Health benefits in 2003: premiums reach thirteen-year high as employers adopt new forms of cost sharing

This paper reports changes in job-based health insurance from spring 2002 to spring 2003. The cost of health insurance rose 13.9 percent, the highest rate of increase since 1990. Employers required larger contributions from employees for the monthly cost of health insurance. Separate copayments and deductibles for hospital services have become commonplace, and provider networks have broadened. There was no change in the percentage of employers offering health plans to their workers. Employers indicate little confidence in any future strategies for controlling health care costs.     

Private health insurance plans in 1978 and 1979: a review of coverage, enrollment, and financial experience.

The private health insurance industry collected $55.9 billion in premiums in 1979 and returned $50.2 billion in benefits to its subscribers. Premiums rose 12.4 percent, slightly faster than in 1978 when premiums rose 11.4 percent, to $49.7 billion. Benefits rose 11.4 percent in 1979, down from the 12.6 rate in 1978. After operating expenses were deducted, the industry showed underwriting losses of $1.4 billion in 1979 and $1.5 billion in 1978. About 78 percent of the population was insured for hospital care, 76 percent for x-ray and laboratory examinations, and about 76 percent for surgical services in 1979. Smaller percentages had coverage for other types of care. An estimated 64 percent of the aged bought private hospital insurance, and about 43 percent bought surgical insurance, mostly to supplement Medicare benefits. An estimated 12 percent of persons under age 65 had no protection against the cost of hospital care either through private insurance or a public program such as Medicare or Medicaid.     

Learning from the Aloha State

Since 1974, Hawaii has required its employers to provide health insurance to all employees working at least 20 hours a week. More recently, the state created a new program to cover the "gap group" of 50,000 uninsured residents, along with a new program to create a "seamless system of health care" for all Aloha State residents. And Hawaii has managed to insure nearly all of its citizens while keeping the annual price of health insurance at nearly half of that paid in many mainland states ($1,300 per person and $4,000 per family). At the same time, life expectancy is the highest in the nation and infant mortality is among the lowest. In seeking to reform a dysfunctional national insurance system, policymakers should learn from the Hawaiian experience, which shows that small business can live with an employer mandate, universal coverage can cut costs by encouraging early preventive care, and a dominant payer can reduce administrative expenses.     

Job-based health insurance in 2001: inflation hits double digits, managed care retreats

Drawing on the results of a national survey of 1,907 firms with three or more workers, this paper reports on several facets of job-based health insurance, including the cost to employers and workers; plan offerings and enrollments; patient cost sharing and benefits; eligibility, coverage, and take-up rates; and results from questions about employers' knowledge of market trends and health policy initiatives. Premiums increased 11 percent from spring 2000 to spring 2001, and the percentage of Americans in health maintenance organizations (HMOs) fell six percentage points to its lowest level since 1993, while preferred provider organization (PPO) enrollment rose to 48 percent. Despite premium increases, the percentage of firms offering coverage remained statistically unchanged, and a relatively strong labor market has continued to shield workers from the higher cost of coverage.     

Health care expenditure patterns for adolescents

Health care expenditure patterns are described using a sample of 2,767 adolescents aged 10 to 18 years from the National Medical Care Utilization and Expenditure Survey. Average total per capita health care expenditures were $525. Average out-of-pocket expenses were $151 in 1988 dollars. The burden of out-of-pocket expenses was distributed unevenly among the families of adolescents. The 10% of adolescents with the highest expenses accounted for 65% of ail out-of-pocket expenses. The presence of health insurance coverage greatly reduced the risk of incurring burdensome out-of-pocket expenses. Health policy interventions to improve health insurance coverage of adolescents are discussed.     

The number of Americans without health insurance rose in 2001 and continued to rise in 2002.

Data from the Census Bureau and the Centers for Disease Control and Prevention indicate that the number of uninsured Americans rose in 2001and in the first quarter of 2002. The main reason insurance coverage fell was a drop-off in employer-sponsored insurance for workers and their dependents. This reduction was triggered by rising unemployment levels and rising health insurance premiums, which made it more difficult for employers to offer insurance or for workers to afford it. The downturn in private coverage was partially offset by increased enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP). About two million mor e children and one million more adults would have been uninsured had it not been for the growth in these programs. Funding for the public programs is, however, threatened by budget shortfalls affecting most states, which administer these programs. Many states have cut their Medicaid programs and are planning further cutbacks. Increasing federal assistance to states and their Medicaid programs could help protect insurance coverage for low-income people during the current economic slowdown. Future SCHIP enrollment could drop sharply because of a shortage of federal funds, and Congress could take steps to bolster SCHIP funding.     

Trends in the golden state: small-group premiums rise sharply while actuarial values for individual coverage plummet

Using multiple databases, this paper examines recent trends in the affordability and comprehensiveness of small-group and individual health insurance markets in California. Both became less affordable over the study period. In 2006, a single person age 32-52 earning the median income who purchased individual insurance spent on average 16 percent of income on premiums and out-of-pocket medical expenses. For individual insurance, the share of medical expenses paid by insurance as opposed to patients declined from 2002 to 2006. In the small-group market, premiums rose more than 50 percent from 2003 to 2006, but the proportion of claims paid by insurers for a standardized population remained constant.     

Premium growth and its effect on employer-sponsored insurance

We use variation in premium inflation and general inflation across geographic areas to identify the effects of downward nominal wage rigidity on employers’ health insurance decisions. Using employer level data from the 2000 to 2005 Medical Expenditure Panel Survey-Insurance Component, we examine the effect of premium growth on the likelihood that an employer offers insurance, eligibility rates among employees, continuous measures of employee premium contributions for both single and family coverage, and deductibles. We find that small, low-wage employers are less likely to offer health insurance in response to increased premium inflation, and if they do offer coverage they increase employee contributions and deductible levels. In contrast, larger, low-wage employers maintain their offers of coverage, but reduce eligibility for such coverage. They also increase employee contributions for single and family coverage, but not deductibles. Among high-wage employers, all but the largest increase deductibles in response to cost pressures.     

Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually

Enrollment is increasing in consumer-directed health insurance plans, which feature high deductibles and a personal health care savings account. We project that an increase in market share of these plans--from the current level of 13 percent of employer-sponsored insurance to 50 percent--could reduce annual health care spending by about $57 billion. That decrease would be the equivalent of a 4 percent decline in total health care spending for the nonelderly. However, such growth in consumer-directed plan enrollment also has the potential to reduce the use of recommended health care services, as well as to increase premiums for traditional health insurance plans, as healthier individuals drop traditional coverage and enroll in consumer-directed plans. In this article we explore options that policy makers and employers facing these challenges should consider, including more refined plan designs and decision support systems to promote recommended services.     

Explaining the decline in health insurance coverage, 1979-1995

The decline in health insurance coverage among workers from 1979 to 1995 can be accounted for almost entirely by the fact that per capita health care spending rose much more rapidly than personal income during this time period. We simulate health insurance coverage levels for 1996-2005 under alternative assumptions concerning the rate of growth of spending. We conclude that reduction in spending growth creates measurable increases in health insurance coverage for low-income workers and that the rapid increase in health care spending over the past fifteen years has created a large pool of low-income workers for whom health insurance is unaffordable.     

The effect of HMOs on premiums in employment-based health plans.

This study documents the effect of HMOs on premiums in employment-based health plans. We analyzed a survey of Minnesota employers conducted in 1986. Among 922 usable observations, 239 firms offered HMOs in addition to fee-for-service (FFS) health plans. We estimated an equation for the probability of offering an HMO, followed by equations for HMO enrollment share, and HMO and FFS premiums. The weighted average HMO and FFS premium in firms that offer HMOs was compared to the premium of FFS-only firms. We found that offering an HMO raises the average premium for family coverage health insurance by $25.14 per month and for single coverage by $3.68 per month. This effect was smaller for firms in the Twin Cities metropolitan area. HMOs may be viewed as a progressive and innovative health care benefit, but they are likely to increase firms' health insurance premiums.     

Universal health insurance: lessons of the 1970s, prospects for the 1990s

In the 1970s, proposals for universal health insurance were not successful. Health care providers, insurers, and others negotiating in the political process foresaw a better future without such legislation. Today, the growth of health insurance coverage has unmistakably reversed. Moral discomfort and self-interest shape the new politics of universal health insurance for the 1990s. Hospitals, physicians, insurers, employers, and tens of millions of individuals would benefit from a universal health insurance plan that was mindful of their concerns and interests. Proposals that require employers to provide insurance for full-time employees and expand public programs to cover to cover other uninsured persons now have the greatest chances for enactment. As leaders, health services and health insurance executives should be in the vanguard of efforts to enact universal health insurance.     

Employer-sponsored health insurance for early retirees: impacts on retirement,health, and health care

The proportion of large employers offering retiree health insurance in the US has declined by half in the past 20 years. This paper examines the potential implications of this change by estimating the effects of a retiree health insurance (RHI) offer on a comprehensive set of labor, health and health care use outcomes in the near-elderly population. An RHI offer increases the probability of early retirement by 37% for both men and women. While the results suggest that an RHI offer has little, if any, effect on health, there is strong evidence that RHI provides significant protection from high out-of-pocket medical costs. In the top 40% of the out-of-pocket spending distribution, those with an offer of retiree coverage spend 22% less on average. Estimates of the value of RHI of over $4,000 per year suggest that increasing opportunities for the near-elderly to purchase coverage at actuarially-fair prices through the individual market or public programs could significantly increase insurance coverage and reduce financial risk for this age group.     

Health benefits in 2004: four years of double-digit premium increases take their toll on coverage

This paper reports changes in employer-based insurance during the past year and since 2001. From spring 2003 to spring 2004, premiums increased 11.2 percent (compared with 13.9 percent last year). Since 2000, premiums have increased 59 percent. Since 2001, employee contributions have grown by 57 percent for single coverage and 49 percent for family coverage, and the percentage of workers covered by their own employer's health plan has fallen from 65 percent in 2001 to 61 percent in 2004. The worst of the current round of premium inflation appears to be over, but employers plan to increase employee cost sharing next year [corrected]     

Employers' benefits from workers' health insurance

Even though many employers believe that health insurance and health affect employees' productivity and firms' performance, health economists typically overlook and rarely measure firms' returns on health-related investments. Some research, however, suggests that firms may benefit economically by providing health insurance coverage for workers and their families. For example, health coverage may help employers recruit and retain high-quality workers. Health may contribute to productivity by reducing the costs of absenteeism and turnover and by increasing workers' productivity. This article reviews the evidence and proposes an agenda for future research. A better understanding of the benefits to employers of offering health coverage to workers may help clarify employers' behavior and help private employers and public officials make appropriate investments in health.     

Ex-worker is unprotected against COBRA caps on AIDS medical care

The 11th U.S. Circuit Court of Appeals ruled that the Americans with Disabilities Act (ADA) does not prohibit an employer from capping HIV-related health-care benefits once an infected worker leaves the job and continues insurance coverage under COBRA, the Consolidated Omnibus Budget Reconciliation Act of 1985. The rule, binding in Georgia, Florida and Alabama, came as a result of a suit filed by August Gonzalez on behalf of Timothy Bourgeois. As an employee of a Hardees restaurant owned by Garner Food Services Inc., Bourgeois was fired 2 months after his employer learned of his AIDS diagnosis. Bourgeois contended he was fired because Garner wanted to avoid costs in its self-insured health plan. After his dismissal, Bourgeois continued paying insurance premiums to his employers group health insurance plan through COBRA, which provides up to $1 million in health care coverage. Garner changed the health insurance plan benefits, capping AIDS-related medical benefits at $10,000 a year, with a lifetime maximum limit of $40,000. By the time Bourgeois died, he owed $90,000. The appeals court ruled that Bourgeois did not qualify as an individual with a disability because he neither held nor desired to hold a position with Garner at or subsequent to the time the alleged discriminatory conduct was committed. The decision could have major implications for people with AIDS who leave their jobs because a former employee cannot use the ADA to challenge discrimination in post-employment fringe benefits.     

美国医疗保障制度改革的先行者——马萨诸塞州医改综述

马萨诸塞州2006年医改被视为2010年奥巴马美国医改的原型和模板,研究马州医改进展和效果,有助于推断美国医改可能取得的成绩及问题.2006年马州医改主要通过以下方式扩大医疗保险覆盖范围,提高医疗服务可及性.一是增加政府投入,扩大面向低收入人群的马州医疗援助计划覆盖范围,新建资助中低收入人群参保的公民健康保障计划,从而提高中低收入人群的参保能力;二是新建医疗保险交易局管理新建计划,干预私营医疗保险市场,新建致力于医疗保险标准化、面向高收入人群的公民健康选择计划;三是强制个人参保,要求雇主为雇员提供保险.综合现有文献,马州医改已取得许多成就,但也存在一定问题.一方面,无保障人群数量不断缩小,居民医疗服务可及性提高,可负担性也有所改进;另一方面,医疗支出快速上升影响了改革的可持续性,制度设计的一些缺陷影响了部分人群的医疗服务可及性,同时安全网计划资金的消减也可能影响医改效果.我国可借鉴马州经验建立商业健康保险管制机构,促进我国商业健康保险市场发展;同时需准备面对全民医保覆盖后的医疗费用快速增长问题,还需警惕全面覆盖后的“参保却不享有”问题.     

The need for and cost of mandating private insurance coverage of contraception

A public policy debate in the US is considering whether it is in the public interest to mandate that private, employment-related health insurance plans cover contraception. Industry representatives oppose mandates as unnecessary and costly, but women's health advocates point out that mandates were necessary to remove other health insurance disadvantages to women. For example, the Pregnancy Discrimination Act of 1978 was necessary to mandate coverage for maternity care. US women rely on contraception to avoid pregnancy for approximately 20 years during their reproductive lives, but health insurance policies vary widely in the amount of contraceptive coverage provided. Some fail to cover contraception but cover sterilization and abortion. Coverage is important because women cite cost as a consideration when choosing a method, and some of the more effective methods are more costly. Estimates show that the cost of covering the full range of approved reversible contraception would be a minimal $21.40/employee/year, of which employers would pay $17.12, a 0.6% increase in costs. The cost of plans that already cover some reversible methods would increase even less. Public opinion overwhelmingly favors mandated contraception coverage, even if employee costs were to increase. Congress is considering legislation to mandate coverage in private, employment-related plans, and the industry has indicated that it will not fight the legislation.     

Do medical out-of-pocket expenses thrust families into poverty?

This paper estimates the impact of medical out-of-pocket expenses on families' well-being using the Survey of Income and Program Participation. Medical out-of-pocket expenses include the out-of-pocket costs from medical services and the family's share of health insurance premiums. Demographic characteristics, insurance status, and medical usage of the family are analyzed to determine which characteristics are most likely to impoverish a family. Families impoverished because of medical out-of-pocket expenses are far more likely to have older heads of the family, at least one family member in poor health, or some adults without health insurance. Families without at least one person who worked full time for the entire year were also likely to be impoverished. However, children in the family had little effect on the probability that the family became impoverished. This odd result is probably due to the high correlation between parental health insurance coverage and the health insurance coverage of their children.     

日本健康保险制度演变历程及启示

对日本医疗保险制度实现全民覆盖的历程以及现状进行分析,发现日本的健康保险制度演变有以下特点：以法律为依据,逐步实现全民覆盖;建立了健康保险基金的合理分担机制;不同保健制度覆盖人群的服务包逐渐趋同、补偿水平逐渐统一;不同保险方案之间建立了风险分担和资金转移机制;加强对供方的约束力,控制医药费用快速上涨。最后针对日本健康保险制度的演变特点给出我国医疗保险制度改革的政策建议：健全医疗保险的法律法规;调整筹资机制,逐步提高个人筹资责任;推进不同医保制度覆盖人群保障待遇的统筹和统一;建立不同健康保险制度之间的风险分担机制;积极探索支付方式改革,控制医药费用快速上涨。