Hostname: page-component-848d4c4894-4hhp2 Total loading time: 0 Render date: 2024-05-30T14:12:48.460Z Has data issue: false hasContentIssue false

The Current State of Employment-Based Health Coverage

Published online by Cambridge University Press:  01 January 2021

Extract

American policymakers and health policy analysts have a love-hate relationship with job-based health insurance. The policy press routinely runs articles about the demise of the current system of voluntary employer-sponsored health insurance coverage. Conservatives argue that it ought to be replaced with individually-purchased insurance, such as tax-favored spending accounts (see Mark Pauly’s article this issue). Liberals assert that government insurance ought to supplant it.

Meanwhile, as the debate rages on about the future of employer coverage, states and the federal government pass legislation buttressing and building on the existing employment-based system. Most recently, California has passed an employer mandate requiring employers to cover their workers (and many other states have contemplated similar legislation) and Maine has adopted a universal coverage initiative that includes a voluntary small employer insurance program offered through a state agency (Dirigo Health Care).

Type
Symposium
Copyright
Copyright © American Society of Law, Medicine and Ethics 2004

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Enthoven, A.C., “Employment-Based Health Insurance Is Failing: Now What?” Health Affairs Web Exclusive (May 28, 2003) <http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.237v1/DC1> (last visited July 1, 2004); Gabel, J.R., “Job-Based Health Insurance, 1977–1998: The Accidental System Under Scrutiny,” Health Affairs 18, no. 6 (1999): 6274; Pauly, M. Percy, A. and Herring, B., “Individual Versus Job-Based Health Insurance: Weighing the Pros and Cons,” Health Affairs 18, no. 6 (1999): 28–44; Reinhardt, U.E., “Employer-Based Health Insurance: A Balance Sheet,” Health Affairs 18, no. 6 (1999): 124–132; Hyman, D.A. and Hall, M., “Two Cheers for Employment-Based Health Insurance,” Yale Journal of Health Policy, Law, and Ethics 2, no. 1 (2001): 23–57.Google Scholar
Francis, T., “Medicare Law Helps Business: A Few Major Corporations Expect Combined Savings in Excess of $2.5 Billion,” Wall Street Journal, March 2, 2004.Google Scholar
“EBRI Research Highlights: Health Benefits,” EBRI Special Report SR-41, Issue Brief, no. 247 (Washington, D.C.: Employee Benefit Research Institute, 2003): 21 at Figure 18; “Employer Health Benefits 2003 Annual Survey: Summary of Findings,” (Washington, D.C.: Kaiser Family Foundation/Health Research and Educational Trust, 2003) [hereinafter cited as Kaiser/HRET 2003 Summary]: 5, available at <http://www.kff.org/insurance/loader.crm?url=/commonspot/security/getfile.cfm&PageID=20688> (last visited June 23, 2004).+(last+visited+June+23,+2004).>Google Scholar
Glied, S., “The Employer-Based Health Insurance System: Mistake or Cornerstone?” in Mechanic, D., Rogut, L., Colby, D. and Knickman, J., eds., Policy Challenges in Modern Health Care (New Jersey: Rutgers University Press, 2005).Google Scholar
Sheils, J. and Haught, R., “The Cost of Tax-Exempt Health Benefits in 2004,” Health Affairs Web Exclusive (February 25, 2004): W4–106–112 <http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.106v1/DC1> (last visited July 1, 2004): This number includes expenditures for the following types of favorable tax treatment for health plans: (1) deductibility of employer contributions to an employment-based health plan, (2) non-inclusion in employee income of the amount their employer pays on their behalf for health insurance, (3) tax-exempt treatment for any investment income that was generated if the employer’s health plan was funded, and (4) deductibility of health insurance premiums for the self-employed.+(last+visited+July+1,+2004):+This+number+includes+expenditures+for+the+following+types+of+favorable+tax+treatment+for+health+plans:+(1)+deductibility+of+employer+contributions+to+an+employment-based+health+plan,+(2)+non-inclusion+in+employee+income+of+the+amount+their+employer+pays+on+their+behalf+for+health+insurance,+(3)+tax-exempt+treatment+for+any+investment+income+that+was+generated+if+the+employer’s+health+plan+was+funded,+and+(4)+deductibility+of+health+insurance+premiums+for+the+self-employed.>Google Scholar
Id., at W4–110.Google Scholar
EBRI Special Report, supra note 3, at 35, table 32.Google Scholar
O’Brien, E., “Employers’ Benefits from Workers’ Health Insurance,” Milbank Quarterly 81, no. 1 (2003): 543; Buchmueller, T.C., The Business Case for Employer-Provided Health Benefits: A Review of the Relevant Literature (Irvine, CA: California Healthcare Foundation, 2000).CrossRefGoogle Scholar
O’Brien, , id.Google Scholar
Newhouse, J., Free for All: Lessons from the RAND Health Insurance Experiment (Cambridge: Harvard University Press, 1993).Google Scholar
Buchmueller, , supra note 8; O’Brien, , supra note 8.; Kessler, R.C., et. al., “The Effects of Chronic Medical Conditions on Work Loss and Work Cutback,” Journal of Occupational and Environmental Medicine 43, no. 3 (2001a): 218225.Google Scholar
Fronstin, P., “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2003 Current Population Survey.” EBRI Issue Brief, no. 264 (Washington, D.C.: Employee Benefit Research Institute, 2003): 4 (citing Fronstin, P. and Snider, S., “An Examination of the Decline in Employment-Based Health Insurance Between 1988 and 1993,” Inquiry (Winter 1996/97):317–325).Google Scholar
Holahan, J. and Wang, M., “Changes in Health Insurance Coverage During the Economic Downturn: 2000–2002.” Health Affairs Web Exclusive (January 28, 2004): W4–3142, at W4–32 <http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.31v1/DC1> (last visited July 1, 2004).+(last+visited+July+1,+2004).>Google Scholar
Kaiser/HRET 2003 Summary, supra note 3, at 5; 91 percent of firms that employ union workers offer health insurance compared with 60 percent of firms that do not have union employees, “Employer Health Benefits 2003 Annual Survey,” (Washington, D.C.: Kaiser Family Foundation/Health Research and Educational Trust) [hereinafter cited as Kaiser/HRET 2003 Survey]: 38, available at <http://www.kff.org/insurance/ehbs2003-abstract.cfm> (last visited June 23, 2004).+(last+visited+June+23,+2004).>Google Scholar
Holahan, and Wang, , supra note 14, at W4-39-40; 82.6 percent of employees in large firms had health insurance coverage, while only 53.6 percent of workers in small firms had coverage.Google Scholar
Fronstin, , supra note 12, at Figure 10.Google Scholar
Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, “Table I.A.2(2001) Percent of private-sector establishments that offer health insurance by firm size and selected characteristics: United States, 2001,” (Medical Expenditure Panel Survey-Insurance Component, 2001) at <http://www.meps.ahrq.gov/MEPSDATA/ic/2001/Tables_I/TIA2.htm> (last visited June 23, 2004).+(last+visited+June+23,+2004).>Google Scholar
Medoff, J.L., Shapiro, H. B., Calabrese, M., and Harless, A.D., “How the New Labor Market is Squeezing Workforce Health Benefits,” The Commonwealth Fund 449 (2001).Google Scholar
Glied, S. and Stabile, M., “Explaining the Decline in Health Insurance Coverage Among Young Men,” Inquiry 37, no. 3 (2000): 295303; Acs, G., “Explaining Trends in Health Insurance Coverage Between 1988 and 1991,” Inquiry 32, no. 1 (1995): 102–110.Google Scholar
Glied, S., Lambrew, J.M. and Little, S., “The Growing Share of Uninsured Workers Employed by Large Firms,” Commonwealth Fund 672 (2003); Medoff, et. al., supra note 19.Google Scholar
Kronick, R. and Gilmer, T., “Explaining the Decline in Health Insurance Coverage, 1979–1995,” Health Affairs 18, no. 2 (1999): 3047.Google Scholar
Glied, S. and Jack, K., “Macroeconomic Conditions, Health Care Costs, and the Distribution of Health Insurance,” National Bureau of Economic Research (NBER), working paper no. W10029, (October 2003).CrossRefGoogle Scholar
Fronstin, , supra note 12, at 13 and 17, Figure 15.Google Scholar
Kaiser/HRET 2003 Summary, supra note 3, at 5.Google Scholar
Fronstin, , supra note 12, at Figure 16.Google Scholar
Glied, , supra note 4; tabulations of the March 2003 Current Population Survey; Hippie, S., “Contingent Work in the Late 1990s” Monthly Labor Review 124, no. 3 (2001): 327.Google Scholar
Reinhardt, U., “Health Care Spending and American Competitiveness,” Health Affairs 8, no. 4 (1989): 521.Google Scholar
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99–272 (April 7, 1986), requires employment-based health plans to offer “qualified beneficiaries” who would otherwise lose coverage under the plan because of the occurrence of a “qualifying event,” the right to continue their health coverage for a specified period of time by paying 102% of the cost of coverage. Employees who terminate employment (either voluntarily or involuntary) may generally continue coverage for up to 18 months, unless they become covered under another group health plan or first become eligible for Medicare during that period. Continuation coverage can also be terminated for certain other reasons, such as non-payment of premiums.Google Scholar
Gruber, J. and Madrian, B.C., “Health Insurance, Labor Supply, and Job Mobility: A Critical Review of the Literature,” NBER working paper no. w8817 (February 2002).Google Scholar
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), P.L. 104–191 (August 21, 1996), provides protections for employees in group health plans from the imposition of waiting periods or additional preexisting condition restrictions. In addition, it protects employees from discrimination in their health plans based on health-related factors. Much more limited protections apply to products sold in the individual marketplace so that employees with existing health problems who lose their jobs and then need to purchase individual coverage may find it difficult to secure that coverage. For a discussion of coverage portability, see Meyer, J. and Stepnick, L., “Portability of Coverage: HIPAA and COBRA,” Commonwealth Fund Issue Brief 569 (November 2002).Google Scholar
Kaiser/HRET 2003 Survey, supra note 15, at 62–64 and Exhibits 4.2, 4.3, 4.4.Google Scholar
Bundorf, K., “Employee Demand for Health Insurance and Employer Health Plan Choices,” Journal of Health Economics 21 (2002): 6588.CrossRefGoogle Scholar
Reinhardt, , supra note 28, at 1.Google Scholar
Herzlinger, R.E., “Let’s Put Consumers in Charge of Health Care,” Harvard Business Review 80, no. 7 (2002): 4452.Google Scholar
Scanlon, D.P. and Chernew, M., et. al., “The Impact of Health Plan Report Cards on Managed Care Enrollment,” Journal of Health Economics 21, no. 1 (2002): 1941; “Quality vs. Costs? A Survey of Healthcare Purchasing Habits and Concerns,” Healthcare Financial Management 54, no. 7 (2000): 68–72.CrossRefGoogle Scholar
Glied, S.A., “Challenges and Options for Increasing the Number of Americans with Health Insurance,” Inquiry 38, no. 2 (2001): 90105.Google Scholar
Gabel, J., Dhont, K., Whitmore, H. and Pickreign, J., “Individual Insurance: How Much Financial Protection Does It Provide?” Health Affairs Supplement Web Exclusives (2002): W17281 <http://content.healthaffairs.org/cgi/content/full/hlthaff.w2.172v1/DC1> (last visited July 1, 2004).CrossRef+(last+visited+July+1,+2004).>Google Scholar
Thorpe, K.E., “Inside the Black Box of Administrative Cost,” Health Affairs 11, no. 2 (1992): 4155; Pauly, Percy, , and Herring, , supra note 1.CrossRefGoogle Scholar
The percentage of employers offering retiree medical benefits has fallen from 66 percent of large firms (5000 employees or more) in 1998 to only 38 percent in 2003; Kaiser/HRET 2003 Survey, supra note 15, at 132 and Exhibit 11.1.Google Scholar
U.S. Bipartisan Commission on Comprehensive Health Care, A Call for Action: Final Report (Washington, U.S. Government Printing Office, 1990).Google Scholar
Wilensky, G.R., “Viable Strategies for Dealing with the Uninsured,” Health Affairs 6, no. 1 (1987): 3346.CrossRefGoogle Scholar
Merlis, M., “Public Subsidies for Employees’ Contributions to Employer-Sponsored Insurance,” Inquiry 38, no. 2 (2001): 121–32.CrossRefGoogle Scholar
Silow-Carroll, S., Waldman, E.K. and Meyer, J.A., “Expanding Employment-Based Health Coverage: Lessons from Six State and Local Programs,” Commonwealth Fund 445 (2001).Google Scholar
Meyer, J.A. and Wicks, E.K., “A Federal Tax Credit to Encourage Employers to Offer Health Coverage,” Inquiry 38, no. 2 (2001): 202213.CrossRefGoogle Scholar
Rosenbaum, S., Borzi, P.C. and Smith, V., “Allowing Businesses and the Self-Employed to Buy Health Care Coverage Through Public Programs,” Inquiry 38, no. 2 (2001): 193201.CrossRefGoogle Scholar
Helman, R. and Chrisensen, R., “Findings From the 2003 Health Confidence Survey: Americans Increasingly Worried About Health Care Costs,” EBRI Notes (Employee Benefits Research Institute, October 2003): 5.Google Scholar