Health Care Coverage and Costs in Small Business: An Exploratory Study

Health coverage and health care costs continue to frustrate employers, employees, and public policy makers. Controlling escalating health costs, improving coverage for the uninsured, and providing retiree health care are all important to the small employer. This study was undertaken to investigate the availability and extent of health care coverage and to assess the effects of health care costs on small firms. The results revealed that the percentage of small firms offering health benefits totaled 58 percent. The availability of group health insurance increases as firm size increases. Small employers cited insufficient profits, high insurance costs, and unavailable group coverage as the primary reasons for not offering health benefits. The results also indicated that the vast majority of small firms opposed a mandated employer-provided health coverage and suggested that small businesses should pool together to form groups to reduce the cost of health care coverage for small firms.     

Health care coverage and costs in small business: an exploratory study

Health coverage and health care costs continue to frustrate employers, employees, and public policy makers. Controlling escalating health costs, improving coverage for the uninsured, and providing retiree health care are all important to the small employer. This study was undertaken to investigate the availability and extent of health care coverage and to assess the effects of health care costs on small firms. The results revealed that the percentage of small firms offering health benefits totaled 58 percent. The availability of group health insurance increases as firm size increases. Small employers cited insufficient profits, high insurance costs, and unavailable group coverage as the primary reasons for not offering health benefits. The results also indicated that the vast majority of small firms opposed a mandated employer-provided health coverage and suggested that small businesses should pool together to form groups to reduce the cost of health care coverage for small firms.     

Employer Health Insurance Offerings and Employee Enrollment Decisions

Objective. To determine how the characteristics of the health benefits offered by employers affect worker insurance coverage decisions.
Data Sources. The 1996–1997 and the 1998–1999 rounds of the nationally representative Community Tracking Study Household Survey.
Study Design. We use multinomial logistic regression to analyze the choice between own-employer coverage, alternative source coverage, and no coverage among employees offered health insurance by their employer. The key explanatory variables are the types of health plans offered and the net premium offered. The models include controls for personal, health plan, and job characteristics.
Principal Findings. When an employer offers only a health maintenance organization married employees are more likely to decline coverage from their employer and take-up another offer (odds ratio (OR)=1.27, p <.001), while singles are more likely to accept the coverage offered by their employer and less likely to be uninsured (OR=0.650, p <.001). Higher net premiums increase the odds of declining the coverage offered by an employer and remaining uninsured for both married (OR=1.023, p <.01) and single (OR=1.035, p <.001) workers.
Conclusions. The type of health plan coverage an employer offers affects whether its employees take-up insurance, but has a smaller effect on overall coverage rates for workers and their families because of the availability of alternative sources of coverage. Relative to offering only a non-HMO plan, employers offering only an HMO may reduce take-up among those with alternative sources of coverage, but increase take-up among those who would otherwise go uninsured. By modeling the possibility of take-up through the health insurance offers from the employer of the spouse, the decline in coverage rates from higher net premiums is less than previous estimates.     

Subsidies to employee health insurance premiums and the health insurance market

One approach to covering the uninsured that is frequently advocated by policy-makers is subsidizing the employee portion of employer-provided health insurance premiums. But, since the vast majority of those offered employer-provided health insurance already take it up, such an approach is only appealing if there is a very high takeup elasticity among those who are offered and uninsured. Moreover, if plan choice decisions are price elastic, then such subsidies can at the same time increase health care costs by inducing selection of more expensive plans. We study an excellent example of such subsidies: the introduction of pre-tax premiums for postal employees in 1994, and then for the remaining federal employees in 2000. We do so using a census of personnel records for all federal employees from 1991 through 2002. We find that there is a very small elasticity of insurance takeup with respect to its after-tax price, and a modest elasticity of plan choice. Our results suggest that the federal government did little to improve insurance coverage, but much to increase health care expenditures, through this policy change.     

Massachusetts reform plus President Bush's tax credits: a national model?

The Massachusetts health reform offers an important opportunity for a new federal-state strategy to cover the uninsured. President George Bush's proposed health insurance tax credits could be added to the Massachusetts health reform. The combined plan would include Medicaid expansions; offer workers affordable coverage through competitive insurance markets; and provide federal, state, employer, and individual financing. Many other states might be interested in similar federal-state partnerships for the forty-five million uninsured Americans. Ending the national impasse on coverage needs this kind of bold initiative.     

The effect of premiums on the decision to participate in health insurance and other fringe benefits offered by the employer: evidence from a real-world experiment

In this paper, we investigate the effect of the out-of-pocket premium on the decision to enroll in employer health insurance and other benefits plans including dental insurance, vision care, long-term care insurance, and wellness benefits. Previous estimates of the effects of premium on takeup of health insurance could be biased toward zero due to a correlation between premium and unobservable demand or plan quality. We solve this problem using data representing hypothetical choices by employees under three different price regimes, providing price variation uncorrelated with either individual-specific or plan-specific unobservables. We find that workers are insensitive to price in health insurance takeup. Workers show much greater price sensitivity to decisions about dental insurance, vision plans, long-term care insurance, and wellness benefits. We conclude that premium subsidies are unlikely to have a substantial impact on increasing insurance rates of workers already offered employer insurance.     

Compensating wage differentials and the impact of health insurance in the public sector on wages and hours

This paper examines the trade-off between wages and employer spending on health insurance for public sector workers, and the relationship between coverage and hours worked. Our primary approach compares trends in wages and hours for public employees with and without state/local government provided health insurance using individual-level micro-data from the 1992–2011 CPS. To adjust for differences between insured and uninsured public sector employees, we create a matched sample based on an employee's propensity to receive health insurance. We assess the relationship between state contribution to the health plan premium, state-level healthcare spending, and the wages and hours of state and local government employees. We find modest reductions in wages are associated with having employer-sponsored health insurance (ESHI), although this effect is not precisely measured. The reduction in wages associated with having ESHI is larger among non-unionized workers. Further, we find little evidence that provision of health insurance increases hours worked.     

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.     

Cost and coverage: implications of the McCain plan to restructure health insurance

Senator John McCain's (R-AZ) health plan would eliminate the current tax exclusion of employer payments for health coverage, replace the exclusion with a refundable tax credit for those who purchase coverage, and encourage Americans to move to a national market for nongroup insurance. Middle-range estimates suggest that initially this change will have little impact on the number of uninsured people, although within five years this number will likely grow as the value of the tax credit falls relative to rising health care costs. Moving toward a relatively unregulated nongroup market will tend to raise costs, reduce the generosity of benefits, and leave people with fewer consumer protections.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

A Needle in a Haystack? Uninsured Workers in Small Businesses That Do Not Offer Coverage

OBJECTIVE: To describe the insurance status of workers at small businesses, and to describe the status of uninsured persons by the employment characteristics (employment status, firm size, and whether the employer offers insurance) of the head of household. DATA SOURCES: Data from the March and February 2001 Current Population Survey, and a survey of 2,830 small businesses in San Diego County conducted in 2001. STUDY DESIGN: The survey of small businesses was undertaken as part of a project testing the response of employers to offers of subsidized coverage. Employers were asked whether they offered insurance, and about the insurance status of their employees. The merged February-March 2001 CPS was used to identify the employment status, firm size, and employer-offering status for uninsured persons in the U.S. DATA COLLECTION: Telephone interviews with small businesses in San Diego County. PRINCIPAL FINDINGS: Only 21 percent of the uninsured in the U.S. are full-time employees (or their dependents) in small businesses (<100 employees) that do not offer insurance. The employment status of the uninsured is heterogeneous: many work for large employers, small employers who do offer insurance, or are self-employed, part-time workers, or have no workers in the household. Although there are many small businesses in San Diego that do not offer coverage, most of them have very few uninsured workers. Over 50 percent of businesses that do not offer coverage have either zero or one uninsured worker. There are very few small businesses that do not offer coverage and that have substantial numbers of uninsured workers. These businesses are not quite as rare as a needle in a haystack, but they are very difficult to find. CONCLUSIONS: If all small businesses that do not offer insurance now could be persuaded to start offering coverage, and if all the full-time workers (and their dependents) in those businesses accepted insurance, the number of uninsured would decline by 21 percent--a significant decline, but leaving 80 percent of the problem untouched. If the prime target for programs of subsidized insurance are small businesses that do not offer coverage now and that have substantial numbers of uninsured workers, the target is very small.     

Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

Children’s Insurance Coverage and Crowd-Out Through the Recession: Lessons From Ohio

Objectives. We estimated changes in children’s insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio.Methods. We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity.Results. From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period.Conclusions. Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children.During the economic recession of 2007 to 2009, 8 million Americans lost employer-sponsored health insurance.1 During this same period, the national rate of uninsurance among adults increased by 15% while the rate for children decreased by 7%, as children increasingly moved from private insurance to public programs including Medicaid and the Children’s Health Insurance Program (CHIP).1 With spending for Medicaid accounting for almost 20% of state budgets,2 increases in Medicaid enrollment raise concerns for many state governments. A key debate among state legislators is whether these changes represent Medicaid fulfilling its planned role as a safety net or whether these increases represent Medicaid replacing or crowding-out private insurance coverage.Crowd-out refers to individuals who are insured by a public program but who otherwise would have private insurance if the public program did not exist. The archetype of crowd-out is when privately insured individuals gain eligibility for Medicaid and drop their private coverage to enroll in the public plan. This scenario is often referred to as public–private “substitution” in the literature.3 It should be noted that individuals who can no longer afford private individual insurance or who lose access to, or cannot afford their employer-sponsored plan, are excluded from crowd-out estimates. For example, a child whose parent has private insurance but cannot afford to include the child on the plan4 would not be considered to be crowded out. The second type of crowd-out, which we refer to as continuation crowd-out, occurs when an individual on a public program becomes eligible to enroll in an employer-sponsored private plan, but chooses to remain on public coverage. This scenario could occur when an unemployed parent begins a new job that offers an affordable, employer-sponsored plan, but the parent decides to keep their child enrolled in Medicaid instead of the newly available private option.The published literature primarily focuses on estimates of crowd-out based on increased enrollment following the expansion of eligibility, such as a state increasing Medicaid income eligibility limits. These estimates vary widely, ranging from high estimates of 50% (i.e., half of individuals gaining Medicaid coverage through an expansion would otherwise have private insurance) to other authors finding near zero crowd-out.5–7 Some of this variability is driven by the sensitivity of the econometric models used8 and some may be attributable to the actual crowd-out that occurred with different expansions of eligibility in different states.5 A smaller literature directly measures substitution from survey data, finding low levels of this type of crowd-out.9,10 From a legislative perspective, these crowd-out estimates reveal the budgetary cost of Medicaid expansions. For the average state in 2012, insuring a child through Medicaid cost $2700 per year.11 At a 50% crowd-out rate, a state would need to budget $5400 to reduce the number of uninsured by 1 child. The $5400 would include coverage for the previously uninsured child and for a second child who previously had private insurance (1 uninsured child and 1 case of crowd-out).The existing crowd-out literature implicitly assumes that crowd-out estimates are stable over time. The econometric approaches used in most studies require a change in Medicaid eligibility to estimate crowd-out, producing a single, national estimate for the policy change.5,12 Absent a more recent change, policymakers assume that crowd-out rates do not change with time because those estimates are not time dependent. This implicit assumption, though, is likely invalid. Crowd-out indicates the use of public insurance while private coverage is still available; the reasons for that are likely dependent on the current cost and expected future cost of insurance, the suitability of access provided by the types of coverage, and noneconomic factors such as the stigma associated with public coverage.13Each of these factors can change over time. Concern about the future cost of insurance during the recession may have been particularly important, as parents may have had strong concerns about retaining their employment or concerns that their employer would stop offering employer-sponsored health insurance. Between January 2007 and January 2010, Ohio’s unemployment rate almost doubled from 5.4% to 10.6%.14 This increase in the unemployment rate may have raised parents’ concerns about future access to health care for their children. If these concerns led to increased enrollment in public insurance, then crowd-out would increase. Previous work has not estimated state-level crowd-out levels over time. We evaluated how many children in Ohio moved from private health insurance to public health insurance and the degree to which those children were crowded out between 2004 and 2012. We estimated total crowd-out (substitution plus continuation) over time to see whether crowd-out levels changed during the recession in Ohio.     

Universal access to health care: a practical perspective

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)     

How does retiree health insurance influence public sector employee saving?

Economic theory predicts that employer-provided retiree health insurance (RHI) benefits have a crowd-out effect on household wealth accumulation, not dissimilar to the effects reported elsewhere for employer pensions, Social Security, and Medicare. Nevertheless, we are unaware of any similar research on the impacts of retiree health insurance per se. Accordingly, the present paper utilizes a unique data file on respondents to the Health and Retirement Study, to explore how employer-provided retiree health insurance may influence net household wealth among public sector employees, where retiree healthcare benefits are still quite prevalent. Key findings include the following:

• -Most full-time public sector employees anticipate having employer-provided health insurance coverage in retirement, unlike most private sector workers.
• -Public sector employees covered by RHI had substantially less wealth than similar private sector employees without RHI. In our data, Federal workers had about $82,000 (18%) less net wealth than private sector employees lacking RHI; state/local workers with RHI accumulated about $69,000 (or 15%) less net wealth than their uninsured private sector counterparts.
• -After controlling on socioeconomic status and differences in pension coverage, net household wealth for Federal employees was $116,000 less than workers without RHI and the result is statistically significant; the state/local difference was not.

     

Use and employer costs of a pharmacotherapy smoking-cessation treatment benefit

BACKGROUND: Employers cite a lack of information on the cost of insurance coverage for smoking-cessation treatment as a barrier to its provision. This study describes the use of a new insurance benefit for smoking-cessation pharmacotherapy, and its pharmaceutical costs to a large public employer between 2001 and 2003. METHODS: Annual enrollment and pharmaceutical claims data were collected from the health plans that contracted with the Wisconsin Department of Employee Trust Funds (ETF). State employees, retirees, and adult dependents who obtained health insurance through the ETF constituted our sample, approximately 150,000/year. Pharmacotherapy benefit use was defined as a paid claim for one of four U.S. Food and Drug Administration-approved smoking-cessation medications. Pharmaceutical cost was defined as the ingredient cost (+) dispensing fee (-) member copayment. Analyses included estimation of the proportion of smokers who used the benefit each year and across 3 years, the average annual cost per user, and the per member per month (PMPM) pharmaceutical cost to the employer. Data were collected from 2001 to 2004 and analyzed in 2005-2006. RESULTS: Annual benefit use among smokers ranged from 6% to 7% with a 3-year rate of approximately 17%. The PMPM cost of the covered pharmacotherapy was approximately 0.13 dollars. CONCLUSIONS: The cost to employers of providing insurance coverage for smoking-cessation pharmacotherapy to their employees is low. By informing insurance purchasing decisions, these results may facilitate the adoption of such coverage, with the goal of ultimately reducing the proportion of employees who smoke.     

Covering the uninsured through TennCare: does it make a difference?

Tennessee created TennCare in 1994 to address the needs of "poor and uninsured citizens ... excluded from the health care system." Under TennCare, Tennessee implemented managed care in its Medicaid program and used savings anticipated from the switch to expand insurance coverage to uninsured and uninsurable adults and children. Our analysis of the expansion suggests that it improved access to care, reduced unmet need, and encouraged use of preventive services, particularly for children. These changes coincided with higher levels of satisfaction with care among TennCare beneficiaries.     

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.     

Determinants of Coverage Decisions in Health Insurance Marketplaces: Consumers' Decision‐Making Abilities and the Amount of Information in Their Choice Environment

Objective

To investigate the determinants and quality of coverage decisions among uninsured choosing plans in a hypothetical health insurance marketplace.

Study Setting

Two samples of uninsured individuals: one from an Internet-based sample comprised largely of young, healthy, tech-savvy individuals (n = 276), and the other from low-income, rural Virginians (n = 161).

Study Design

We assessed whether health insurance comprehension, numeracy, choice consistency, and the number of plan choices were associated with participants'' ability to choose a cost-minimizing plan, given their expected health care needs (defined as choosing a plan costing no more than $500 in excess of the total estimated annual costs of the cheapest plan available).

Data Collection

Primary data were collected using an online questionnaire.

Principal Findings

Uninsured who were more numerate showed higher health insurance comprehension; those with more health insurance comprehension made choices of health insurance plans more consistent with their stated preferences; and those who made choices more concordant with their stated preferences were less likely to choose a plan that cost more than $500 in excess of the cheapest plan available.

Conclusions

Increasing health insurance comprehension and designing exchanges to facilitate plan comparison will be critical to ensuring the success of health insurance marketplaces.     

Cost estimate of health care coverage for the medically indigent in Hawaii

The objective of the study was to estimate the cost of health insurance coverage of the medically indigent in Hawaii. The number of uninsured was estimated deductively from the coverages of those insurance companies doing business in the state, with an additional factor for persons with more than one policy coverage. Age and sex breakdowns of the uninsured were entered into actuarial tables and fee-for-service and HMO plan costs were obtained for the most prevalent health plan in the state. Annual coverage is estimated at US$46.090866 million and US$58.040700 million for fee-for-service and HMO plans, respectively. Seven potential sources of financing and five recommendations for further research are given.