Embraceable you: how employers influence health plan enrollment.

Based on data from a 1999 national survey of 1,939 randomly selected employers, this paper examines the policies that affect the percentage of workers eligible for and enrolled in a firm's health plan. In 1994, 14 percent of employees worked for a firm offering cash-back payments, but fewer than 1 percent worked for a firm with income-related premiums or deductibles. The strongest determinants of eligibility rates are the waiting time for new employees before they are deemed eligible, and eligibility standards for part-time workers. The primary determinants of the take-up rate are lowest monthly employee contribution for single coverage, and the percentage of the workforce earning less than $20,000 per year.

Trends in out-of-pocket spending by insured American workers, 1990-1997.

This paper examines trends in out-of-pocket spending for insured workers from 1990 to 1997. Data are from the Consumer Expenditure Survey conducted by the U.S. Bureau of Labor Statistics. The survey collects detailed quarterly data on all consumer spending from logs kept each year by more than 10,000 households with job-based health insurance. During the study period, total out-of-pocket spending in constant dollars remained unchanged. Spending for medical expenses, drugs, and supplies declined by 23 percent, but this decline was offset by rising employee contributions for health insurance premiums. The shift to managed care, whose benefit structure requires less cost sharing, may have played a role in reducing out-of-pocket spending.

Job-based health insurance, 1977-1998: the accidental system under scrutiny.

This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research (AHCPR) in 1977, 1987, and 1996; and surveys of employers by the AHCPR in 1977, by the Health Insurance Association of America in 1988, and by KPMG Peat Marwick/Kaiser Family Foundation in 1998. During the study years, in 1998 dollars, the cost of job-based insurance increased 2.6-fold, and employees' contributions for coverage increased 3.5-fold. The percentage of nonelderly Americans covered by job-based insurance plummeted from 71 percent to 64 percent. This decline occurred exclusively among non-college-educated Americans. An information-based global economy is likely to produce not only greater future wealth but also greater inequalities in income and health benefits.

Health benefits for the terminally ill: reality and perception.

This paper examines the availability and scope of hospice benefits as well as employers' attitudes and knowledge about care for the terminally ill. Data are drawn from a national random sample of 1,502 employers with 200 or more workers and from focus groups with employee benefits managers and their insurance advisers, brokers, and consultants. Major findings are that 83 percent of employers offer explicit hospice benefits, with most other firms covering hospice through high-cost case management. Most employers support the concept of hospice care because they believe that it reduces medical expenses.

Clinical staffing in staff- and group-model HMOs.

Analysts frequently have used health maintenance organization (HMO) staffing patterns as a yardstick for estimating national clinical workforce requirements. Based on a nationwide survey of fifty-four staff- and group-model HMOs, the largest sample yet used in an analysis of this type, this DataWatch examines physician-to-member ratios, the use of nonphysician providers, and HMOs' methods of estimating clinical staffing needs. Overall physician staffing ratios and primary care physician staffing ratios closely resemble those reported in previous studies, but they exhibit wide variability and are strongly correlated with HMO size. Although caution should be exercised when using HMO staffing ratios in projections of physician workforce requirements, the ratios described here support projections of a specialty physician surplus.

How Clinton's health benefit package compares to today's employer-sponsored plans.

Will you and your employees be better or worse off under the Clinton Health Security Act? A national survey of nearly 2,000 large and small businesses finds that a few workers will pay a lot less and receive a lot more insurance coverage than they receive today, while those who lose ground will just be a little worse off.

Small businesses' changing views on health reform.

Our national sample of 750 randomly chosen firms with fewer than 50 employees reveals surprising findings about the traditional views of small business on health care reform. A substantial segment of the small business community is sympathetic to health care reform, including such controversial measures as mandating that all employers contribute to the coverage of their workers, limits on health care spending, and altering the tax treatment of employer contributions for health insurance. Without premium savings, fewer than half of small businesses support the concept of health insurance purchasing cooperatives. With premium savings, a majority support it.

Is managed competition a field of dreams?

In recent months, managed competition has gained the upper hand in the debate over how to reform the U.S. health system and likely will be a part of President-elect Clinton's proposal. But recent data reveal that managed care plans, an important piece of the managed competition approach, have not significantly altered the rate of increase in costs. These findings cast doubt on the assumption by managed competition advocates that the proper incentives exist to cause the health delivery system to reorganize itself.

Can a universal coverage system temper the underwriting cycle?

The health insurance industry has experienced a pronounced six-year cycle of earnings for nearly three decades--three years of profits followed by three years of losses. This profitability cycle triggers a turbulent pricing cycle. After reviewing three schools of thought about the causes of the cycle, in this article we examine new evidence to determine the probable impact on the cycle of a private-public, universal coverage, national health plan. We find no evidence of a cycle in the pricing and use of health care services. Since 1985, the relationship between the overall economy and health insurance trends has weakened. We conclude that the root causes of the cycle are essentially internal to the insurance industry, and, therefore, national health care reform will have little impact on the underwriting cycle.

The price of state mandated benefits.

States have passed more than 700 statutes mandating that insurers cover specific providers, diseases, or people who otherwise might have difficulty obtaining coverage. We report findings from three econometric studies that examine the effects of mandates on the cost of insurance, the small employer's decision to offer health insurance, and the large employer's decision to self-insure. Study results indicate that mandates raise the price of health insurance substantially, that nearly one of every six small firms that do not offer health insurance would in an essentially mandate-free environment, and that about half of the large firms that are converting to self-insurance would not if there were no mandates.

The erosion of purchased health insurance.

In this paper, we trace the decline of purchased health insurance and examine the reasons for the rapid growth of self-insurance between 1981 and 1985. Then, using nationally representative data on benefits in larger private sector firms, we examine the changing content of self-insured plans and compare them with fully insured conventional plans from commercial insurers and Blue Cross and Blue Shield Plans. Between 1981 and 1985, the percentage of employees in mid- to large-sized firms covered by self-insurance grew from 21% to 42%. Self-insured plans cost more than purchased plans in 1981, and continued to cost more in 1985. Their higher premiums were not due to richer benefit packages. Indeed, they less often covered "fringe" services and required greater cost sharing via higher deductibles and coinsurance. Upon considering both the efficiency and the equity issues of self-insurance, we sound a cautionary note on this growing trend.