
these issues.




Artists and Health Insurance Report                                                   4
CONCLUSIONS
Based on the findings of our research review we are able to make several conclusions
regarding artists and health insurance in Washington.

    •   Artists as a whole appear to have uninsured rates that are similar to general
        workforce value. Specific artist professions may have more or less of a
        problem than artists in general.
    •   We believe the major issue facing the artist population in regards to healthcare
        costs and health insurance is the overall cost of these items to the average
        artist family. While specific research should be performed to validate our
        conclusion, we believe artist families pay more in direct medical expenses,
        premium sharing and member cost-sharing than does the average non-artist
        family. Our primary reasoning for drawing this conclusion is based on the
        following:
            o Self-employment rates for artists are higher – Self-employed individuals
                are more likely to purchase individual insurance which typically results
                in both a higher premium level (due to adverse selection pricing, and
                other considerations) and the worker footing a greater portion of or the
                entire premium bill. Self-employed individuals are also more likely to
                forego insurance coverage.
            o Unemployment rates for artists are slightly higher and for some
                professions within the art community are substantially higher – this also
                leads to uninsured and direct medical expenses,
            o Artists are more likely to work for non-profit firms – these types of
                organizations are less likely to offer benefits and when they do offer
                benefits it is more likely that the employee will share in the cost
                through both premium sharing and lower valued benefit plans (higher
                member cost-sharing).

We believe the artist population is an excellent population for studying alternative
non-employer based insurance solutions. While healthcare coverage and costs are a
major issue for most occupation groups, artists as a group are outside the employer
based insurance model. Artists are well represented in Washington and Seattle, and
have a high density in urban areas close to medical providers and insurance
alternatives. Further we believe artists as a group are more exposed to healthcare
costs and are financially motivated to explore alternative insurance options. The
findings in this report provide a basis for policymakers, insurance providers and others
to work together towards new opportunities in health care coverage.




This report and the Washington State Health Insurance Project is a program of Leveraging Investments in
Creativity (www.lincnet.net) in partnership with Artist Trust (www.artisttrust.org). Funding is provided in
part by the Paul G. Allen Family Foundation, Ford Foundation, and Nathan Cummings Foundation.




Artists and Health Insurance Report                                                                       5
                                      Main Report

Background

Health care and health insurance are at the center of national concern today. After
experiencing a few years of declining health insurance trend rates, we once again are
seeing the cost of covering medical care increase at double-digit inflation levels. The
percentage of population covered by health insurance is dropping; and employee
sharing of premiums is increasing while coverage levels are decreasing. For self-
employed individuals and contract employees it is becoming increasingly difficult to
find affordable healthcare plans.

The artist community, with its high levels of self-employment and perceived high level
of uninsured, is feeling the impact of these changes dramatically.

This report, commissioned by Leveraging Investments in Creativity (LINC) in
partnership with Artist Trust, draws upon available research to summarize information
about the artist population in Washington State and their healthcare coverage.

Leveraging Investments in Creativity (LINC) is a ten-year national campaign to improve
conditions for artists in all disciplines, so that artists can more readily perform their
creative work and contribute to community life. It is an outgrowth of research
undertaken by a consortium of 38 funders, resulting in the 2003 report by the Urban
Institute, “Investing in Creativity.”

The National Artists Insurance Initiative and the Washington Artists Health Insurance
Project (WAHIP) are LINC’s efforts to expand artists’ access to insurance.

The National Artists Insurance initiative is focused on creating a national network of
innovators and experts to identify and share ideas and best practices, and serve as a
catalyst for others. Additionally, they seek to develop information, tools and
approaches regarding access to insurance for artists and connect artists with other
allied interest groups.

The Washington Artists Health Insurance Project (WAHIP) is a pilot project, in
cooperation with the Artist Trust, to forge new strategies to improve artists’ access to
health insurance in Washington State. The project will serve as a model for
development of state-based health insurance initiatives to expand health insurance
coverage among artists.

Components of WAHIP include the creation of a consortium of experts from health
care, workers’ benefits, insurance, the arts and related sectors to identify
opportunities to expand artists’ access to health insurance and healthcare;
formulation of related plans, programs or services; and conducting research regarding
the artist population and insurance in Washington State that supports these goals.
This report is part of that research effort.




Artists and Health Insurance Report                                                    6
Purpose

The intent of this report is to provide increased information to healthcare
policymakers, the insurance industry and the arts sector regarding artists and health
insurance in Washington State.

The information in this report is intended to offer readers a foundation for making
decisions regarding artists and their health insurance. It may also serve as a valuable
illustration of populations that do not fit into the typical employer based insurance
models. Furthermore, the extension of health insurance to the artist community may
prove a useful model for exploring alternatives to employer based insurance solutions.

This report is based on review of available research on artist and non-artist
populations at the national and the state levels. The available research on artists and
their health insurance coverage is limited and in many instances draws upon data that
are not statistically credible. Moreover, the studies are not comparable because the
researchers use varying basis for defining both the artist population and their health
insurance coverage. In recognition of these limitations the conclusions in this report
reflect the expert deductions of the authors based on the findings drawn from
disparate and not always statistically credible research reports. Despite these caveats
the report brings together the best possible estimates on artists and their health
insurance coverage from the available research reports and articles.

The research and data sources used to prepare this report are listed in the
bibliography. A few research reports because of their scope and quality were central
to the preparation of this report; they are:

   •   Markusen and Schrock based on the Current Population Survey (CPS),
   •   National Endowment for the Arts (NEA) based on the Bureau of Labor Statistics
       (BLS),
   •   Census Bureau data,
   •   Medical Expenditure Panel Survey (MEPS) data.

In addition to these sources we also regularly refer to the Washington State Access to
Health Insurance Project (a federally funded grant program), which, although it has a
small sample size of primary occupation artists, is consistent with other larger samples
and is directly applicable to the population being studied.

The reader should be aware that many of the figures in this report are based on
limited data sources with small sample sizes. While caveats are made in some
sections of the report, this initial caveat is intended to serve as a reminder to the
reader that, other than the above sources, all conclusions and calculations should be
validated through larger research efforts before the assumption of accuracy is made.
The smaller data sources and research efforts are included in order to paint the best
overall picture of artists, healthcare and insurance.




Artists and Health Insurance Report                                                   7
Report Layout

The remainder of this report summarizes available research in the following manner:

   1.   Population Characteristics of Artists
   2.   Healthcare Needs of Artists
   3.   Access to Health Insurance of Artists
   4.   Implications for Health Insurance

Appendices are also included for several subjects as follows:

   •    Appendix   A – Gap Analysis
   •    Appendix   B – Alternative Health Insurance Models
   •    Appendix   C - Washington State Access to Health Insurance Project
   •    Appendix   D – Glossary of Terms
   •    Appendix   E – Advisory Board Members




Artists and Health Insurance Report                                                   8
Population Characteristics of Artists

Nature and Scope of Population
Artists comprise a unique and disparate population.          Ranging from symphony
performers to part-time craft artists, from ballet troupe members to photographers, it
is no easy task to define an “artist”. There is no accepted list of professions that
constitutes the artist community. It is important that the reader keep in mind that
the definition of an artist may differ from source to source and that, accordingly
differences in findings may be the result of a difference in underlying artist mix.
Where possible these differences are noted.

It should also be noted that the majority of data sources regarding artists summarized
in this report refer to artists as only those who self-report their primary occupation as
being that of artist. Those artists with a primary occupation other than art-related
are typically NOT covered in the analysis unless explicitly noted. The characteristics
of artists whose art related careers are primary versus secondary can vary
substantially. The reader is reminded to take this into consideration.


Type of Artists and Number of Artists
Several research sources study the mix and number of artists within the Washington
community and the nation as a whole. In particular, data collected by Markusen and
Schrock from the Current Population Survey (CPS) and information from the National
Endowment for the Arts (NEA) from the Bureau of Labor Statistics (BLS) contained
useful information on the mix of artists.

The definition of “artist”, as mentioned above, impacts the estimate of the number of
artists for a population. Also key is whether a particular source considers artists who
have a primary job in a non-artist capacity.

Based on available information, we estimate that Washington State is home to
approximately 19,400 primarily employed artists with nearly 60% of those living in the
Seattle region. Due to both the criteria of artist as a primary occupation and the
definition of artist we believe these figures may underestimate the true number of
artists by 15% to 20%1.

Table 1 summarizes the relevant CPS and BLS information. As shown, adjustments are
made to account for employed civilian workforce artists in the Markusen analysis, and
to similar occupation definitions in the NEA analysis.




1
 Alper, Neil and Gregory Wassal. 2000. “Once in a Blue Moon” reports a 10% to 20%
underestimate. An NEA summary of BLS study shows an 18% underestimate.


Artists and Health Insurance Report                                                    9
                                                  Table 1
                                           Artist Populations, 2000


                                                   Artist Labor Force1

                                                                                      Total US
             Study                            Seattle     Wash.         U.S.        Labor Force
             Markusen2                        13,656     24,603      1,119,599
             Markusen - employed2             10,768     18,691        860,814      129,708,876
                   3
             NEA                                         46,465      1,927,400      137,668,735
                               4
             NEA - adjusted                              20,030        930,350      137,668,735


             Derived estimate                 11,200     19,400        895,000

                                                Artists as share of labor
                                                          force
                                              Seattle     Wash.         U.S.
                                       2
             Markusen - employed               0.88%      0.68%           0.66%
                               4
             NEA - adjusted                               0.67%           0.68%


             Derived estimate                  0.88%      0.68%           0.67%


             1. Includes only primary occupation artists. Total may be 10% to 25% higher.
             2. From Markusen analysis of 2000 Census Bureau data.
             3. NEA Note #85, Artist Labor Force by State, 2000.
             4. All artist occupations less architects, designers and announcers.



The differences in the two studies shown in Table 1 may be the result of many factors,
in particular self-reported information. As shown, when adjusting the Markusen
Census data to account for only employed artists and using the adjusted NEA summary
of BLS information, the estimated proportion of artists in the civilian labor force is
quite similar. Washington is estimated to have 0.67% to 0.68% of the workforce as
artists, with a nationwide estimate of 0.66% to 0.68%, indicating that Washington is
essentially average in terms of artists in the labor force. Seattle area artists are
estimated at a somewhat higher share of the labor force of 0.88%.

Derived estimates, as shown in Table 1, represent our estimate based on the
combination of data sources.

Another measure of the penetration of artists in a community is the number of art
related businesses found in a region. According to a study by Americans for the Arts
the Seattle-Tacoma-Bremerton area ranks eighth in terms of number of arts-related
businesses, institutions and organizations with 12,138 as of January 2004. Per capita
this places Seattle-Tacoma-Bremerton as the number one MSA (Metropolitan Statistical


Artists and Health Insurance Report                                                               10
Area) with an average of 3.415 arts-related businesses, institutions and organizations
per 1,000 lives2.

This finding of arts related businesses is consistent with Markusen’s findings of overall
higher concentrations of artists in the Seattle region. Among studied MSAs, Markusen
places Seattle fourth (behind Los Angeles, New York and San Francisco/Oakland) using
a concentration ratio (artist share % for the region divided by artist share % for the US
as a whole).

The mix of artists found in the Seattle and Washington area is different from that
found in other regions and the nation as a whole. Chart 1 summarizes the mix of
artists in Washington State3. Table 2 contains a summary of available information
regarding the distribution of artists in the region4. Based on the NEA analysis,
Washington has a greater distribution of fine artists/art directors and writers, with
fewer actors, producers and musicians as shown in Chart 2.


                                                                            Chart 1
                                                                   Distribution of Artists
                                                                  Washington State, 2000




                                                                           Other
                                                  Photographers
                                                                            3%
                                                      13%                                           Fine artists & art directors
                                                                                                                31%




                                           Writers
                                            21%                                                            Actors
                                                                                                            2%
                                                                                                   Producers
                                                               Musicians
                                                                 16%                                 12%
                                                                                       Dancers & choreographers
                                                                                                  2%

    Source: NEA Note #85, Artist Labor Force by State, 2000.




2
  Americans for the Arts release. June 28, 2004.
3
  NEA Note #85. May 2004.
4
  NEA and Markusen analysis of 2000 Census data.


Artists and Health Insurance Report                                                                                                11
                                                                                                  Table 2
                                                                              Artist Distributions, 2000



                                                                                                                 US
                                    NEA - Adjusted1                                                             Total                      WA             Seattle
                                    Fine artists & art directors                                                 24.9%                 30.3%
                                    Actors                                                                        4.1%                     2.0%
                                    Producers                                                                    15.0%                 12.4%
                                    Dancers & choreographers                                                      2.9%                     1.9%
                                    Musicians                                                                    18.3%                 16.3%
                                    Writers                                                                      17.4%                 20.4%
                                    Photographers                                                                13.3%                 13.5%
                                    Other                                                                         4.0%                     3.2%
                                    Total                                                                       100.0%       100.0%

                                                                                                                 US
                                    Markusen2                                                                   Total                   WA                Seattle
                                    Visual artists                                                                                     46.2%               45.8%
                                    Performing artists                                                                                 17.0%               17.9%
                                    Musicians & composers                                                                              16.9%               15.5%
                                    Writers & authors                                                                                  20.0%               20.8%
                                    Total                                                                                    100.0%                       100.0%


                                    1. NEA Note #85, Artist Labor Force by State, 2000.
                                    2. From Markusen analysis of 2000 Census Bureau data.

                                                                                                  Chart 2
                                                             Washington vs U.S. Distribution of Artists, 2000
                    35%

                    30%

                    25%

                    20%

                    15%

                                                                                                                                                                    U.S.
                    10%
                                                                                                                                                                    Washington
                      5%

                      0%
                                                                                 choreographers


                                                                                                    Musicians




                                                                                                                           Photographers
                               Fine artists & art




                                                                                                                                                  Other
                                                                  Producers
                                                    Actors




                                                                                                                 Writers
                                                                                   Dancers &
                                  directors




 Source: NEA Note #85, Artist Labor Force by State,
 2000.




Artists and Health Insurance Report                                                                                                                                         12
With different occupational categories (Visual artists, performing artists, musicians &
composers and writers & authors) the Markusen research indicates that the difference
in artist distribution between Washington State in total and its primary MSA Seattle is
relatively minimal. The biggest difference is a slight decrease in musicians offset by
smaller increases in performing artists and writers & authors as summarized in Chart 3.


                                                                        Chart 3
                                            Seattle vs Washington Distribution of Artists, 2000


    50%

    45%

    40%

    35%

    30%

    25%                                                                                                            Washington
                                                                                                                   Seattle
    20%

    15%

    10%

      5%

      0%
                    Visual artists                Performing artists   Musicians & composers   Writers & authors
 Source: Markusen analysis of 2000 Census data.




Both the number of artists and number of art related businesses in Washington State,
in general, and Seattle, in particular, point towards the region being a prime
candidate as a model for exploring alternative health insurance models. Seattle has a
high concentration of artist-related businesses per capita and artists per capita. With
relatively average artist distributions the region should be representative of a typical
artist population and should also be able to draw upon experiences from other similar
regions.


Personal Characteristics
Having determined that the Washington region has a relatively average distribution of
artists by occupation, the next analysis is a study of the personal characteristics of the
artist population which include:

    •      Age/gender
    •      Race
    •      Regional Density
    •      Education
    •      Marriage Status and Family Size
    •      Family Income
    •      Migration

Here again, we rely on the Markusen analysis of Census 2000 data for a large portion of
our artist characteristic data. We rely on a few other sources for national or other
regional data regarding both artist and non-artist populations. As a reminder, when


Artists and Health Insurance Report                                                                                        13
discussing an “artist” for the majority of these data sources we are referring to those
included in the research who self-report their primary occupation as art-related.

Age/gender
The average age of primary occupation artists in Washington is about 42 years, which
is nearly 7% higher than the average age of the employed populations in the State.
The average age of the artists in Seattle and the US is slightly lower than that of
Washington State.

The proportion of males among primary occupation artists is higher than the overall
employed population in Washington as well as in Seattle and the US as a whole. The
proportion of male artists is lower in Washington (54%) as compared to artists across
the U.S. (56%).

Table 3 displays age and gender information for artists in the U.S., Washington State
and Seattle regions5. The table shows that artists who report their primary job as art-
related tend to be older than the total employed population; specifically, the average
Washington artist is 6% to 7% older than the average employed person in the state. The
age difference is somewhat lower for Seattle and the entire US. The age difference
between the artists and employed populations is due to expected higher number of
65+ aged artists and also due to unexpected lower number of <35 artists.

Note that the average ages shown in Table 3 are not the actual averages of the
populations, rather they are approximations for the purpose of comparison6.

Chart 4 displays age distributions for artist and all employed populations in Washington
State.

Table 3 also demonstrates that artist populations tend to have a slightly higher
concentration of males than females, with Washington and Seattle regions averaging
approximately 54% to 56% male artists compared to only 53% to 54% for a standard
population. Nationally there is also a higher ratio of males in the employed artists
population than for the average workforce.




5
 Markusen, Ann and Greg Schrock. 2004. Analysis of 2000 Census data.
6
 Distribution weighted by a mid-point of the age bands in the research (e.g., 25-34 assumed to
be 29).


Artists and Health Insurance Report                                                         14
                                                              Table 3
                                            Artist Age and Gender Characteristics, 20001



                                                             US                       WA                       Seattle

                                                               All                      All                            All
                      Age2                         Artists   Employed       Artists   Employed           Artists     Employed
                       <35                           33.8           37.1      30.6            36.6         33.6             37.8
                     35-64                           60.2           59.6      62.3            60.9         60.8             59.9
                       65+                             6.0            3.4      7.1              2.5         5.6              2.3
                     Total                          100.0          100.0     100.0          100.0         100.0           100.0


 Average Age                                         40.8           39.3      41.9            39.2         40.5             38.9
     Artists % of All Employed                    103.8%                    106.7%                       104.2%


                   Gender2
                      Male                           56.3           53.3      53.6            53.4         55.7             53.7
                   Female                            43.7           46.7      46.4            46.6         44.3             46.3


 1. From Markusen analysis of 2000 Census Bureau data.

 2. Only primary occupation artists are included. Including all artists may change distributions.




                                                                  Chart 4
                                      Washington State Age Distribution: Artist vs All Employed

   30%


   25%


   20%


   15%                                                                                                             WA Artists
                                                                                                                   WA All Employed

   10%


     5%


     0%
                 16-24               25-34          35-44         45-54       55-64        65 and over
 Source: Markusen analysis of 2000 Census
 data.




Artists and Health Insurance Report                                                                                             15
There were several other sources that contain information on age and gender of artists
(but not of non-artist populations)7,8,9,10. There was variation in these data sources
and none were as credible as the Markusen summaries.

Generally, the differences between artists and overall populations in Washington and
Seattle are minor.

Race
Artists in Washington State and the Seattle region tend to have a higher proportion of
whites than that for the total workforce. 87% of Seattle artists and 89% of
Washington artists are estimated to be white, which is higher than the percent of
whites among all employed persons, 79% in Seattle and 82% in Washington.

The race estimates were also derived from the Markusen study. These estimates were
similar to estimates reported by the Access to Health Insurance analysis which also
found high proportions of artists to be white.

Regional Density
A higher proportion of artists (48%) live in King County compared to other workers in
the labor force (33%).

Within King County, Seattle has over three times the rate of artists per employed
person as compared to the rest of the county.

Both the Markusen Census data and the Access to Health Insurance information point
towards artists tending to live in urban or King County regions. Although artists are
spread throughout the state, a high proportion live in counties surrounding Puget
Sound.

According to the Census data used by Markusen, for instance, 33% of all employed
persons live in King County, but fully 48% of employed artists live in the county. The
Access to Health Insurance analysis also indicated a high proportion of respondents in
the King County region.

Within King County, the City of Seattle has over 3 times the rate of artists per
employed person than the rest of the county with 1.8% of the employed population
reporting as employed artists. This compares to a statewide average of 0.7%. Chart 5
displays artists as a percent of all employed by region.




7
  Hamilton, Jenny. Washington State Access to Health Insurance Project. 2002 and 2004.
8
  Future of Music Coalition. August 26, 2002. “Health Insurance and Musicians.”
9
  Jeffri, 1998. Information on Artists 2.
10
   Dreeszen, Craig. October 2004. Craft Emergency Relief Fund – National Craft Artist
Research Project.


Artists and Health Insurance Report                                                      16
                                                                      Chart 5
                                                      Artists as Percent of All Employed, 2000



            2.0%

            1.8%

            1.6%

            1.4%

            1.2%

            1.0%

            0.8%

            0.6%

            0.4%

            0.2%

            0.0%
                                     Seattle                       King County                   WA State
     Source: Markusen analysis of 2000 Census data.




Other available information did not contradict these findings11.


Education
Artists have higher education levels than the entire workforce. In Washington 60% of
artists have an associates or higher degree compared to 39% for the overall
workforce. This is similar to national education levels for artists and non-artists.

Available data sources consistently indicate a high level of education among the artist
populations. Among the Markusen Census 2000 data, 60% of Washington and 64% of
Seattle employed artists have an associates or higher college degree. This compares
to 39% and 47% for the general workforce for Washington and Seattle, respectively.
On a national basis artists are also more highly educated than the average workforce
member with 61% of employed artists having a college degree compared to 35% for the
average employed person. Chart 6 summarizes distribution by education for artists
and all employed.




11
  The Craft Emergency Relief Fund study found that 35% of craft artists surveyed live in an
urban setting.


Artists and Health Insurance Report                                                                         17
                                                                         Chart 6
                                                      Distribution of Artists by Level of Education
                                                                 Washington State, 2000

            40.0

            35.0

            30.0

            25.0

            20.0
                                                                                                                   Artists
            15.0                                                                                                   All Employed

            10.0

             5.0

             0.0
                    Less than high      High school or    Some college   Associates   Bachelors   Masters degree
                       school             equivalent                      degree       degree       or higher
     Source: Markusen analysis of 2000 Census data.




Other sources also found high levels of education amongst artists12,13,14.


Marriage Status and Family Size
The available information is limited but it appears that the percent married among
Artists (about 40%) is substantially lower than for the national workforce (45% to
50%).

Few of the research sources provide information regarding marital status or family
size. This is unfortunate because marital status and family size are important
considerations for health insurance purposes. In fact, spousal coverage can be a major
source of coverage for those who do not have employer provided insurance.

Jeffri’s studies had 37% to 38% of respondents indicate they were married for the four
sites under consideration.

These marriage rates compare to national workforce levels of 45% to 50% for a typical
commercial population. While this might indicate a lower than average marriage rate
amongst artists it is likely that the survey sources are not sufficient to draw this
conclusion.

Jeffri’s work does contain estimates for the populations she surveyed.        Her
information indicated 59% to 60% of artists were singles with no other dependents.



12
   The Access to Health Insurance analysis information also found that 60% of artist respondents
in Washington had a college degree, matching the Census information exactly.
13
   Jeffri, in her Information on Artists 2 studies, found a very high percentage of her
respondents to have college degrees, ranging from 78% to 81% for the four sites studied.
14
   NEA Research Notes also reported a high level of education among artists.



Artists and Health Insurance Report                                                                                          18
Artists with one dependent comprised 25% of the population, with the remainder (15%
to 16%) having two or more dependents.

In contrast the rates for national workforce are in the range of 45% single, 20% with
one dependent, and 35% with two or more dependents. Despite the limited
information, it would appear that fewer artists are married and those who are married
have fewer dependents compared to the overall workforce.

Other sources showed similar lower levels of marriage15.


Family Income
Family income of artists is somewhat lower than that for the total workforce in
Washington. The median family income of artists in 2000 was $50,800 in Washington
compared to $54,600 for all employed families. However, there are a greater
proportion of artists who either fall below or are above 500% of the poverty line
compared to all employed persons, indicating a skewing of economic success among
artists.

A common perception is that of the starving artist. Census data collected by Markusen
on family income, however, paints a different picture. While it is true that a greater
portion of artists are under the poverty line than for all employed persons, it is also
true that there is a greater portion of artists who have a family income greater than
500% of the poverty line. Specifically in Washington, 7% of employed artists have a
family income less than the poverty line compared to 6% for the typical employed
person and 41% of employed artists have a family income greater than 500% of the
poverty line compared to 38% for the average workforce. A similar pattern is observed
at the national level as well as in Seattle.

Correspondingly there is a lower percent of artists whose household incomes fall
between 200% and 500% of the poverty line. This indicates that as compared to a
standard workforce a greater portion of artists struggle to make financial means meet,
but when artists are successful their success is often greater than for other
professions.

Chart 7 contains a summary of the distribution of family income by percent of poverty
line for artists and all employed in Washington State for 2000.




15
 The Future of Music Coalition survey had only 29% of respondents indicate they were
married. Undoubtedly this is because the respondents were skewed towards younger males.


Artists and Health Insurance Report                                                       19
                                                                  Chart 7
                                Distribution of Artists by Family Income as % of Poverty Line, 2000

   45%

   40%

   35%

   30%

   25%
                                                                                                            WA Artists
   20%
                                                                                                            WA All Employed

   15%

   10%

     5%

     0%
            500% or more           400-499%        300-399%      200-299%    100-199%   Less than 100%
 Source: Markusen analysis of 2000 Census data.




For illustrative purposes, Table 4 displays recent official average poverty thresholds by
selected family size as reported by the US Census Bureau.

                                                                Table 4
                                                  Poverty Thresholds, 2001 to 20041



          Family Size                                          2001          2002           2003          2004


          One person <65                                      $9,214        $9,359        $9,573         $9,827


          Family of four2                                     $17,960       $18,244       $18,660        $19,157



          1. U.S. Census Bureau.
          2. With two related dependent children.



Median family income in 2000 of artists ($50,800) is somewhat lower in Washington
than all occupations ($54,600). This differs from the nationwide average where
employed artists have a higher median family income at $56,000 compared to $54,000
for total workforce. Seattle area artists are similar to Washington artists in total, in
that their incomes are lower than national income for artists.




Artists and Health Insurance Report                                                                                      20
Other data sources gave mixed results with some similar to the Markusen data16 and
others indicating a not so rosy picture. The latter, however, tend to be more skewed
to particular survey samples.


Migration
Artists are more likely to move from place to place and across state lines than total
workforce.

One factor that is sometimes overlooked when considering healthcare insurance is the
tendency of a population to migrate in and out of regions. To the extent that
migration crosses state lines (and even within smaller regions to some extent) it may
prove more difficult for a person to maintain consistent healthcare insurance. Waiting
periods and qualifying requirements can complicate the health insurance process.
Well established persons with existing health insurance who do not migrate out of an
area are more likely to keep existing health insurance than those who move.

Markusen analyzed Census 2000 data on migration characteristics of employed artists.
Of most interest are those moving over state lines. Table 5 shows that employed
artists are less likely than other occupations to remain in the same house
(approximately 2 to 3 percentage points for both Washington and the U.S.) and are
more likely to move across state lines (3 and 7 percentage points respectively).

                                                  Table 5
                                         Artist Migration, 20001


                                                        WA state             United States

                                                               All                     All
           Migration status, 5 years ago           Artists   Employed      Artists   Employed
           Lived in same house                      43.6           46.0     47.3       50.8
           Moved within state                       39.0           39.2     30.9       33.3
           Moved into state                        17.4             14.8    22.7       15.9
                                         Totals    100.0           100.0   100.0      100.0


           1. From Markusen analysis of 2000 Census Bureau data.




Employment Characteristics
Just as personal characteristics are useful in assessing health insurance coverage so
too are employment characteristics.        Three aspects of employment, namely


16
  The Access to Health Insurance analysis displays a remarkably similar result for a limited
survey. Over 80% of survey participants were at levels of family income in excess of 200% of
the poverty line. This compares to the Markusen Census information that puts the number of
employed artists with family income in excess of 200% of the poverty line at 81%.


Artists and Health Insurance Report                                                             21
employment status, self-employment and second employment status, are described
below.

Employment Status
The unemployment rate among artists is higher than the overall unemployment rate
of the labor force by about 2 percentage points. This is true for Washington and the
nation as a whole.

 Artists are three times more likely to work for non profit organizations than the
general workforce.

Naturally, one of the primary methods for obtaining health insurance is to be covered
through an employer’s benefit plan. In 2003, the U.S. Census Bureau estimates that
60% of Americans were covered through employment-based insurance.

According to NEA research of BLS statistics, the 2003 nationwide unemployment rate
for all artists reached 6.1%. This compares to the unemployment rate for the total
civilian workforce of 5.6%. For adjusted NEA artists (removing architects, designers
and announcers) the unemployment rate increases to 7.7%.

Chart 8 displays nationwide unemployment rates from 2000 to 2003 for the civilian
workforce, all professionals, all artists and adjusted artists (all artists less architects,
designers and announcers) from an NEA study.


                                                                                    Chart 8
                                                   Nationwide Unemployment Rates: 2000 to 2003

 9.0%

 8.0%

 7.0%

 6.0%

 5.0%                                                                                                Total civilian workers
                                                                                                     Professional occupations
 4.0%                                                                                                All artist occupations
                                                                                                     Adjusted artist occupations
 3.0%

 2.0%

 1.0%

 0.0%
                       2000                              2001                          2002   2003
 Note: Adjusted artists is all artists less architects, designers and announcers.
 Source: NEA Note #87, Artist Employment in 2003.




Chart 9 shows 2003 nationwide unemployment rates for artistic professions.




Artists and Health Insurance Report                                                                                             22
                                                                                                           Chart 9
                                                       Nationwide Unemployment by Artist Profession, 2003
                        35%

                        30%

                        25%

                        20%

                        15%

                        10%

                          5%

                          0%




                                                                                                                                                                                 Announcers
                                                                              choreographers


                                                                                               Musicians




                                                                                                                        Photographers
                                  Fine artists & art




                                                                                                                                        Other artists


                                                                                                                                                        Architects


                                                                                                                                                                     Designers
                                                                Producers &
                                                       Actors




                                                                                                              Writers
                                                                 directors

                                                                                Dancers &
                                     directors




     Source: NEA Note #87, Artist Employment in 2003.




Other research sources found consistent unemployment rates among artists17.

While we did not discover useful information regarding artists by size of firm, using
Census data it can be shown that of those artists who are employed by an employer, a
much higher proportion work for nonprofit organizations than for the standard
workforce.    Roughly three times the proportion of artists work for nonprofit
organizations than in the standard workforce. This holds true for both Washington and
nationwide artists.

It is our supposition that of those working for a private employer a larger than normal
percentage work for smaller employers. Further research will be needed to validate
this supposition.

Self-employment
More artists are self-employed compared to other workers. In Washington 46% of the
employed artists are self-employed compared to 10.5% for the general workforce.

Markusen analyzed Census 2000 self-employment rates for employed artists and found
that artists are far more likely to be self-employed than individuals for total
occupations. As shown in Table 6 and Chart 10, nearly 46% of employed artists in
Washington are self-employed as compared to 10.5% for the general workforce. These
findings are similar for Seattle and for nationwide figures as well.




17
  Jeffri reported unemployment rates ranging from 7.4% to 8.6% for artists she surveyed in the
four sites of her studies for 1997.



Artists and Health Insurance Report                                                                                                                                                           23
                                                                          Table 6
                                             Employed artists by self-employment status, 20001


                                                                      United States                    WA state                   Seattle

                                                                                  All                            All                    All
 Self-employment status                                            Artists      Employed          Artists      Employed   Artists     Employed
 Self-employed, unincorporated                                        33.6               6.6        39.6            7.3     35.7              6.4
 Self-employed, incorporated                                           6.3               3.2         6.0            3.2       7.2             3.3
 Wage and salary, private employer                                    41.8             68.1         35.5           66.0     40.0             70.2
 Wage and salary, nonprofit                                           13.5               7.1        13.1            6.8     11.4              6.8
 Wage and salary, public                                               4.5             14.6          5.5           16.3       5.5            13.1
 Unpaid family worker                                                 0.4              0.3          0.3             0.3     0.2               0.2
 Totals                                                             100.0            100.0        100.0           100.0   100.0             100.0

 1. From Markusen analysis of 2000 Census Bureau data.




                                                                     Chart 10
                    Distribution of Washington Artists and All Employed by Employment Status, 2000



     70%

     60%

     50%

     40%
                                                                                                                            Artists
     30%                                                                                                                    All Employed

     20%

     10%


       0%
                Self-employed          Private employer   Non-profit employer   Public employer        Other

   Source: Markusen analysis of 2000 Census data.




Second Occupation Status
Artists are far more likely to have second jobs than other workers. This tends to
result in artists being undercounted in surveys which use primary income generating
occupation as the means of determining a profession.

Complicating the discussion of health insurance and artists is the number of artists
with second occupations. These can be individuals who either perform their art as
their primary job, with a secondary job being another occupation, or whose artistic
career is actually their second occupation. Both of these scenarios can complicate the
health insurance discussion.


Artists and Health Insurance Report                                                                                                   24
As mentioned above those individuals with artistic based second occupations are not
counted in many research analyses and thus the number of artists may be
undercounted by 15% to 20% for some studies. These individuals, however, do hold
primary jobs that may or may not provide health insurance benefits. Additionally,
some analysis suggests that a substantial portion of artists who list their primary
occupation as something other than art based are likely to pursue their art regardless
of its monetary return.

A 1995 study by the Monthly Labor Review18 demonstrated that several artist
occupations had high levels of employees who worked a second job. The top
occupation for which employees worked second jobs was firefighters with 28.1% with
second occupations. However, several artist occupations finished in the top 15, led by
“Artists, performers, and related workers, not elsewhere classified” with 16.0%
working second jobs. Also high on the list were “Musicians and composers” and
“Actors and directors” with 13.0% and 11.8%, respectively.


Attitude Characteristics
Attitude information on artists is not dealt with in the available studies. But attitudes
are important to addressing issues of health insurance coverage. Some of the
important among them are:

     1.   Willingness of artists to join groups for the purpose of healthcare coverage,
     2.   Extent to which artists are willing to accept assistance or subsidized programs,
     3.   Ability of artists to withstand hardships more than an average population,
     4.   Willingness to try new approaches and creative solutions.

There is some indication that artists appear willing to join groups for the purpose of
obtaining health insurance19.


Summary
The analysis of Washington and Seattle area artists’ artistic disciplines, personal
characteristics and employment characteristics as summarized above indicate a
population that is quite consistent with national artist populations. Additionally, this
artist population is often quite consistent with general workforce populations. These
consistencies lend credence to the idea that other regions and other population’s
experiences with alternative healthcare or insurance programs can be drawn upon to
form concepts that may prove useful to Washington State artists. Also, should an
alternative health insurance device for artists prove successful in this state that
experience may extrapolate well to other similar situations.

In a following section (Implications for Health Insurance), the key summary findings
from each of the above characteristics are used to discuss their implications on health
insurance coverage and costs.


18
  Monthly Labor Review. 1995. Characteristics of multiple jobholders.
19
  Community Partnership for Arts and Culture. February 2005. “Advancing Support Systems
for Artists in the Cleveland Metropolitan Area.” 73% of respondents indicated a desire to obtain
health insurance through an insurance consortium.


Artists and Health Insurance Report                                                           25
Healthcare Needs of Artists

Unlike for demographic characteristics we did not find a data source that stood out as
encompassing all artists in regards to their health care needs and health status. Given
the similarities between Washington artists and U.S. artists any nationwide data on
artists’ health status would likely be relevant to the Washington region. In the
absence of a good all-encompassing study, however, we must instead review anecdotal
survey information and health status for similar types of populations or individuals.

Health Information on Artists
Though there are few sources, it appears artists may be at least average in health
status. There is some indication that certain artist professions are more likely to be
exposed to occupational hazards.

Following are a few sources pertinent to artist’s healthcare status and needs. Many of
these sources are based on limited survey information.

     •   The Access to Health Insurance analysis of artists indicates that artists and
         their family members generally consider themselves to be healthy (either
         excellent or very good health) regardless of insured status. However, those
         describing themselves as being in poor health were more likely to be uninsured.
     •   Investing in Creativity20 , a study of U.S. artists, found that a high proportion of
         artists (51%) were exposed to occupational hazards, including dangerous
         chemicals for visual artists, body stress by dancers and so forth. To the extent
         these workers are not covered by workers’ compensation these injuries and
         illnesses will be a health insurance burden and need.
     •   A study on independent workers in New York City21 (many of whom are
         classified as being in “creative” occupations) found that of uninsured workers
         fully 85% avoided seeking medical care due to lack in coverage in the previous
         two years. This finding was echoed by a study Health Care Coverage in
         America22, which found that the uninsured were over twice as likely to forego
         treatment for serious symptoms, even those for which care was thought
         necessary. While this does not necessarily reflect on the health status of
         artists as a whole, it does indicate that uninsured workers may face increased
         health care needs due to lack of coverage and resulting poorer health status.
     •   Insurance      rate    setting     industry      information23     indicates    that
         occupations/industries such as entertainers have healthcare needs that are less
         than average (from 0% to 5% lower on the average, adjusted for differences in
         age, gender, region and other risk factors). This type of information is useful
         in determining whether artists have greater or lower healthcare needs than a
         standard workforce. The different characteristics of artists (age, gender,
         region, marriage status) can also be used to adjust for varying healthcare
         needs.

20
   Jackson, Maria Rosario et al. 2003. “Investing in Creativity, A Study of the Support Structure
for U.S.” Artists, 2003.
21
   Buchanan, Stephanie and Sara Horowitz. 2004. “Educated, Employed and Uninsured, How
Independent Workers Fall Out of the Social Safety Net, Working Today.”
22
   Cover the Uninsured Week. 2004. “Health Care Coverage in America: Understanding the
Issues & Proposed Solutions.”
23
   Health insurance industry rate setting factor information, The Sonata Group.


Artists and Health Insurance Report                                                            26
Other studies show that artists say their health status decreases with age24 and that
groups formed for the purpose of obtaining health insurance tend to have higher
healthcare costs25.

Other Information
Not much information is available, but other occupations with high levels of self-
employment find themselves to be healthier than does an average workforce. Also,
uninsured individuals tend to be healthier than those in public programs.

Given the dearth of information on artist’s health status and needs we also look to
other sources to draw conclusions regarding particular characteristics of artists in
general.

According to a 2003 survey of households (MEPS)26 individuals covered by private
healthcare insurance were far more likely to list their health status as better than
good (excellent and very good) than either those covered under public insurance or
the uninsured. Interestingly, however the uninsured population generally listed their
health status as better than those covered by public programs, as shown in Table 7.



                                              Table 7
                         Healthcare Status by Type of Insurance, 20031



                        Status        Private    Public     Uninsured
                         Good +          71.1%    55.2%           59.9%
                          Good           21.9%     26.2%           27.8%
                         < Good           7.0%     18.6%           12.3%
                                       100.0%     100.0%          100.0%


                        1. MEPS, 2003 data.



This finding was echoed in other similar studies. Even catastrophic coverage pools are
often shunned by the uninsured as being too expensive (Seattle Times report27) which
can explain part of this finding.




24
   Jeffri on San Francisco artists found that 56% of respondents said their healthcare needs have
increased with age.
25
   Fraternal organizations, etc., often have a higher corresponding healthcare cost (5% to 10%),
insurance industry information, The Sonata Group.
26
   Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality:
Medical Expenditure Panel Survey, 2003.
27
   Most high-risk consumers shun costly insurance pool, Seattle Times, January 22, 2005.


Artists and Health Insurance Report                                                           27
Although not many other similar populations were found, at least one with high self-
employment rates was found whose members rated themselves to be healthier than
did other workers28.

Little other information was found regarding health status of artists or other similar
occupations. Based on the information that was available we see no reason to assume
that simply being an artist impacts ones need for healthcare or health status any
differently than other average occupations.




28
  Health Care For All. November, 1996. “Health Survey of the Fishing Population in
Massachusetts.” This study of a population with a high proportion of self-employed or small
business employees found that workers considered themselves to be relatively healthy. The
working fishing population, both insured and uninsured, had only 5% who considered
themselves to be in poor or fair health. This compared to statewide averages of 16% of
uninsured and 8% of insured that considered themselves to be in poor or fair health.


Artists and Health Insurance Report                                                           28
Access to Health Insurance of Artists

Based on a review of available information, as summarized above, we have a relatively
good understanding of both the characteristics and, to a lesser extent, the health
needs of artists in Washington. What remains is a review of the information regarding
health insurance and artists. Geographically, we already know that a high proportion
of artists live in major MSAs, which indicates access to healthcare providers should not
be an issue.

Artists and Health Insurance
Based on available information it appears 70% to 85% of artists have health insurance
nationwide. Washington State survey information finds a similar percentage have
insurance in the state. These rates of coverage are consistent with those of the
general population workforce.

As mentioned previously, we did not find a single source of data that provides a
detailed and statistically credible accounting of artists and health insurance coverage
status. However, there are a number of available survey results and anecdotal
information that together paint a picture that may be reflective of the artist
population.

Following is a summary of key points from the available resources (note that the time
frames for these studies vary by a number of years in some cases and uninsured rates
vary from year to year):

     •   The Access to Health Insurance analysis, although based on small samples,
         consistently found in the 2002 and 2004 surveys that artists have a similar rate
         of families with health insurance as for the general statewide workforce,
     •   The Theatre Puget Sound survey29 found 72% of artists to be insured but with
         39% paying their own full premium and 37% paying a partial premium (2004),
     •   Community Partnership for Arts and Culture’s report, Advancing Support
         Systems for Artists in the Cleveland Metropolitan Area30, found in their survey
         that 76% of respondents indicated they have health insurance. The majority
         indicated that their coverage was through individual insurance,
     •   The Craft Emergency Relief Fund (CERF) found that 82% to 89% of craft artists
         in the studies had health insurance (2004),
     •   In Investing in Creativity it was shown that 80% of artists have healthcare
         coverage although 51% of artists pay for their own (compared with 8% of other
         workers). The report also indicated that 25% buy the typically more expensive
         individual health insurance (2003),
     •   The Future of Music Coalition study found that 56% of artists have health
         insurance (2002),
     •   Joan Jeffri’s report Changing the Beat found that 76% to 82% of American
         Federation of Musicians jazz musicians in three regions (New York, San
         Francisco, and New Orleans) had health insurance (2000),

29
  Theatre Puget Sound, 2004.
30
  Community Partnership for Arts and Culture, February, 2005. “Advancing Support Systems
for Artists in the Cleveland Metropolitan Area.”


Artists and Health Insurance Report                                                        29
     •   Working Today’s study, Educated, Employed and Uninsured, reports that 47% of
         independent workers in New York experienced gaps in coverage in the past two
         years (2004). This compares to a Families USA report which found for the two
         year period from 2003 to 2004 approximately one in three Americans under age
         65 had some gap in coverage.


Some older sources also contained relevant information31,32,33.

Many of these sources and surveys are skewed to a certain type of artist population or
have too few respondents to be credible. Further, without a better overall data
source and with little supporting information for many of the research sources it is
impossible to accurately adjust the figures shown above to count for differences in
populations studied.

However, as discussed below, these figures do compare to an average working aged
(18 to 64) population insured rate of 78% to 79% on a nationwide basis.

In our opinion these results are relatively similar.

It should be noted that further review of data sources may be required to determine
whether percent of insured artists refers to the artists only or the artists and their
dependents, which impacts the comparison figure. Many sources quote uninsured
levels for a general population which is comprised of all individuals, including children
and those over age 65 (when retirement and Medicare is most likely to begin). When
comparing these figures to those for uninsured rates for artists the findings may not be
on a directly comparable basis.

For example, the MEPS data used to arrive at the insured rate of 78% to 79% above is
for individuals aged 18 to 64 (but includes all individuals not just employed or
employed eligible). If those under 18 and those 65 and over are included the insured
rate increases to 83% to 84%.

Other Populations
In regards to non-artist populations and other studies on uninsured rates there were a
few other findings we found pertinent. Following are some of the key findings:

     •   For all individuals (not just working aged adults)
             o The U.S. Census Bureau 3 year average (2001-2003) uninsured rate is
                 15.1% for the U.S. as compared to 14.3% for the State of Washington,
             o MEPS data is consistent with the last two years of data (2002, 2003)
                 having uninsured rates of 16.4% and 16.6% on a nationwide basis,
     •   For working aged adults (18 to 64) – which is best compared to adult artists

31
   Jeffri – 77% to 79% with some form of health insurance or medical coverage in four major
cities (LA, NY, SF, Minn/St. Paul), (1997).
32
   Gotham Gazette, 2002 – reports that some sources report that as few as 6 of 10 artists are
covered by health insurance.
33
   Artists Foundation. 1994. Task force report to Congress. Study found that only 70% of artists
in major MSAs had health insurance coverage, twice the uninsured rate of the average
workforce.


Artists and Health Insurance Report                                                           30
            o MEPS data for the two years have an uninsured rate of 21.5% and 20.9%.
              This is the information used above to compare to the insured rate of
              artists,
   •   A Families USA report finds that for people under the age of 65 the percentage
       with a “gap in coverage” over the two year period from 2003-2004 were 33.3%
       for the U.S. in total and 29.9% for Washington State. These figures are higher
       than the uninsured rates shown for the Census Bureau and MEPS data. Note,
       however, that we expect these figures to be higher than the “snapshots” from
       the Bureau and MEPS data,
   •   The Study of the Fishing Population of Massachusetts (a population with high
       self-employment) found 43% of adults in fishing population were uninsured
       versus 13% statewide,
   •   Firm size – MEPS – Table 8 displays that for those employees employed by a
       private organization, there is a direct correlation between firm size and
       whether or not a firm offers health insurance and, ultimately, the number of
       employees with health insurance.



                                          Table 8
        Establishments offering Health Insurance and Employees with Health Insurance1
                                      2002, by Firm Size


                                                           Firm Size
                                 Total      <10     10-24      25-99    100-999    1000+
   Establishments offering Health Insurance
       United States             57.2%      36.8%   67.8%       82.4%      95.4%   98.8%
       Washington                57.0%      38.0%   70.0%       79.2%      95.0%   99.2%


   Employees enrolled in Health Insurance
       United States             55.1%      31.0%   43.7%       49.9%      57.4%   64.3%
       Washington                54.3%      31.6%   58.6%       48.0%      56.8%   61.3%


   1. MEPS, 2002 data.



The percent of both employers who offer a health plan and of employees enrolling in a
health plan are directly related to employer size. According to 2002 MEPS (Medical
Expenditure Panel Survey) data large employers (1,000+ employees) are most likely to
offer at least one health plan with 99% of firms offering insurance both nationally and
in Washington. Employers with less than 10 employees, on the other hand, offer
health insurance plans less than 40% of the time. This is likely correlated to self-
employed individuals as well.




Artists and Health Insurance Report                                                        31
Increasing Costs
An issue as large, or potentially larger, than any other health insurance issue facing
artists, is that of higher healthcare costs potentially experienced by artists. As with
many occupations, artists insured through an employer are experiencing greater
premium sharing and benefit cost sharing than previously. Also, medical premium
trend rates are again increasing at double-digit levels.

Particular to the artist community, however, is the large number of self-employed or
unemployed artists. These individuals, if not covered under a spouse’s or partner’s
medical plan, must either purchase individual insurance or go without coverage. Both
of these options result in potentially higher medical-related expenses.

The more hidden of these two is the individual insurance issue. Individual insurance
premiums are, on the average, considerably higher than those found in group
insurance (age rating can lessen or eliminate this issue for some younger artists). So
while these artists will show up as “insured”, they are footing the entire premium bill
themselves, which is a higher premium to begin with, and for often lower benefit
levels. Some studies indicate that more than half of artists pay their own health
insurance premiums34.

Additionally, many artists may work in smaller firms that are less likely to offer
insurance, typically have lower benefits and may require a greater employee sharing
of premium costs.

The combination of these factors makes the healthcare costs faced by artists to be of
primary concern. At least one survey of artists found affordability to be listed as a
primary barrier to obtaining health insurance35.


Summary

Our findings indicate that contrary to popular belief, artists may not in fact
experience considerably higher uninsured rates than non-artist occupations when
adjusted for income, age, gender and geographic residence. However, primarily due
to much higher self-employment rates, we believe artists may face much higher
healthcare related expenses as a percent of income (for similar populations) due to
more artists having to purchase individual insurance, higher premium sharing and
higher cost-sharing.




34
   Investing in Creativity, 51% of artists pay their own health insurance versus 8% for other
workers.
35
   Advancing Support Systems for Artists in the Cleveland Metropolitan Area.


Artists and Health Insurance Report                                                             32
Implications for Health Insurance

Personal and employment characteristics of a population are key to understanding
their healthcare needs, access to health insurance and cost of health coverage. Each
of these health insurance related issues are discussed in turn below in the context of
the specific characteristics of the artist community identified above.


Healthcare Needs

Age, gender, family size and health status are important determinants of the
healthcare needs of the population. Healthcare needs are a reflection of the
healthcare costs and therefore health insurance rates.

       Age: Healthcare needs increase with age. The average age of primary
       occupation artists in Washington was found to be 7% higher than the average
       age of the employed population. Even though the artists have a higher
       proportion of the over 65, who are likely to be covered by Medicare, the artists
       also have a lower proportion of the young (<35) in their population. Even
       among the under 65 the artists have a higher age than the employed
       population. Artists in Seattle on average are younger than the rest of the state
       but their average age is still higher than the age of the employed population in
       Seattle. Accordingly, based on age it would appear that healthcare needs of
       the artists are higher than the general employed population.

       Gender: Among the young (<35), males have lower healthcare needs than
       females while the reverse is true for older age. The proportion of males among
       the primary occupation artist community in Washington is substantially higher
       than that of females but the male / female ratio is similar to that of the
       general workforce in the state. However, in Seattle the proportion of males is
       higher than that of the all employed population in Seattle. Given the age
       distribution differences between the artists and the all employed workforce
       the higher proportion of males in Seattle should result in similar healthcare
       needs as those of the employed. Based on gender, the differences between the
       artists and all employed people are too small to result in differences in their
       respective healthcare needs.

       Family Size: The larger the family size the higher healthcare needs of the
       family. There is limited information, but it appears that family size of artists is
       lower than that of the employed population. A lower family size implies lower
       healthcare needs among the artists compared to the employed.

       Health Status: The health of the population is an obvious indicator of
       healthcare needs. We did not find a major difference between the health care
       needs of the artists and the employed population. The available data on health
       insurance coverage suggests that the coverage of the artists is similar to that of
       employed population. However there are others who allege that artists suffer
       from higher lack of coverage than others. There may be some truth to their
       allegations because the unemployment rate among artists is higher than the


Artists and Health Insurance Report                                                    33
       general labor force. If that is true then one would expect artists to have higher
       healthcare needs because people without health insurance put off getting the
       care they need.

       Race: While there may be some differences in healthcare needs by race, and
       by the socio-economic impacts of race, we have not analyzed race as a factor
       in obtaining health insurance as race is not a risk factor used in insurance rate
       setting.

Based on the characteristics of the artist population there is no strong evidence of
higher or lower healthcare needs between artists and the total employed population.
It may be argued that because of higher age and lack of coverage or lower benefits
due to higher costs that the healthcare needs of the artists are higher than those of
the employed.


Access to Healthcare Insurance

Access to health insurance depends upon many factors with some of the most
important among them being the availability of group health insurance choices in the
local area, income to afford the health plans, working for employers who offer group
plans, and availability of affordable individual plans or access to associations that
offer group health plans.

       Regional Density: Urban areas offer many more health insurance options than
       rural areas. Since a higher proportion of artists live in urban areas they have
       better access to healthcare insurance than the average employed person in
       Washington.

       Self Employment: Self employment means that workers do not have access to
       employer provided group health plans. Obtaining individual insurance is both
       difficult and more expensive on the average. It comes with more limitations
       such as pre-existing conditions and fewer options of plans. Higher premiums
       often lead to individuals choosing lower benefit levels. More artists are self-
       employed compared to other workers and therefore their access to healthcare
       insurance is lower than other workers.

       Employer Type: All employers do not offer similar access to health insurance.
       Large employers are more likely to offer health insurance than smaller
       employers. Similarly non-profit organizations are less likely to offer health
       insurance coverage. Artists are much more likely to work for non-profit
       organizations and those who work for private employers we propose may be
       more likely to work for smaller employers than the general workforce.
       Accordingly, artists are likely to have lower access to healthcare insurance.

       Family Income: Income determines the ability to buy health insurance
       coverage, lower income families are less likely to seek and get coverage than
       higher income families. Artists have lower average family income than the total
       workforce in Washington. They also have a much higher proportion of people
       who fall below the poverty line compared to all employed persons. This would



Artists and Health Insurance Report                                                  34
       suggest that Artists may have lower access to healthcare insurance than other
       groups.

       Unemployment: Unemployment is usually accompanied by loss of health
       insurance coverage since most people get their health insurance coverage
       through their employers. Also the loss of income that accompanies
       unemployment makes it less likely for unemployed people to maintain their
       coverage. The unemployment rate among artists is higher than the overall
       unemployment rate, which means that artists have lower access to health
       insurance.

In summary, artists typically live in urban areas where they have greater access to
health insurance options and medical providers, but they are self employed, work for
smaller employers, have lower family income and experience higher unemployment
and therefore they do not have the same access to coverage as the general workforce.


Cost of Health Insurance

Cost of health insurance faced by an individual depends upon several considerations
including their health status and opportunity to purchase health insurance through a
group,

       Health Status: As already argued, the health status of artists is similar to that
       of others in Washington. If the artist community, as is alleged by some, has a
       higher percent of uninsured then it is likely that needed care is not sought or
       delayed. Similarly, and more likely, lesser benefit levels due to purchase of
       individual insurance will also lead to a delay in seeking medical care.
       Persistence of unmet healthcare needs over time can worsen the health status.
       The higher unemployment rate among artists implies breaks in coverage that
       may also lead to delay in care and adversely impact the health status of the
       artists. It should be noted that we did not find evidence to support lower
       health status or lower insured rates among artists but that may be because we
       did not have sufficient or credible information available to irrefutably make
       that claim. Health insurance companies track the health risk represented by
       occupations and adjust the premiums they charge to cover for that risk. If the
       health status of a segment of the artist community has deteriorated due to lack
       of health insurance coverage, then they are likely to face higher health
       insurance costs.

       Group Purchase: Group purchase allows individual risk to be spread across all
       members of the group that lowers the health insurance costs faced by
       individuals in the group. In general, the larger the group, the lower the health
       insurance costs. Health insurance costs for individual coverage are higher on
       average also because individuals who seek health insurance are likely to be less
       healthy than those who decide to forego health coverage. The high rate of self-
       employment among the artists means that for many the only available option is
       to seek individual health insurance. Not only is individual health insurance
       more expensive but it is more limited in scope and breadth of benefits than
       group plans. It is therefore not as attractive. Given that artists may work for


Artists and Health Insurance Report                                                  35
       smaller employers and many are self employed it follows that on average they
       face higher health insurance costs compared to an average member of the
       workforce.

Little information is available on the health status of artists. Based on similar
populations we do not anticipate any great variation in healthcare cost based on
health status. However, we believe the cost borne by artists for healthcare services
and healthcare coverage is disproportionately higher than that for other occupations.
Artists have a much higher self-employment rate, and tend to work for nonprofit
organizations, which lead to greater premium cost-sharing, greater insurance
premiums, and lower benefits (resulting in higher benefit cost-sharing).




Artists and Health Insurance Report                                               36
Gaps in Data

The data and research available for this report came from wide and varied sources.
While there was considerable breadth to the available analyses there was often a
substantial lack of depth in regards to artists and insurance. There are gaps in data
that preclude certain levels or areas of analysis.

Appendix A contains a discussion of potential categories of data collection that might
further the knowledge of artists and insurance needed for expanding or developing
insurance coverage for this or similar populations.




Alternative Insurance Models

Given a better understanding of the issues facing artists and the characteristics of
those artists it appears the artist community is a viable population for considering
alternative non-employer based insurance models.

There are several key factors that make a process such as this feasible:

   •   Artists are underserved by group insurance models due to a very high
       proportion of self-employed individuals,
   •   There is good incentive for artists and artist-related organizations to address
       this issue. Health insurance premiums are increasing rapidly. Unemployment
       and uninsured rates are increasing and benefits are decreasing,
   •   The cost of healthcare experienced by the artist population is higher than that
       for the average workforce. Artists face more individual insurance, greater
       premium cost-sharing and higher levels of unemployment,
   •   An extremely high proportion of artists are self-employed or work for smaller
       firms. This leads logically to artists being prime candidates for health
       insurance solutions though a non-employer based model,
   •   Artists are highly concentrated in small geographic regions with good access to
       medical providers (inner cities) which allows the population to be targeted
       more efficiently,
   •   There is some evidence that artists (at least in some sub-occupations) are open
       to banding together for common purposes and may be more open to unique
       solutions to problems.


Appendix B contains a list of alternative non-employer based insurance solutions,
along with a discussion of some of the pros and cons of each solution.




Artists and Health Insurance Report                                                37
Conclusion and Key Findings

This summary analysis revealed that in many ways the artist community is similar to
other professions. However, there are unique characteristics and situations that
differentiate the artist population. Hopefully a better understanding of healthcare
and insurance related issues will assist the search to find solutions that will improve
the insurance situation of both artists and the general community.

Our analysis revealed relatively strong data available regarding the demographic
characteristics of artists with less reliable information on health status and insurance.
However, based on the compilation of data available we believe there are several key
findings and conclusions.


Key Findings
Our basic findings are that in many ways the artist population in Washington State is
similar to artists across the nation and to non-artist populations as well.

There do exist some key differences, however, particularly compared to non-artist
employment characteristics. Key findings are summarized as follows:

Number and Type of Artists
   • Washington and Seattle have a high concentration of artists as compared to
     nationwide averages,
   • Washington exhibits a somewhat greater distribution of fine artists/art
     directors and writers, with fewer actors, producers and musicians as compared
     to national averages.

Personal Characteristics
Most of the personal characteristic information available for artists is specific to
artists whose primary occupation is arts-related.

Typically Washington artists have similar personal characteristics to nationwide artists.
Often the characteristics are similar to an average workforce as well.

Areas of similarity, limited data or likely small impact include:

   •   Age/gender, Race, Marriage Status and Family Size, Migration

Items of greater interest for purposes of discussion regarding health insurance and
alternative insurance models may include:

   •   Education – Artists are more highly educated than a standard workforce,
   •   Family Income – While somewhat similar, artists do display a tendency to have
       either higher or lower family income levels than a standard population,
   •   Regional Density – Artists are much more concentrated in inner cities, with
       accordingly greater access to healthcare providers and insurance than rural
       areas.




Artists and Health Insurance Report                                                   38
Employment Characteristics
As compared to personal characteristics with its relative similarities to standard
populations, the employment characteristics of artists exhibit far more interesting
results.

   •   Unemployment – Artists have a slightly higher unemployment rate (2
       percentage points) than standard populations. Some artist professions are
       considerably higher (actors),
   •   Type of employer – Artists are much likelier to work for non-profit
       organizations and perhaps work for smaller employers,
   •   Self-employment – Artists are more than four times as likely to be self-
       employed,
   •   Second Occupations – Either as a primary or secondary job, artists have one of
       the highest levels of second occupation rates of any occupation.

Attitude Characteristics
Further research is necessary to draw many conclusions regarding this category. Some
research indicates a desire on the part of artists to join groups in order to obtain
health insurance and an interest in coverage that can be sustained over time,
regardless of employer relationships.

Healthcare Needs of Artists
Artists appear to be approximately average in terms of health status as compared to
other populations. Further and more detailed research is required to confirm this
finding.

Health Insurance and Artists
While a more detailed research effort is recommended there are a number of sources,
anecdotal and otherwise, regarding this topic. Some of our findings include:

   •   It appears 70% to 85% of artists have health insurance coverage, dispelling the
       belief that artists face considerably higher uninsured levels than other
       populations.
   •   Artists, however, appear to face higher healthcare related costs (direct
       medical expenses, premium sharing, benefit plan cost sharing) than other
       populations.


Conclusions
Based on our analysis we believe there are several conclusions that can be drawn
regarding the health insurance needs of Washington artists.

Artists do NOT have substantially higher uninsured levels than other groups. In fact,
the percent of artists with insurance is very similar to standard workforce levels.

Artists have higher unemployment rates (2 percentage points), are four times as
likely to be self-employed, three times as likely to work for non-profit organizations,
more likely to work for smaller employers, and much more likely to work second jobs,
as compared to a standard workforce. Each of these characteristics likely leads to
greater health-related expenses for artists.



Artists and Health Insurance Report                                                 39
The greatest health-related threat to artists is the higher cost of healthcare related
expenses. Artists themselves indicate this cost as a great barrier, and each of the
employment characteristic differences lead to a greater sharing for direct medical
expenses, having to pay more or all of insurance premiums, the average greater
expense of non-group coverage, lower benefits with corresponding higher member
cost-sharing.

More research is needed in particular regarding healthcare and insurance costs for
artists.


Recommendations
Based on our analysis and findings we believe there several additional research efforts
may prove valuable.

The ongoing survey effort should be used to fill in the gaps where specific data was
missing from available research. These include at least the following:

   •   Insurance coverage rates by:
           o Personal and employment status information from respondents
           o Type of insurance coverage (public, employer-based, association,
              individual)
           o Employment status
           o Employer size
           o Family size
   •   Second occupation impact on health insurance
   •   Spousal coverage rates
   •   Premium and out-of-pocket expenses

Further research, in addition to the ongoing survey, is warranted regarding artists’
healthcare related costs. In particular, this should address:

   •   Direct medical expenses (health status)
   •   Avoided medical care
   •   Individual insurance
   •   Group insurance premium sharing
   •   Gaps in coverage

We recommend that analysis be performed for different artistic professions. While
the goal is a solution for artists as a whole, our study indicates that artists are far
from a homogenous group. It is desirable to at least understand the differences in
personal characteristics, employment characteristics and insurance costs and coverage
rates for different groups within the artist community.



Richard Minifie, ASA, MAAA                               Claudia Bach
The Sonata Group, LLC                                    AdvisArts Consulting, Inc.
rminifie@sonatagroup.com                                 claudia@advisarts.com



Artists and Health Insurance Report                                                   40
                                      Appendices



Appendix A - Gaps in Data

Appendix B - Alternative Health Models

Appendix C - Washington State Access to Health Insurance Project

Appendix D - Glossary of Terms

Appendix E - Advisory Group Members




Artists and Health Insurance Report                                41
Appendix A – Gaps in Data

Our review of available research and data found relatively good information regarding
artists’ demographic information and less complete information regarding insurance
needs and insurance. The 2005 WAHIP Survey and other research may fill in some of
the gaps found in this analysis.

With respect to artists’ demographic characteristics there are several categories for
which better data will increase our understanding of the difference between a
standard workforce, and the correlation between the characteristics and health
insurance. These include the following:

   •   Personal Characteristics
          o Marriage status – This information is important for understanding both
               dependents for insurance purposes and the prevalence of spouses for
               medical coverage through spouse’s employers
          o Family size – This is important for understanding number and mix of
               dependents by artist for insurance purposes.
          o Participation in artist-related organizations (e.g., unions, etc.)
   •   Employment Characteristics – for any further studies on insurance rates and
       costs these characteristics in particular should be collected
          o Employment status – In particular those that are self-employed and
               unemployed,
          o 2nd occupation rates – this category is important in order to fully
               understand the undercounting of artists in studies that only use self-
               reported primary occupation as an indicator of artist occupations.
          o Size of employer
   •   Definition of Artist – Collected survey or other data should, to the extent
       possible, be consistent with a uniform definition of artists (see Appendix C)


As compared to the demographic information available, we found the data on insured
rates, insurance costs and other insurance related data to be considerably lacking for
artist populations. The information available was typically specific to a particular
surveyed group and not for artists as a whole. Additionally there was very little
information comparing artists to other non-artist populations. And, the information
that was available typically fell far below what an interested observer would desire to
draw credible conclusions.

There is a wide variety of insurance related information that will be valuable in
understanding the insurance needs of artists. When collecting any missing information
we recommend that as many demographic and employment characteristics as possible
be determined for the individuals or groups being studied. Main categories of
information include the following:

   •   Insured status – Uninsured, private insurance, public insurance, etc. While the
       information available did paint a consistent picture, it was more anecdotal in
       nature or specific to a limited survey group. By key categories such as:
           o Employment status
           o Employer size



Artists and Health Insurance Report                                                 42
   •   Source of insurance – this information will prove valuable, again by different
       characteristics
           o Spouse/partner or worker
           o Primary job or secondary job for those that moonlight
   •   Dependent coverage – who is covered by a family’s insurance (employee only,
       spouse, children)
   •   Healthcare and insurance costs – This information is vital for understanding the
       true cost of healthcare for artists as compared to other groups. Information
       should be collected for as many demographic characteristics as possible, but at
       least by employment status, insured status, and type of insurance:
           o Premium – for individual insurance
           o Premium sharing for group insurance
           o Cost sharing (copays, coinsurance, deductibles) estimates
           o Other medical expenses or total medical expenses for the uninsured
   •   Coverage gaps – Based on reviewed information it seems that artists have a
       much higher likelihood of a gap in insurance for any time period (2 years, 5
       years, etc.) than the standard working population. This information is
       different than uninsured rates and can reflect on the transient nature of
       healthcare coverage for the artist population. Collection of information by key
       characteristics is desirable.
   •   Health Status – while difficult to measure even self-reported information on
       perceived health status may show trends by coverage levels.


One option that could be considered is that complete analyses be performed by artist
sub-occupation. The summary of available information found large differences, in
some instances, between subgroups in terms of income, unemployment, uninsured
rates and other factors.    By analyzing the top few sub-occupations a better
understanding may be arrived at than from trying to consider all characteristics for all
occupations.




Artists and Health Insurance Report                                                  43
Appendix B - Alternative Health Models

Following is a list of potential alternative health models. The models are divided
between public and private programs. The research of this and other analyses may be
used to assist in determining which alternative health models may best serve the
needs of the artist population.

Public Programs
   1. Universal single-payer healthcare – Financed by taxes, universal healthcare
       would ensure coverage of all individuals.
           a. Pros – The social impact of covering all individuals
           b. Cons – Subject of fierce debate; comes with its own substantial
              problems including access to healthcare in a timely manner and
              rationing of care
   2. Tax credits – Allows medical insurance premiums to be deducted from taxable
       income
           a. Pros – enhances affordability of health insurance for lower income
              individuals
           b. Cons – reduces taxes which may need to be offset in other manners;
              does not change the insurance mechanisms for providing coverage to
              self-employed and unemployed
   3. Expansion of use of Community Clinics – This may be coordinated at a state
       level.
           a. Pros – clinics are already in place
           b. Cons – requires marketing effort to increase usage, may require more
              clinics. Clinics are already reporting increased usage in Washington
              State
   4. Insurance mandates – Requiring every individual to have health insurance
           a. Pros – would potentially reduce the negative view of the individual
              market by insurers by helping to ensure a more uniform mix of
              enrollees; could help reduce premiums to self-employed and employees
              of small firms
           b. Cons – Questionable how many people would still avoid coverage
   5. Expansion of Medicaid, Basic Health Plan, State High Risk Pools – existing
       systems may be expanded to cover more low-income or high-risk individuals
       and families
           a. Pros – the systems are already in place
           b. Cons – someone has to pay for it; existing systems already have existing
              problems
   6. Reconsider Mandated Benefits legislation for small employers – some mandated
       benefits may increase the costs of providing healthcare coverage which may
       reduce the number of insurance options
           a. Pros – could result in higher rate of insureds
           b. Cons – questionable how much impact some mandates have on raising
              health insurance premiums

Private Programs
    7. Alumni association plans – offer group insurance to members. For artists this
       can include alumnis of arts schools and training programs




Artists and Health Insurance Report                                                44
           a. Pros – can provide access to lower healthcare costs for some
               professionally trained artists
           b. Cons – alumni associations may already be in place for desired schools;
               may be difficult to organize
   8. Association Health Plans (AHPs) – provides members with access to a variety of
       services including health insurance. Interest in a federal AHP program.
           a. Pros – has worked successfully in many instances
           b. Cons - Currently on a state level, associations cannot be formed
               exclusively to provide insurance; as with any voluntary organization
               geared towards covering the uninsured there will be selection issues
   9. Small business purchasing cooperatives – employers band together to get better
       prices and more plans. Must have three or more employees to join in
       Washington
           a. Pros – can lower costs and increase options; some precedence in state
           b. Cons – can be difficult to sign up enough employees
   10. Costco model – uses wholesale purchasing power to obtain lower rates
           a. Pros – is successful for members of Costco
           b. Cons – requires the creation and joining of a wholesale organization,
               other than Costco likely too difficult to create for sole purpose of artists
   11. Professional Employee Organizations (PEOs) – serve as HR departments
           a. Pros – can make tasks easier for small businesses not familiar with the
               system
           b. Cons – adds a layer of administrative cost; not likely to substantially
               increase the number of covered people
   12. Voluntary Employee Beneficiary Associations (VEBAs) – pre-funded healthcare
       trust funds that allow for collective purchase of healthcare and that grow tax-
       free. Can only be used to pay for qualified healthcare benefits
           a. Pros – can exist solely to provide healthcare benefits; employers must
               be in same line of business so can make artist specific
           b. Cons – not necessarily an insurance mechanism; must have sufficient
               reserves to pay expenses; not necessarily ideal for self-employed and
               small businesses as the same selection issues will present as currently
               found in the market
   13. Taft-Hartley Health and Welfare plans – plans funded by multiple employers for
       union workers. Money is kept in a trust.
           a. Pros – can be artist specific; aggregation of artists will help in reducing
               insurance premiums; some indications of previous successes with unions
               in an artistic community
           b. Cons – would have to rely on existing unions or help create new ones;
               different opinions on whether unions work well in artist community
   14. Multiple-Employer Welfare Arrangements (MEWAs), Multiple-Employer Trusts
       (METs), and “MEWA-like” organizations – provides health and other benefits to
       employees of unrelated businesses.
           a. Pros – might be artist specific depending on structure; can be successful
               in lowering healthcare insurance costs
           b. Cons – have been cases of low quality administration of MEWAs
   15. Health Savings Accounts (HSAs), Medical Savings Accounts (MSAs), and Health
       Reimbursement Accounts (HRAs) – provides for tax-free contributions by
       employers and employees (depending on structure). Often combined with
       catastrophic insurance coverage.



Artists and Health Insurance Report                                                     45
           a. Pros – essentially provides a tax credit; depending on structure can be
              rolled over
           b. Cons – must have a system in place to provide the catastrophic
              insurance component; the HSA itself is not an insurance mechanism
   16. Funding of Artist specific Clinics – some past incidences of a community funding
       their own primary care clinics to provide basic health services
           a. Pros – could help ensure artists receive primary care
           b. Cons – involves creation of clinics, hiring, business of providing
              healthcare; still not an insurance for more specialized medical services
   17. Partnering with Insurers to develop artist specific marketing efforts – would
       depend on finding a willing insurer
           a. Pros – working with the industry rather than running into biases that
              may be existent in current system
           b. Cons – unclear what program could be implemented

This listing is not intended to be comprehensive. It is expected that the WAHIP
process may investigate or develop additional alternative health models.




Artists and Health Insurance Report                                                 46
Appendix C - Washington State Access to Health Insurance Project

The Sonata Group reviewed and used results from the Washington State Access to
Health Insurance Project. Specifically, we reviewed an extract of survey results
specific to artists in Washington State with Jenny Hamilton for 2002 and 2004 data.
The definition of artist used for the extract was determined as described below.

Analysis of Washington State Population Survey (WSPS) data from 2002 and 2004
relating to artists and insurance was done between November 2004 and January 2005
by Jenny Hamilton, Vicki Wilson and Mich’l Needham, Senior Policy Advisors with the
State Planning Grant on Access to Health Insurance.

The definition of artist used for analysis was arrived at by selecting from detailed
occupational codes set out in the BLS/US Bureau of Census’ Standard Occupational
Code. Discussions regarding definition included the researchers named above, Ann
Markusen, Director, Project on Regional and Industrial Economics at the University of
Minnesota and WAHIP Project Consultant, Claudia Bach. Additional discussion was held
with arts researchers at the LINC Research meeting held in Boston in November 2004
and with the WAHIP Advisory Group.

Decisions on inclusion of OES codes were arrived at by:

   1) surveying the varied code definitions of artists used by government agencies,
      national arts organizations and academic experts;
   2) reading the code manual to infer how closely the activities covered appeared
      to match artistic practice or were closely arts-related;
   3) checking national industry by occupation matrices to determine the extent of
      self-employment in each detailed occupation, since artists are known to exhibit
      high rates of self-employment; and
   4) looking at the same source to determine the industrial distribution of the
      occupation.

We included all visual and performing artists, photographers, musicians, and writers, a
minimalist definition, and added a number of occupations from the design, technical,
professional, service and craft-worker occupational groups where the nature of the
work, degree of self-employment and distribution of the occupation by industry
appeared to warrant designation as arts-related.

The codes listed below represent all codes included for analysis, however, this does
not imply that all codes shown were represented in the WSPS samples for 2002 or
2004. In actuality, 20 of the selected OES codes were included in 2002 and 2004.
Analyses were therefore limited to descriptions of the artists and their family
members surveyed. They do not represent the total population of Washington’s
artists.




Artists and Health Insurance Report                                                 47
  OES                                                                          Included in Included in
  Code                           Occupational Title                            2004 WSPS 2002 WSPS

25-1121   Art, Drama, and Music Teachers, Postsecondary                            X           X
25-4012   Curators                                                                 X           X
25-4013   Museum Technicians and Conservators
27-1011   Art Directors                                                            X           X
27-1012   Craft Artists                                                            X           X
27-1013   Fine Artists, Including Painters, Sculptors, and Illustrators            X           X
27-1014   Multi-Media Artists and Animators                                        X           X
27-1019   Artists and Related Workers, All Other
27-1021   Commercial and Industrial Designers                                      X
27-1024   Graphic Designers                                                        X           X
27-1027   Set and Exhibit Designers                                                X
27-1029   Designers, All Other                                                     X           X
27-2011   Actors                                                                   X           X
27-2012   Producers and Directors                                                  X           X
27-2031   Dancers                                                                  X           X
27-2032   Choreographers
27-2041   Music Directors and Composers                                            X           X
27-2042   Musicians and Singers                                                    X           X
27-2099   Entertainers and Performers, Sports and Related Workers, All Other
27-3041   Editors                                                                  X           X
27-3043   Writers and Authors                                                      X           X
27-4021   Photographers                                                            X           X
27-4031   Camera Operators, Television, Video, and Motion Picture
27-4032   Film and Video Editors                                                   X           X
39-3092   Costume Attendants                                                                   X
39-5091   Makeup Artists, Theatrical and Performance
49-9063   Musical Instrument Repairers and Tuners
51-5012   Bookbinders (hand)                                                                   X
51-7099   Woodworkers, All others(incl wood carver)                                X           X




Artists and Health Insurance Report                                                           48
Appendix D - Glossary of Terms

This glossary includes terms from the report as well as other commonly used
healthcare and health insurance terms. Definitions for some terms are from
http://www.agencyinfo.net/iv/medical/health-glossary.htm.

   access. A person's ability to obtain affordable medical care on a timely basis.

   actuaries. The insurance professionals who perform the mathematical analysis necessary
   for setting insurance premium rates.

   adjusted community rating (ACR). A rating method under which a health plan or MCO
   divides its members into classes or groups based on demographic factors such as geography,
   family composition, and age, and then charges all members of a class or group the same
   premium. The plan cannot consider the experience of a class, group, or tier in developing
   premium rates. Also known as modified community rating or community rating by class.

   adverse selection. See antiselection.

   alternative health insurance model. An insurance coverage solution different than an
   employer-based insurance model.

   annual maximum benefit amount. The maximum dollar amount set by an MCO that limits
   the total amount the plan must pay for all healthcare services provided to a subscriber in a
   year.

   antiselection. The process by which individuals with higher family health need are more
   likely to select richer benefit plans than healthier individuals or those with fewer
   dependents.

   benefit design. The process an MCO uses to determine which benefits or the level of
   benefits that will be offered to its members, the degree to which members will be
   expected to share the costs of such benefits, and how a member can access medical care
   through the health plan.

   blended rating. For groups with limited recorded claim experience, a method of
   forecasting a group's cost of benefits based partly on an MCO's manual rates and partly on
   the group's experience.

   broker. A salesperson who has obtained a state license to sell and service contracts of
   multiple health plans or insurers, and who is ordinarily considered to be an agent of the
   buyer, not the health plan or insurer.

   Bureau of Labor Statistics (BLS). A federal government bureau that collects and reports
   on labor demographic and other occupation information.

   capitation. A method of paying for healthcare services on the basis of the number of
   patients who are covered for specific services over a specified period of time rather than
   the cost or number of services that are actually provided.




Artists and Health Insurance Report                                                         49
   catastrophic coverage. Insurance coverage intended to safeguard individuals against
   catastrophic healthcare needs. Typically these plans have high deductibles and out-of-
   pocket maximums.

   Children's Health Insurance Program (CHIP). A program, established by the Balanced
   Budget Act, designed to provide health assistance to uninsured, low-income children either
   through separate programs or through expanded eligibility under state Medicaid programs.

   Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). A program of
   medical benefits available to inactive military personnel and military spouses, dependents,
   and beneficiaries through the Military Health Services System of the Department of
   Defense. See also TRICARE.

   claim. An itemized statement of healthcare services and their costs provided by a hospital,
   physician's office, or other provider facility. Claims are submitted to the insurer or
   managed care plan by either the plan member or the provider for payment of the costs
   incurred.

   closed access. A provision which specifies that plan members must obtain medical services
   only from network providers through a primary care physician to receive benefits.

   coinsurance. A method of cost-sharing in a health insurance policy that requires a group
   member to pay a stated percentage of all remaining eligible medical expenses after the
   deductible amount has been paid.

   community rating. A rating method that sets premiums for financing medical care
   according to the health plan's expected costs of providing medical benefits to the
   community as a whole rather than to any sub-group within the community. Both low-risk
   and high-risk classes are factored into community rating, which spreads the expected
   medical care costs across the entire community.

   Consolidated Omnibus Budget Reconciliation Act (COBRA). A federal act which requires
   each group health plan to allow employees and certain dependents to continue their group
   coverage for a stated period of time following a qualifying event that causes the loss of
   group health coverage. Qualifying events include reduced work hours, death or divorce of a
   covered employee, and termination of employment.

   copayment. A specified dollar amount that a member must pay out-of-pocket for a
   specified service at the time the service is rendered.

   cost sharing.    The amounts paid by the covered person for deductibles, copays and
   coinsurance.

   credibility. A measure of the statistical predictability of a group's experience.

   Current Population Survey (CPS). A joint survey project between the Bureau of Labor
   Statistics and the Census Bureau.      The effort provides demographic, employment,
   insurance and other household information.

   deductible. A flat amount a group member must pay before the insurer will make any
   benefit payments.




Artists and Health Insurance Report                                                        50
   Employee Retirement Income Security Act (ERISA). A broad-reaching law that establishes
   the rights of pension plan participants, standards for the investment of pension plan assets,
   and requirements for the disclosure of plan provisions and funding.

   employer based insurance models. Insurance provided through an employer, typically
   known as group coverage.

   experience rating. A rating method under which an MCO analyzes a group's recorded
   healthcare costs by type and calculates the group's premium partly or completely according
   to the group's experience.

   Federal Employee Health Benefits Program (FEHBP). A voluntary health insurance
   program administered by the Office of Personnel Management (OPM) for federal
   employees, retirees, and their dependents and survivors.

   fee schedule. The fee determined by an MCO to be acceptable for a procedure or service,
   which the physician agrees to accept as payment in full. Also known as a fee allowance,
   fee maximum, or capped fee.

   fully funded plan. A health plan under which an insurer or MCO bears the financial
   responsibility of guaranteeing claim payments and paying for all incurred covered benefits
   and administration costs.

   geographic accessibility. Health plan accessibility, generally determined by drive time or
   number of primary care providers in a service area.

   group market. A market segment that includes groups of two or more people that enter
   into a group contract with an MCO under which the MCO provides healthcare coverage to
   the members of the group.

   guaranteed issue. An insurance policy provision under which all eligible persons who apply
   for insurance coverage and who meet certain conditions are automatically issued an
   insurance policy.

   Health Insurance Portability and Accountability Act (HIPAA). A federal act that protects
   people who change jobs, are self-employed, or who have pre-existing medical conditions.
   HIPAA standardizes an approach to the continuation of healthcare benefits for individuals
   and members of small group health plans and establishes parity between the benefits
   extended to these individuals and those benefits offered to employees in large group plans.
   The act also contains provisions designed to ensure that prospective or current enrollees in
   a group health plan are not discriminated against based on health status.

   health maintenance organization (HMO). A healthcare system that assumes or shares both
   the financial risks and the delivery risks associated with providing comprehensive medical
   services to a voluntarily enrolled population in a particular geographic area, usually in
   return for a fixed, prepaid fee.

   health savings account (HSA). A tax free saving account for medical expenses combined
   with a high deductible health plan (HDHP).

   health status. A relative measure of a person’s level of healthiness.




Artists and Health Insurance Report                                                          51
   high deductible health plan (HDHP). A catastrophic coverage plan with a high deductible
   that can be combined with savings accounts such as a Health Savings Account (HSA).

   hold harmless provision. A contract clause which forbids providers from seeking
   compensation from patients if the health plan fails to compensate the providers because of
   insolvency or for any other reason.

   individual market. A market segment composed of customers not eligible for Medicare or
   Medicaid who are covered under an individual contract for health coverage.

   individual stop-loss coverage. A type of stop-loss insurance that provides benefits for
   claims on an individual that exceed a stated amount in a given period. Also known as
   specific stop-loss coverage.

   integrated delivery system (IDS). A provider organization that is fully integrated
   operationally and clinically to provide a full range of healthcare services, including
   physician services, hospital services, and ancillary services.

   large group. A large pool of individuals for which health coverage is provided by the group
   sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number
   of members, depending on the MCO.

   lifetime maximum benefit amount. The maximum dollar amount set by an MCO that limits
   the total amount the plan must pay for all healthcare services provided to a subscriber in
   the sub-scriber's lifetime.

   loss rate. The number and timing of losses that will occur in a given group of insureds
   while the coverage is in force.

   managed care. The integration of both the financing and delivery of healthcare within a
   system that seeks to manage the accessibility, cost, and quality of that care.

   managed care organization (MCO). Any entity that utilizes certain concepts or techniques
   to manage the accessibility, cost, and quality of healthcare. Also known as a managed care
   plan.

   Management Services Organization (MSO). An organization, owned by a hospital or a
   group of investors, that provides management and administrative support services to
   individual physicians or small group practices in order to relieve physicians of non-medical
   business functions so that they can concentrate on the clinical aspects of their practice.

   manual rating. A rating method under which a health plan uses the plan's average
   experience with all groups—and sometimes the experience of other health plans—rather
   than a particular group's experience to calculate the group's premium. An MCO often lists
   manual rates in an underwriting or rating manual.

   market segmentation. The process of dividing the total market for a product or service
   into smaller, more manageable subsets or groups of customers.

   Medicaid. A jointly funded federal and state program that provides hospital expense and
   medical expense coverage to the low-income population and certain aged and disabled
   individuals.



Artists and Health Insurance Report                                                          52
   Medical Expenditure Panel Survey (MEPS).          Survey of household demographic and
   insurance information.

   medical savings account (MSA). A trust that employees of small businesses may establish
   to pay for out-of-pocket medical expenses.

   Medicare. A federal government hospital expense and medical expense insurance plan
   primarily for elderly and disabled persons. See also Medicare Part A, Medicare Part B, and
   Medicare Part C.

   Medicare Part A. The part of Medicare that provides basic hospital insurance coverage
   automatically for most eligible persons. See also Medicare.

   Medicare Part B. A voluntary program that is part of Medicare and provides benefits to
   cover the costs of physicians' services. See also Medicare.

   Medicare Part C. The part of Medicare that expands the list of different types of entities
   allowed to offer health plans to Medicare beneficiaries. Also known as Medicare+Choice.
   See also Medicare.

   Medicare supplement. A private medical expense insurance plan that supplements
   Medicare coverage. Also known as a Medigap policy.

   Mental Health Parity Act (MHPA). A federal act which prohibits group health plans that
   offer mental health benefits from applying more restrictive limits on coverage for mental
   illness than for physical illness.

   Metropolitan Statistical Area (MSA). An identification of regions by urban area.

   National Endowment for the Arts (NEA).          A public agency dedicated to supporting
   excellence in the arts.

   network. The group of physicians, hospitals, and other medical care providers that a
   specific managed care plan has contracted with to deliver medical services to its members.

   non-group market. A market segment that consists of customers who are covered under an
   individual contract for health coverage or enrolled in a government program.

   open access. A provision that specifies that plan members may self-refer to a specialist,
   either in-network or out-of-network, at full benefit or at a reduced benefit, without first
   obtaining a referral from a primary care provider.

   out-of-pocket maximums. Dollar amounts set by MCOs that limit the amount a member
   has to pay out of his or her own pocket for particular healthcare services during a
   particular time period.

   outpatient care. Treatment that is provided to a patient who is able to return home after
   care without an overnight stay in a hospital or other inpatient facility.

   Patient Bill of Rights. Refers to the Consumer Bill of Rights and Responsibilities, a report
   prepared by the President's Advisory Commission on Consumer Protection and Quality in the
   Health Care Industry in an effort to ensure the security of patient information, promote



Artists and Health Insurance Report                                                         53
   healthcare quality, and improve the availability of healthcare treatment and services. The
   report lists a number "rights," subdivided into eight general areas, that all healthcare
   consumers should be guaranteed and describes responsibilities that consumers need to
   accept for the sake of their own health.

   plan funding. The method that an employer or other payor or purchaser uses to pay
   medical benefit costs and administrative expenses.

   pooling. The practice of underwriting a number of small groups as if they constituted one
   large group.

   pre-existing condition. In group health insurance, generally a condition for which an
   individual received medical care during the three months immediately prior to the
   effective date of coverage.

   preferred provider organization (PPO). A healthcare benefit arrangement designed to
   supply services at a discounted cost by providing incentives for members to use designated
   healthcare providers (who contract with the PPO at a discount), but which also provides
   coverage for services rendered by healthcare providers who are not part of the PPO
   network.

   premium. A prepaid payment or series of payments made to a health plan by purchasers,
   and often plan members, for medical benefits.

   premium sharing. The portion of insurance premium rates paid by the member or
   individual (with the remainder paid by the employer).

   prepaid care. Healthcare services provided to an HMO member in exchange for a fixed,
   monthly premium paid in advance of the delivery of medical care.

   primary care. General medical care that is provided directly to a patient without referral
   from another physician. It is focused on preventative care and the treatment of routine
   injuries and illnesses.

   primary care provider (PCP). A physician or other medical professional who serves as a
   group member's first contact with a plan's healthcare system. Also known as a primary care
   physician, personal care physician, or personal care provider.

   primary occupation. The self-reported principal source of income of a worker.

   purchasing alliances. Locally based, privately operated organizations that offer affordable
   group health coverage to businesses with fewer than 100 employees. Also known as
   purchasing pools, health insurance purchasing co-ops (HPCs), employer purchasing
   coalitions, or purchasing coalitions.

   rating. The process of calculating the appropriate premium to charge purchasers, given the
   degree of risk represented by the individual or group, the expected costs to deliver medical
   services, and the expected marketability and competitiveness of the MCO's plan.

   renewal underwriting. The process by which an underwriter reviews each year all the
   selection factors that were considered when the contract was issued, then compares the
   group's actual utilization rates to those the MCO predicted to determine the group's
   renewal rate.


Artists and Health Insurance Report                                                         54
   reserves. Estimates of money that an insurer needs to pay future business obligations.

   risk-adjustment. The statistical adjustment of outcomes measures to account for risk
   factors that are independent of the quality of care provided and beyond the control of the
   plan or provider, such as the patient's gender and age, the seriousness of the patient's
   illness, and any other illnesses the patient might have. Also known as case-mix adjustment.

   secondary occupation. An occupation taken in addition to a primary occupation.

   self-employment. The status of an individual who works, but not for an employer, rather
   for himself.

   self-funded plan. A health plan under which an employer or other group sponsor, rather
   than an MCO or insurance company, is financially responsible for paying plan expenses,
   including claims made by group plan members. Also known as a self-insured plan.

   small group. Although each MCO's size limit may vary, generally a group composed of 2 to
   99 members for which health coverage is provided by the group sponsor.

   stop-loss insurance. A type of insurance coverage that enables provider organizations or
   self-funded groups to place a dollar limit on their liability for paying claims and requires
   the insurer issuing the insurance to reimburse the insured organization for claims paid in
   excess of a specified yearly maximum.

   third party administrator (TPA). A company that provides administrative services to MCOs
   or self-funded health plans.

   TRICARE. A healthcare plan, avail-able to more than 6 million military personnel and their
   families, which is administered by private contractors who are selected for participation
   through a competitive procurement process. TRICARE offers members three plan options:
   TRICARE Prime (a capitated HMO with nominal premiums and copayments), TRICARE Extra
   (a PPO with standard CHAMPUS deductibles), and TRICARE Standard (the current fee-for-
   service CHAMPUS plan with provider choice and no premiums). See also Civilian Health and
   Medical Program of the Uniformed Services.

   unemployment. A workers’ status of gainful employment. In some studies this includes
   only those who have filed for unemployment benefits.

   underwriting. The process of identifying and classifying the risk represented by an
   individual or group.

   US Census Bureau. Federal organization that completes the official census count of the
   U.S. every ten years.

   usual, customary, and reasonable (UCR) fee. The amount commonly charged for a
   particular medical service by physicians within a particular geographic region. UCR fees are
   used by traditional health insurance companies as the basis for physician reimbursement.

   workers' compensation. A state-mandated insurance program that provides benefits for
   healthcare costs and lost wages to qualified employees and their dependents if an
   employee suffers a work-related injury or disease.




Artists and Health Insurance Report                                                         55
Appendix E – Advisory Group Members



Sean Corry – Vice President, Sprague Israel Giles, Inc. Insurance

Barbara Courtney – Executive Director, Artist Trust

Jenny Hamilton – Executive Policy Advisor, Washington State Governor’s Executive
Policy Office and Senior Policy Analyst, State Planning Grant on Access to Health
Insurance

Lance Heineccius – Health Services Consulting, former director of policy and research
for the Washington State Health Services Commission

Leann Johnson – Cultural Services Manager, City of Vancouver, Washington;
Washington State Arts Commissioner

Joan Kalhorn – Executive Director, Screen Actors Guild, Seattle Branch

Matthew Kwatinetz – Artistic Director and CEO, Capitol Hill Arts Center

Karen Zellar Lane – Executive Director, Theatre Puget Sound

Patricia Lichiello – Senior Health Policy Researcher, UW School of Public Health and
Community Medicine; Clinical Faculty UW; Robert Wood Johnson Forums

Dave Meinert – Blue Team Artist Management, President of the Pacific Northwest
Chapter of the Recording Academy, Mayor's Seattle Music Office Advisory Committee

Margaret Stanley – retired, past Senior Vice President of Regence BlueShield, Seattle;
Health Benefits Administrator at CalPERS; and former Administrator of the Washington
State Health Care Authority and chair of the Public Employees Benefits Board

Beth Takekawa – Associate Director, Wing Luke Asian Museum

Lori Whittaker, MD – Staff Assistant to Congressman Jim McDermott on issues related
to health care and social services

Larry T. Yok – Director, Human Resources Consulting Group, Group Health
Cooperative

WAHIP Project Consultant
Claudia Bach – AdvisArts Consulting and lead consultant for Leveraging Investments in
Creativity (LINC) and Artist Trust insurance initiatives




Artists and Health Insurance Report                                                 56
                                      Bibliography

Note: A brief description of the resource is found in parenthesis following each listing.


Actors’ Fund/Artists’ Health Insurance Resource Center (AHIRC). 2001. “Survey for the
Uninsured.” (Informal/self-selected survey of entertainment professionals in New York
City; 466 surveys completed.)

AHIRC. “Looking for health insurance in Washington state? Here's how to find out your
options.” http://www.actorsfund.org/ahirc. (Summary of insurance options in
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Alper, Neil and Gregory Wassal. 2000. More Than Once in a Blue Moon: Multiple
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Americans for the Arts. June 28, 2004. “New Study of Creative Industries Reveals that
Eleven Metropolitan Areas Have More Than 10,000 Arts-Related Businesses Each.” New
York: Americans for the Arts. Press release. (A report on arts related businesses in
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Anthony, Wayne B. April, 2004. “Community Healthcare Cooperatives: A Strategic
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Artist Trust. 1998. Seattle, WA. (Self-selected survey of local artist characteristics.)

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Buchanan, Stephanie and Sara Horowitz. 2004. “Educated, Employed and Uninsured:
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Community Partnership for Arts and Culture. February 2005. “Advancing Support
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findings in the Cleveland area.)




Artists and Health Insurance Report                                                    57
Cover the Uninsured Week. 2004. “Health Care Coverage in America: Understanding
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Dreeszen, Craig. October 2004. “Craft Emergency Relief Fund - National Craft Artist
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Families USA. September, 2004. “Health Care - Are you better off today than you
were four years ago?” (Summary of research performed using data from the Census
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Future of Music Coalition. August 26, 2002. “Health Insurance and Musicians: A
Preliminary Report.”
http://www.futureofmusic.org/research/healthsurveyresults.cfm. (Informal/self-
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Hamilton, Jenny. January 21, 2005. “Talking Points About Selected Washington
Artists and their Family Members.” Washington State Planning Access to Health
Insurance. (An analysis of Washington Census survey results prepared for WAHIP. See
Appendix C.)

Health Care For All. November, 1996. “Health Survey of the Fishing Population in
Massachusetts.” (Detailed survey information on the fishing population with high
levels of self-employment.)

Hostetter, Martha. October 01, 2002. “Artists and Health Insurance.” Gotham
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Solutions for Uninsured Americans.” House Education & the Workforce Committee. (A
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businesses.)

Jack, Carolyn. April 30, 2004. “Health insurance, other help for artists are under
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Jackson, Maria Rosario et al. 2003. Investing in Creativity: A Study of the Support
Structure for U.S. Artists. Washington D.C.: The Urban Institute Press. (A synthesis of
available information from several sources including interviews with more than 450
people.)



Artists and Health Insurance Report                                                   58
Jeffri, Joan. 1998. “Information on Artists II.” New York: Columbia University,
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Internet & American Life Project. (A national survey of self-identified artists and an
online survey of 2,755 musicians.)

Markusen, Ann, Greg Schrock, and Martina Cameron. July 2003. “The Artistic
Dividend.” Minneapolis: University of Minnesota, Project on Regional and Industrial
Economics, Humphrey Institute of Public Affairs. (A thorough review of Census Bureau
data and case studies. Used extensively for demographic characteristics of artists.)

Markusen, Ann, Greg Schrock, and Martina Cameron. March 2004. “The Artistic
Dividend Revisited.” Minneapolis: University of Minnesota, Project on Regional and
Industrial Economics, Humphrey Institute of Public Affairs. (A thorough review of
Census Bureau data and case studies. Used extensively for demographic
characteristics of artists.)

Markusen, Ann and Greg Schrock. 2004. “Leveraging Investments in Creativity (LINC)
Creative Communities: Census 2000 Arts Analysis.” Minneapolis: University of
Minnesota, Project on Regional and Industrial Economics, Humphrey Institute of Public
Affairs. (Analysis of Artistic Dividend and related Census Bureau data for LINC.)

Medical Expenditure Panel Survey data. 2002 and 2003. (General un-insurance, and
insurance cost information)

Monthly Labor Review. 1995. “Characteristics of multiple jobholders.” (Information
on second occupations by primary occupation.)

National Endowment for the Arts. October 2004. “Artist Employment in 2003.”
Research Division, Note #87. Washington, D.C.: National Endowment for the Arts. (A
summary of four years of unemployment data for artists and the standard population
as well as information on education, second occupations and other items.)




Artists and Health Insurance Report                                                      59
National Endowment for the Arts. May 2004. “Artist Labor Force by State, 2000.”
Research Division, Note #85. Washington, D.C.: National Endowment for the Arts. (A
state by state comparison of the distribution of artists by profession.)

National Endowment for the Arts. May 2002. “Artist Employment in 2001.” Research
Division, Note #80. Washington, D.C.: National Endowment for the Arts. (Trends in
artist unemployment.)

National Endowment for the Arts. September 2003. “Artist Employment, 2000-2002.”
Research Division, Note #84. Washington, D.C.: National Endowment for the Arts.
(Trends in artist unemployment.)

Seattle Times. January 22, 2005. “Most high-risk consumers shun costly insurance
pool.” (Information on the uninsured and catastrophic risk pools.)

Seattle Times. July 30, 2004. “Cost of care for state's uninsured hits $318 million in
2002”. (Uninsured Washington State costs for 2002.)

Seattle Times. August 27, 2004. “More Americans in poverty and uninsured, Census
says.” (Article on poverty and the uninsured in America, 2002, 2003.)

Theatre Puget Sound. 2004. “Artists Medical Insurance Survey.” (Survey frequencies
based on 239 responses.)

U.S. Census Bureau. 2004. “The 2004 HHS Poverty Guidelines.” (2004 and other year
poverty levels.)

U.S. Census Bureau. September, 2003. “Health Insurance Coverage in the United
States: 2002.” (Poverty and uninsured information based on the 2003 Current
Population Survey).

US Census Bureau. August, 2004. “Income, Poverty, and Health Insurance Coverage in
the United States: 2003.” (2003 data on poverty and the uninsured by select
characteristics.)




Artists and Health Insurance Report                                                      60

								
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