After the mandates: Massachusetts employers continue to support health reform as more firms offer coverage

Based on a spring 2008 survey of 1,003 randomly selected Massachusetts firms, this paper examines views and responses of employers to health care reform after employer and individual mandates went into effect. A majority of firms view reform as "good for Massachusetts." The percentage of firms with three or more workers offering coverage increased from 73 percent to 79 percent. Massachusetts employers are less likely than employers nationally to indicate plans to terminate coverage or restrict eligibility for health benefits, which suggests that crowd-out is not occurring.     

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 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-sponsored health insurance: pressing problems, incremental changes

Despite large premium increases, employers made only modest changes to health benefits in the past two years. By increasing copayments and deductibles and changing their pharmacy benefits, employers shifted costs to those who use services. Employers recognize these changes as short-term fixes, but most have not developed strategies for the future. Although interested in "defined-contribution" benefits, employers do not agree about what this entails and have no plans for moving to defined contributions in the near future. While dramatic changes in health benefits are unlikely in the short term, policymakers may want to watch for future erosions in health coverage.     

Health Insurance Premium Increases for the 5 Largest School Districts in the United States, 2004–2008

Background

Local school districts are often one of the largest, if not the largest, employers in their respective communities. Like many large employers, school districts offer health insurance to their employees. There is a lack of information about the rate of health insurance premiums in US school districts relative to other employers.

Objective

To assess the change in the costs of healthcare insurance in the 5 largest public school districts in the United States, between 2004 and 2008, as representative of large public employers in the country.

Methods

Data for this study were drawn exclusively from a survey sent to the 5 largest public school districts in the United States. The survey requested responses on 3 data elements for each benefit plan offered from 2004 through 2008; these included enrollment, employee costs, and employer costs.

Results

The premium growth for the 5 largest school districts has slowed down and is consistent with other purchasers—Kaiser/Health Research & Educational Trust and the Federal Employee Health Benefit Program. The average increase in health insurance premium for the schools was 5.9% in 2008, and the average annual growth rate over the study period was 7.5%. For family coverage, these schools provide the most generous employer contribution (80.8%) compared with the employer contribution reported by other employers (73.5%) for 2008.

Conclusions

Often the largest employers in their communities, school districts demonstrate a commitment to provide choice of benefits and affordability for employees and their families. Despite constraints typical of public employers, the 5 largest school districts in the United States have decelerated in premium growth consistent with other purchasers, albeit at a slower pace.Local school districts are one of the largest employers in the United States, employing roughly 8 million employees in 2008.1 Locally, they are often one of the largest (if not the largest) employers in the communities they serve. Like many large employers, school districts offer an array of benefits to their employees, including health insurance. Employee benefits comprise 34.3% of total compensation for public-sector employees,2 with health insurance representing 10.9% of total compensation.2     

An international survey of attitudes of medical geneticists toward mass screening and access to results

A survey on mass screening was sent to 1,053 medical geneticists in 18 nations, of whom 677 responded. Three theoretical screening situations were proposed, screening in the workplace for genetic susceptibility to work-related disease, carrier screening for cystic fibrosis, and presymptomatic testing for Huntington disease. Of the respondents, 72 percent thought screening in the workplace should be voluntary, and 81 percent said employers should have no access without the worker's consent, including 22 percent who believed that employers should have no access at all. There was strong consensus in all but one nation that insurance companies should have no access to test results without the worker's consent, and strong consensus in two countries that they should have no access at all. Most (82 percent) believed that screening for cystic fibrosis should be applied to the entire population, but 18 percent believed that it should be applied primarily to Caucasians. In all, 66 percent of respondents believed that individuals at risk for Huntington disease should be told their test results only if they say that they wish to know, recognizing a "right not to know" whether they will develop the disease in later life. Twelve percent thought that spouses should have access to test results if they asked, and 26 percent thought that spouses should be informed of results even if they did not ask. Geneticists in all nations were vividly aware of the potential damage from third party access to results, especially access by insurance companies. They had little sympathy with insurers' needs to assess actuarially accurate premiums.     

Worksite hypertension programs: results of a survey of 424 California employers.

More than 30 million American workers 17 years of age or older have some degree of hypertension, and nearly two-thirds of these workers have blood pressure greater than 160/95 mm Hg. Many employer-sponsored hypertension detection and control programs have been reported, but much of the information about these programs is anecdotal and based on perceptions rather than on formal evaluation. To gain an estimate of the number and nature of such programs among California employers, the authors surveyed 424 California organizations with more than 100 employees at one or more sites. Experienced survey researchers conducted 30-minute telephone interviews with key personnel of these firms to probe their companies'' health promotion activities, including those devoted to hypertension screening and control. Of the 424 organizations, 43 (10.1 percent) had worksite hypertension programs, and 24 (5.7 percent) were planning to initiate such a program within the following 12 months. But 357 employers neither offered a hypertension program at the time of the survey nor planned to initiate one within the following year. Survey responses indicated that during the 3 years before the survey, the number of worksite hypertension programs among the organizations surveyed had increased by 110 percent. This rapid rate of increase, together with the nearly 50 percent increase in number of programs that employers were planning for the following 12 months, suggest that the number of similar programs in other regions may also be growing at an accelerating rate. The National Heart, Lung, and Blood Institute''s strong endorsement of worksite hypertension programs and employers'' current interest in health promotion and disease prevention activities should act as a spur for further growth of these programs. For maximum growth, however--especially among smaller companies--active promotion by business and community groups is essential.     

Hospital specialization: product-line planning during the market reformation

Rational expectations theory dictates that firms respond to shifts in the demand function as a result of substantial reforms in the insurance marketplace. Federal health reform has enhanced the benefits of specialization. Hospital product-line specialization trends are studied using multiple regression analysis for the period 2001-2010. The observed 32.8 percent rise in specialization was associated with a 9.8 percent decline in unit cost per admission. The number of specialized hospitals has grown by 174 percent in the past decade. Other hospitals are getting more specialized by reducing their product lines. Specialization has been highest in competitive West Coast markets and lowest in the rate-regulated states (New York and Massachusetts). Hospitals have less incentive to contain costs by decreasing the array of services offered in stringent rate-setting states. The term "underspecialization" is advanced to capture the inability of some hospitals to selectively prune out product lines in order to specialize. Such hospitals spread resources so thinly that many good departments suffer. Unit cost per case (DRG-adjusted) is higher in the less specialized hospitals.     

Occupational and environmental medicine in the United States: A proposal to abolish workers' compensation and reestablish the public health model

The workers' compensation model of occupational and environmental medicine should be converted to a public health model. Occupational and environmental medicine, as a part of the public health infrastructure,could play a much more substantive part in bringing about a national program to deal with occupational and environmental health. The workers' compensation insurance system could be discontinued at any time,but it will be vital to do so when national health insurance is adopted in the United States. Abolishing workers' compensation would remove the perverse incentives that currently undermine the practice of occupational medicine. Medical care for workers should be provided by health care professionals who are not subject to influence by employers or insurers.Eligibility for benefits should not be determined by health and safety professionals. Wage-replacement benefits for workers should be determined by guidelines established by government and industry that prevent manipulation of health and safety professionals by employers and insurers. A nationwide comprehensive system to track work-related injury and illness, superior to the current reliance on records provided by employers and collated by government agencies, should be adopted. When unusually high rates of injuries, illnesses,and fatalities occur, government inspectors ought to respond and regulate the industry accordingly.Occupational health and safety professional strained in public health can and should participate in these activities, but not when they are in the employ of industry or insurers.     

Managing health care costs: strategies available to small businesses

Although health care costs continue to rise at an alarming rate, small businesses can take steps to help moderate these costs. First, business firms must restructure benefits so that needless surgery is eliminated and inpatient hospital care is minimized. Next, small firms should investigate the feasibility of partial self-insurance options such as risk pooling and purchasing preferred premium plans. Finally, small firms should investigate the cost savings that can be realized through the use of alternative health care delivery systems such as HMOs and PPOs. Today, competition is reshaping the health care industry by creating more options and rewarding efficiency. The prospect of steadily rising prices and more choices makes it essential that small employers become prudent purchasers of employee health benefits. For American businesses, the issue is crucial. Unless firms can control health care costs, they will have to keep boosting the prices of their goods and services and thus become less competitive in the global marketplace. In that event, many workers will face a prospect even more grim than rising medical premiums: losing their jobs.     

Focused on integrated administration

As employers continue to tinker with designing stronger benefits packages, the impetus to reevaluate once-overlooked areas such as how their statutory disability program is doing probably will get more notice, as well. For employers residing in states with government-operated and mandated disability programs, the option at least to explore self-insuring this program should not be overlooked.     

Preemployment evaluations: dilemmas for the family physician.

Preemployment evaluations present primary care physicians with numerous medical, ethical, and legal dilemmas. These examinations are especially problematic for community-based primary care providers unaccustomed to standards used by physicians in occupational settings. In response to a mailed questionnaire, 255 family physicians and general practitioners described their current methods of performing these examinations. Forty percent reported that employers routinely provide no information about the job for which the prospective employee is being evaluated. Respondents differed according to number and type of laboratory tests routinely included as part of a preemployment evaluation and in the proportion of prospective employees disqualified on the basis of the examination. Twenty-four percent reported no disqualifications, and 34 percent disqualified 5 percent or more. The percentage reporting medical and psychological information also varied. One-half routinely reported alcohol and drug abuse to employers, and of these, only one-half obtained a waiver for the release of such information. Five of every 6 physicians believed that it was more important to "tell the truth to the employer" than to "protect the interests of the employee." Our findings show that no consensus exists among the primary care physicians in our survey about the performance of preemployment evaluations. Because this can have serious consequences to workers, employers, and physicians, we propose guidelines for primary care physicians who perform preemployment evaluations.     

The Cost of Unintended Pregnancies for Employer-Sponsored Health Insurance Plans

Background

Pregnancy is associated with a significant cost for employers providing health insurance benefits to their employees. The latest study on the topic was published in 2002, estimating the unintended pregnancy rate for women covered by employer-sponsored insurance benefits to be approximately 29%.

Objectives

The primary objective of this study was to update the cost of unintended pregnancy to employer-sponsored health insurance plans with current data. The secondary objective was to develop a regression model to identify the factors and associated magnitude that contribute to unintended pregnancies in the employee benefits population.

Methods

We developed stepwise multinomial logistic regression models using data from a national survey on maternal attitudes about pregnancy before and shortly after giving birth. The survey was conducted by the Centers for Disease Control and Prevention through mail and via telephone interviews between 2009 and 2011 of women who had had a live birth. The regression models were then applied to a large commercial health claims database from the Truven Health MarketScan to retrospectively assign the probability of pregnancy intention to each delivery.

Results

Based on the MarketScan database, we estimate that among employer-sponsored health insurance plans, 28.8% of pregnancies are unintended, which is consistent with national findings of 29% in a survey by the Centers for Disease Control and Prevention. These unintended pregnancies account for 27.4% of the annual delivery costs to employers in the United States, or approximately 1% of the typical employer''s health benefits spending for 1 year. Using these findings, we present a regression model that employers could apply to their claims data to identify the risk for unintended pregnancies in their health insurance population.

Conclusion

The availability of coverage for contraception without employee cost-sharing, as was required by the Affordable Care Act in 2012, combined with the ability to identify women who are at high risk for an unintended pregnancy, can help employers address the costs of unintended pregnancies in their employee benefits population. This can also help to bring contraception efforts into the mainstream of other preventive and wellness programs, such as smoking cessation, obesity management, and diabetes control programs.     

Massachusetts health care reform: a look at the issues

Massachusetts recently enacted a major health reform that could move the state to close to universal health insurance coverage. We describe some of the politics behind the legislation and the law's key details. We discuss four major issues that the plan would face: (1) a definition of affordability-how much should be borne by individuals and how much by government; (2) issues the state will face in implementing the Insurance Connector; (3) whether employers will respond by dropping coverage; and (4) whether the financing would be adequate, both immediately and over time. Massachusetts will face challenges, but it offers a model that could be followed elsewhere.     

Early Effects of the San Francisco Paid Sick Leave Policy

Objectives. We examined employers’ responses to San Francisco, California’s 2007 Paid Sick Leave Ordinance.Methods. We used the 2009 Bay Area Employer Health Benefits Survey to describe sick leave policy changes and the policy’s effects on firm (n = 699) operations.Results. The proportion of firms offering paid sick leave in San Francisco grew from 73% in 2006 to 91% in 2009, with large firms (99%) more likely to offer sick leave than are small firms (86%) in 2009. Most firms (57%) did not make any changes to their sick leave policy, although 17% made a major change to sick leave policy to comply with the law. Firms beginning to offer sick leave reported reductions in other benefits (39%), worse profitability (32%), and increases in prices (18%) but better employee morale (17%) and high support for the policy (71%). Many employers (58%) reported some difficulty understanding legal requirements, complying administratively, or reassigning work responsibilities.Conclusions. There was a substantial increase in paid sick leave coverage after the mandate. Employers reported some difficulties in complying with the law but supported the policy overall.The Bureau of Labor Statistics estimates that in 2009 only 61% of workers nationwide in private industry had access to paid sick leave, with part-time (26%) and low-wage (33%) workers less likely to report access.1 There are health benefits to be gained by the adoption of a paid sick leave policy: reducing spread of influenza and infectious diseases in the workplace and childcare facilities2–4 and allowing workers to visit physicians, which may reduce unnecessary hospitalization and subsequent sickness absence.5 Previous research shows that the availability of paid sick leave is associated with increases in workers using sick leave, reductions in presenteeism (workers being on the job while sick), decreases in job loss because of sickness, and increases in the ability to care for sick children.6–20 Workers benefit from the insurance against loss of income or employment, and there may be economic benefits for employers, such as reducing job turnover and limiting productivity decreases because of presenteeism.21 However, mandated benefits may have detrimental effects on wages, employment, and business profitability.22,23In recent years, San Francisco, California, has been at the forefront of worker protection, implementing a citywide minimum wage requirement in 2004,24 mandatory paid sick leave in 2007,25 and an employer health benefit mandate in 2008.26 On February 5, 2007, San Francisco became the first jurisdiction to enact a policy25; recently, Connecticut27; New York City28; Portland, Oregon29; Seattle, Washington30; and Washington, DC31 passed laws requiring paid sick leave, and many other jurisdictions are considering similar policies.32 The San Francisco Paid Sick Leave Ordinance (PSLO) requires employers to provide paid sick leave to all employees (including part time and temporary). Paid sick leave must accrue at a rate of 1 hour for every 30 hours worked after the first 90 calendar days of employment.33 Enforcement is complaint driven, and the Office of Labor Standards Enforcement receives an average of 4 complaints a month.34 A small study (n = 26) 1 year after the PSLO went into effect found that San Francisco employers reported little benefit from reduced absenteeism, lower turnover, or improved morale and little impact on profitability.35 There is growing momentum for paid sick leave requirements across the United States32 but little evidence to inform us of their effects on employers, employees, or customers over the longer term.36We examined the 2009 Bay Area Employer Health Benefits Survey data to report changes employers made to comply with the sick leave mandate and the types of firms that made the greatest changes to sick leave policies. We analyzed the types of policies firms offer, employer-reported changes in other benefits, employee morale, prices, profitability, presenteeism, and absenteeism associated with changes in sick leave policy. We investigated employer sentiment, including support for the mandate and difficulties with implementation. We sought to inform policymakers about the impact of the PSLO on employers in San Francisco and allow policymakers in other cities or states considering similar legislation to assess the likely effects of such a policy.