Co-creating an equitable health benefits policy

Written by Sarah Reed, December 2025.

The Switzer Foundation aims to create employee policies and benefits that reflect our commitment to embed equity and justice throughout our operations, and in order to recruit, support, and retain an excellent staff. Like many small organizations, the foundation struggles to offer health benefits that meet our staff members’ needs, while managing the rapidly rising costs of health-related expenses. The purpose of this article is to share about the collaborative process we used to design a new health benefits policy, with the hope of supporting Switzer Fellows who are navigating similar challenges at their own organizations.

Health benefits history

In the foundation’s early years with a paid staff, Switzer offered a traditional group health insurance plan to employees located in Maine. (Staff located outside of Maine were offered a modest subsidy to offset the cost of obtaining their own plan.) During this time, health benefits costs increased rapidly and options for small-group plans narrowed; the foundation changed health insurance plans several times, ultimately offering a high-deductible plan plus a health savings account (HSA).

When Switzer hired its third staff member in a new state, the foundation conducted research on alternative benefits options. Group health insurance plans were not available to a small staff distributed across multiple states, and we could not find a larger group plan to join. Health reimbursement arrangements (HRAs) emerged as an alternative. In 2022, the foundation shifted its health benefits to a qualified small employer health reimbursement arrangement (QSEHRA), in order to provide equitable health coverage to all employees in any location; the plan allowed staff to select their own insurance plans and to be reimbursed for any type of medical expense.

More recently, we discovered that, due to IRS regulations, HRA plans do not cover the same health expenses for employees in domestic partnerships as they do for married employees. As a result, the foundation once again reviewed our employee health benefit options, with a goal of ensuring they meet staff needs and support all staff equitably.

Our collaborative process

We began by reviewing best practices for workplace health equity. The following list of best practices was adapted from articles by Sherman & Dankwa-Mullan (2022) and the American Heart Association (2021):

• Offer paid family and medical leave for all employees
• Offer affordable and accessible health care coverage for all employees
• Offer health benefits options rather than “one size fits all” plans
• Provide equitable financing of health care coverage (e.g., wage-based benefits subsidies, deductible amounts scaled to wages)
• Facilitate employee understanding of health benefits and provide decision support for plan selection
• Offer employee assistance programs (but take care with health promotion programs that can exacerbate inequities)
• Solicit feedback from employees on health benefits options and outcomes
• Provide employees with a voice in organizational decision-making regarding health benefits
• Advocate externally for comprehensive, understandable, and affordable health care access

Next, we conducted a staff needs assessment, to understand which considerations for choosing a health benefit option were most important to individual staff members. This step met the best practice of soliciting feedback from employees on health benefits options and outcomes. Overall, staff assigned the highest priority to needs related to flexibility and autonomy (e.g., “It is important to me to be able to spend my health benefits on any type of expense,” “It is important to me to choose how my health benefits are allocated”). Staff assigned moderate priority to needs related to affordability (e.g., “It is important to me to minimize my personal financial contribution to health benefits,” “It is important to me to have a low annual deductible or out-of-pocket maximum”). Finally, staff assigned the lowest priority to needs related to accessibility and support (e.g., “It is important to me to have health benefits paid directly or reimbursed rapidly,” “It is important to me to access resources to help me choose a health insurance plan”).

With best practices and staff needs in mind, the staff met several times to collaboratively review three health benefits options. This step met the best practice of providing employees with a voice in organizational decision-making regarding health benefits. First, we eliminated the option of offering a group health insurance plan, because it did not meet the staff’s needs for flexibility and autonomy and it did not meet the best practice of offering health benefits options rather than a “one size fits all” plan. Second, we considered other types of health reimbursement arrangements (HRA) besides the QSEHRA plan; although they had potential to meet staff needs for flexibility and autonomy, we eliminated these options because they did not provide equitable coverage for all family structures. The remaining option for consideration was a health benefits subsidy.The primary question was how best to allocate the subsidy–should it be divided equally among the staff, or should it vary by some factor(s)?

Switzer’s new policy

The Switzer Foundation’s new health benefits policy offers variable subsidies to fully cover the cost of premiums for individual health and dental insurance, while encouraging staff members to choose the coverage that best meets their needs. This subsidy meets the best practice of offering affordable health care coverage to all employees, while addressing potential inequities in the cost of health insurance due to marriage status, access to a family member’s group plan, age, and location. The new policy allocates the remainder of the annual health benefits budget as a wage-based subsidy for out-of-pocket medical expenses (with lower wage employees receiving a larger subsidy). This meets the best practice of providing equitable financing of health care coverage, while addressing potential inequities in health care affordability related to pay rate. Finally the policy recommends that the health benefits budget increases should be linked to annual increases or projections of increases in health care costs (Cox et al. 2025), and the budget should include a contingency fund (~10%) to cover potential staff transitions or health insurance changes.

Looking ahead, the Switzer Foundation will continue annual surveys to assess staff members’ experiences with the new health benefits policy, which meets the best practice of soliciting feedback from employees on health benefits options and outcomes. We will communicate about our process with peer organizations and Switzer Network members, in an effort to advocate externally for comprehensive, understandable, and affordable health care access. Finally, we will work with our staff to make adjustments to the health benefits policy to meet our ultimate goal of ensuring the benefits meet staff needs and support all staff equitably.

Conclusion

In closing, it is important to acknowledge that this process is hard! The affordability and accessibility of health care is a major systemic problem in the United States, and we are a small organization trying to find creative solutions within a limited budget. We aimed to approach this topic collaboratively and in alignment with our values for equity and justice. A collaborative approach is challenging, not only because it takes more time, but also because it asks individuals to consider potentially conflicting ideas about organizational equity and individual well-being. We hope that by sharing our experience and the resources we consulted, we can support Switzer Fellows who are seeking to support health equity at their own organizations. We welcome your feedback on our new policies and other models to share with the Switzer Network community.

References

• American Heart Association. 2021. Driving Health Equity in the Workplace. https://www.heart.org/-/media/Healthy-Living-Files/Well-being-Works-Better/Driving-Health-Equity/CEORTHealthEquityManuscript.pdf

• Cox et al. 2025. Health Care Costs and Affordability. Kaiser Family Foundation. https://www.kff.org/health-costs/health-policy-101-health-care-costs-and-affordability/ 

• McCormick. 2025. How Lean Foundations Give Employees Health Insurance. Exponent Philanthropy. https://exponentphilanthropy.org/blog/how-lean-foundations-give-employees-health-insurance/ 

• Sammer. 2021. Is It Time to Tie Employee Health Care Costs to Pay? Society of Human Resources Management. https://www.shrm.org/topics-tools/news/all-things-work/time-to-tie-employee-health-care-costs-to-pay

• Sherman & Dankwa-Mullan. 2022. For the Commercially Insured, Equitable Benefits Begin with Equitable Health Insurance Design. American Journal of Health Promotion. https://journals.sagepub.com/doi/full/10.1177/08901171211073408b

• U.S. Centers for Medicare & Medicaid Services. 2025. How Insurance Companies Set Health Premiums. https://www.healthcare.gov/how-plans-set-your-premiums/