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Employer-Sponsored Insurance — Riding the Health Care Tiger
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     Employers and the health insurance companies who serve them are on the frontlines of the struggle with the problems of the costs and quality of health care in the United States. Although the system of employer-sponsored insurance is not well designed to deal with these problems,1 it has nevertheless struggled gamely to do so. In part one of this two-part report, I reviewed the history of employer-sponsored insurance in the United States and the implications of relying on this institution to insure many Americans.1 Here, I examine the approaches that employers and insurers are using to deal with problems of cost and quality, the success of these activities, and how employer-sponsored insurance is likely to evolve over the next 20 years.

    In general, U.S. companies and the health care plans that insure them have pursued two related but different strategies to constrain the costs of insurance and improve the quality and efficiency of the health care available to employees. The first strategy has been to shift costs to others either by increasing employees' payments under employer-sponsored plans or by ceasing to offer health care benefits altogether. The second strategy has been to improve the efficiency and the quality of care through reforms to the health care system, including some that involve increased cost-sharing by employees. Because the tactics employers are using to pursue these strategies are new and evolving, reaching firm judgments about the ultimate effect of these reforms remains difficult. Still, preliminary information offers hints regarding how the new approaches will affect employer-sponsored insurance and the nation's health care system overall.

    Employers' Health Care Costs

    Although some sophisticated employers have become increasingly concerned about the quality of health care their employees receive, the growing cost of insurance premiums — rising at multiples of general inflation — has captured their attention2,3,4 (Figure 1). To make the numbers understandable, commentators use a familiar analogy: "It is a well-known fact that the U.S. automobile industry spends more per car on health care than on steel," said Lee Iacocca, the retired chairman of the Chrysler Corporation, who is one of the few business leaders to advocate openly for national health insurance.5

    Figure 1. Increases in Health Insurance Premiums, as Compared with Overall Inflation Rates and Workers' Earnings, 1988–2005.

    Data on increases in health insurance premiums reflect the cost of premiums for a family of four. Asterisks indicate an estimated percentage that differs significantly (P<0.05) from that for the previous year. The dagger indicates an estimated percentage that differs significantly from that for the previous year (P<0.01). Adapted from the Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits, 1999 to 2005.

    Economists argue that workers ultimately pay the costs of health care in the form of reduced take-home pay.6 However, employers often think that they share the burden. For one thing, they cannot reduce compensation below the minimum wage and so must absorb the increased costs of insurance for workers at or near that level of pay.7

    In the 1990s, employers responded to cost pressures by using managed care companies to pressure providers to reduce their prices and the use of expensive services. Supported by their patients, however, providers successfully fought off managed care.8,9 Employers concluded from this experience that they had made fundamental mistakes during the managed care era. They had underestimated the power of providers to protect their own autonomy and resist external economic pressure. Employers concluded that companies needed help from their employees to tame health care costs, but unfortunately, employers had also erred in taking their employees "out of the game" of cost control by reducing the employees' out-of-pocket expenses at the point of purchase.10 "Unless employees pay for health care services out of their own pockets," says the National Business Group on Health, "they have little incentive to comparison shop for the best price or to consider the most appropriate use of services."10

    Shifting Costs to Employees

    To bring their employees back into the cost-control game, employers are requiring them to pay more out of pocket than they have been paying for their insurance and the health care services they receive. Between 1999 and 2005, workers' average monthly contribution to family coverage increased from $129 to $226 (although the proportion of the premium paid by workers — 26 percent — did not change, on average).11 During this period, the average annual deductibles also increased dramatically: for the most popular type of plan, point-of-service coverage, the increase was almost by a factor of five, from $49 in 1999 to $229 in 2005. Further ratcheting up cost-sharing, a number of firms have begun to offer insurance plans with very high deductibles, ranging from $1,000 to $5,000. Between 2003 and 2005, the proportion of all firms offering health plans with high deductibles increased from 5 percent to 20 percent (and to 33 percent among large firms with more than 5000 employees).11

    Proponents of increased cost sharing by employees argue that it has the beneficial effect of making the employees think twice about whether to seek and use health care services, thus reducing unnecessary use. The classic, decades-old RAND Health Insurance Experiment confirmed that patients use fewer services when they pay more for them out of pocket, but it also made it clear that patients reduce the use of necessary services (including preventive care) as much as unnecessary services.12

    The ultimate form of cost shifting to employees is to drop health insurance coverage altogether. The proportion of all firms offering health care benefits fell from 69 percent in 2000 to 60 percent in 2005,11 causing 5 million employees to lose their insurance coverage.13 This change accounts for most of the increase in the number of uninsured Americans during this period. Only 47 percent of firms with fewer than 10 workers offer insurance. And of course, the elimination of health benefits for retired employees constitutes another form of draconian cost shifting, in some instances to Medicare and in others to retired persons who have not reached the age of 65 years.1

    Improving the Performance of the Health Care System

    In addition to shifting costs to employees, employers have also been pursuing a range of strategies directed in whole or part at improving the performance of the health care system.3 There are too many of these strategies to review them comprehensively, but some of the most important are described here.

    Consumer-Directed Health Care

    To soften the blow of high deductibles and to encourage better choices of health care by their employees, employers have combined high-deductible health plans with several other innovations to create a new type of health insurance product known as consumer-directed health plans.14,15,16 Two aspects of these plans distinguish them from high-deductible health plans. First, consumer-directed health plans use tax-exempt "accounts" to reduce the costs of deductibles to employees. Second, at least in theory, consumer-directed health plans empower employees as health care consumers by providing them with information about the cost and quality of available health care services.

    Three new types of accounts now offer tax benefits to employees who enroll in high-deductible health plans17 (Table 1). The first and newest of these accounts is the health savings account (HSA).14 Created by the Medicare Modernization Act of 2003, HSAs are the equivalent of individual retirement accounts and were created for the unique purpose of holding funds that can be expended only to cover the out-of-pocket medical expenses of persons who are enrolled in high-deductible health plans. The funds in HSAs may be contributed by either employees or employers, but once deposited, the funds belong to consumers and can travel with them wherever they work. Annual contributions cannot exceed the deductible — a minimum of $1,000 for the individual or $3,000 for a family. As of 2005, 2.6 percent of U.S. firms offered HSAs, and 810,000 employees had enrolled in such plans.11

    Table 1. Characteristics of Heath Care Accounts.

    The second type of account is the health reimbursement account (HRA). HRAs are similar to HSAs but are much more flexible from the employer's point of view. Under this arrangement, employers reimburse all or part of the employee's out-of-pocket expenses up to a specified annual limit but do not actually deposit any funds into an account.17 In effect, companies offer their employees credit on which they can draw. The Internal Revenue Service does not tax HRA payments as income to the employee. The employer can decide whether unused credit for a given year can be rolled over into subsequent years, and the accounts are not portable. In practice, they are often paired with high-deductible health plans, but they do not have to be.17 In 2005, HRAs were offered by 1.9 percent of firms and 1.6 million employees had enrolled in programs that included them.11

    The oldest of the three types of accounts is the medical savings account (MSA). Created in 1996 under provisions of the Health Insurance Portability and Accountability Act, the MSA is essentially identical to an HSA — it is a portable, tax-exempt pool of funds to which employers, employees, or both may contribute that can be used only to pay for health care expenses up to a certain maximum. The tax-exempt account is combined with a catastrophic health care plan that takes effect when the account is exhausted. The major difference between an MSA and an HSA is that because of political opposition at the time MSAs were created, Congress made the MSA available only to a limited segment of the employer community — firms with 50 or fewer employees or to persons who are self-employed.11

    Another element that firms combine with high-deductible health plans to produce consumer-directed health plans is increased information for employees and dependents about the costs and the quality of the performance of providers. The theory is that after payment of out-of-pocket expenses has sensitized employees to the importance of choice in health care consumption, employees will be receptive to the use of information about providers' performance in order to obtain better value for their money. It is this process of empowerment through the provision of improved information to consumers as a basis for making choices that justifies calling these health plans "consumer-directed."

    Consumer-directed health plans are controversial from many viewpoints.16 Some critics fear that these plans will disproportionately attract healthy employees who see opportunities to pay lower premiums while accumulating tax-free funds to use for future health care.18 This result will tend to undermine further the risk pools created by employer-sponsored insurance and hasten its unraveling. Early studies suggest that employees enrolled in these plans tend to have a history of lower health care expenses than others incur.19 Critics also believe that consumer-directed health plans will do little to contain costs, because most expenses are incurred by patients with a chronic illness who will regularly use up their deductibles and then spend just as heavily as before under the catastrophic provisions of consumer-directed health plans. Others are skeptical that consumer-directed health plans can find ways to empower consumers to make wise health care choices, given the limits on available data about providers' performance and the uncertain effects of past efforts to inform consumers' health care choices.16 To date, consumer-directed health plans have not, in fact, made much performance data available to employees enrolled in them.20 Finally, as the low enrollment data indicate, employees have not rushed to enroll in these plans, and early evidence suggests some dissatisfaction among those who have enrolled.21

    More positively, these plans are very new, so that it is too early to draw conclusions about their ultimate popularity or effect. They do seem to increase the cost consciousness of those enrolled in them and to reduce the use of health care services.21 Employers have the option of exempting certain high-value services, such as preventive care and evidence-based services for the chronically ill, from deductible requirements. Finally, advocates contend that whatever their shortcomings, consumer-directed health plans are a humane and reform-minded way of preserving the availability of some coverage for employees whose firms might otherwise drop health insurance altogether.22

    Paying for Performance

    Along with consumer-directed health care, a second strategy to reform the health care system pursued in employer-sponsored insurance is paying for performance, through which employers, working with insurers, agree to reward providers who offer a better quality of care, care at a lower cost, or both. Pay-for-performance arrangements have exploded in number and no systematic list of them exists, but it is clear that they vary widely in what they reward and how they do so.23 Some arrangements are focused on hospitals, some on groups of physicians, and some even compensate individual physicians on the basis of their performance.24,25

    At first glance, the pay-for-performance idea has a compelling logic. It corrects a major flaw in the current fee-for-service system, which compensates providers without regard to the quality or efficiency of their services and thus offers them no financial incentive to improve their services.24 However, paying for performance also has potential downsides. Performance is difficult to measure, and there is concern that what is measurable might drive out what is important. Providers might also avoid sick poor patients whose care may be more difficult to manage than that of healthy rich patients, thereby improving the providers' cost or quality statistics. It is also unclear whether employers would be happy if paying for performance resulted in an increase in the quality of care but at a higher expense than in the current system. Systematic studies have just begun to test the effects of pay-for-performance programs.26

    Disease Management

    Another idea for reforming the health care system that has recently been embraced by employers is disease management. Disease management comprises a diverse family of interventions that include various approaches to achieving the common purpose of increasing the proportion of patients with chronic illnesses who receive evidence-based care.27 By 2005, 41 percent of all employers and 68 percent of large employers were offering their employees at least one disease-management program, with the number of employers increasing yearly.3 The experience with disease-management programs to date seems to confirm the potential of these programs to improve the quality of care,28 but their potential to control costs remains uncertain.27 According to Helen Darling, president of the National Business Group on Health, many disease-management programs are promising in their results, "but no way can we count on those programs for savings."

    Incentives to Change Employees' Behavior

    Employers are using a variety of financial incentives and information-sharing strategies to encourage employees to improve their health or to choose services or providers that are low in cost or of good quality. Some companies are purchasing tiered insurance programs, in which employees pay less in premiums or cost sharing if they use low-cost pharmaceuticals or low-cost or high-quality providers.2 In 2005, 68 percent of employers reported using tiered programs of copayments to encourage the purchase of inexpensive pharmaceuticals (i.e., generic or brand-name drugs on which discounts have been negotiated). Efforts to encourage employees to use high-performing doctors and hospitals are new and less common. These programs can be seen as complementary to pay-for-performance systems for providers: tiered copayments reward employees for making good decisions about which providers to use, just as paying for performance rewards doctors and hospitals for doing their jobs well. The effectiveness of tiered payments directed at choosing among providers depends, however, on whether reliable information about providers' performance is available, which up to now has been scarce, and on the employees' ability to use this information effectively, which has not been conclusively demonstrated. Tiered programs based solely or predominantly on providers' costs may also threaten academic health centers and other organizations that care for sicker patients or that contribute to social missions, such as teaching and research, which are inadequately compensated in the marketplace.29 Taking a very different approach, in 2005, 39 percent of employers offered gifts, discounts, or low premiums to employees for completing a health-risk appraisal and 36 percent provided financial incentives for personal health-improvement programs.

    Other Programs to Reform the Health Care System

    Other initiatives pursued by employers have included the development of national or local business coalitions that attempt to use their collective purchasing power to encourage providers to improve their quality of care or lower their costs. The strengths and limitations of such coalitions were discussed in part one of this report.1 Some employer-sponsored insurance plans have continued to use the utilization-review and prior-authorization programs that were so controversial during the era of managed care.11 One company, Wal-Mart, has even discussed plans to avoid hiring or retaining sick employees.30,31

    Implications of Reforms for Employer-Sponsored Insurance and the Health Care System

    One of the most important questions now facing the U.S. health care system is whether the responses mounted by employers to date, and other responses in the future, will prove sufficient to stabilize and sustain employer-sponsored insurance. A second critical question is, if employer-sponsored insurance continues to erode, what will that erosion mean for the health care system generally.

    Increases in the cost of insurance premiums have begun to moderate in the past two years (Figure 1). One projection suggests that in 2006 employers' average premiums may increase less than 7 percent, a big improvement over the double-digit averages of the early 2000s, before companies began to shift costs to employees and pursue other reform strategies.3,32 However, some observers are skeptical of the long-term ability of recent reforms to contain employers' costs. According to Dr. Arnold Milstein, an experienced health care consultant who advises many companies, the adoption of consumer-directed health plans, high-deductible health plans, and cost-shifting strategies will be "worth maybe two years of pain relief."

    With respect to the effects of reforms to employer-sponsored insurance on the quality of care, uncertainty also abounds. Consumer-directed health plans may improve the ability of some workers to make better health care choices, but employers face a fundamental problem: they lack the clout in most markets to affect providers' behavior through the devices they are currently using. The most important effect of the employer-sponsored insurance initiatives related to the quality of care may arise not from the direct actions of employers but from the employers' influence on the Medicare program, which has considerable market power and has begun to adopt changes pioneered in the private sector. The problem facing employers, however, may be that these changes will improve the value of services — the health care return for each dollar invested — but will not reduce costs.

    These considerations have led many observers to predict the continued decline of employer-sponsored insurance as a source of insurance in the United States. The main disagreement seems to be about the pace of the decline, not its direction. "I don't think we're falling off a cliff," says Jon Gabel, who has studied employer-sponsored insurance closely for many years. "We are seeing a gradual erosion of employer-sponsored health insurance." Helen Darling, of the National Business Group on Health, seems more concerned: "You can't look at the data and not believe we have very dramatic things ahead of us."

    There appear to be two reasons underlying the current pessimism about the ability of employer-sponsored insurance to resist the cost pressures that are undermining it. The first is the apparently untamable nature of the health care tiger. Demand for life-extending health care services is so powerful, and our health care industry is so resourceful in feeding it, that only an extraordinarily powerful contravening force would have any hope of restraining the rise of health care costs. So far, the U.S. community of employers has not shown itself equal to the task — it is too scattered, too preoccupied with other local and international threats, and too unsophisticated about the health care market. The second reason for pessimism is that some of the solutions that employer-sponsored insurance has arrived at most recently, including consumer-directed health plans and shifting costs to employees, could ultimately hasten the decline of employer-sponsored insurance by undermining the integrity of the risk pools that are essential to the viability of private insurance.

    Given the costs and uncertainties of employer-sponsored insurance, a logical question that arises is why employers have not washed their hands of it completely — perhaps, like Lee Iacocca, by embracing a federal takeover of the insurance function. The answer involves both practical and ideological calculations. First, employers actually like providing health insurance to their employees. They believe doing so generates good will and loyalty, and studies suggest that they are correct in this view.33 Second, according to Helen Darling, firms believe that whatever their problems, they are better at managing health care costs than the government is and that ultimately they would pay more in taxes for government-provided coverage than they currently pay for employer-sponsored insurance. Third, leaders of U.S. companies tend to be antigovernment as a matter of faith and ideology. Thus, they are willing to tolerate considerable pain to avoid transferring new authority to the public sector.

    These considerations make it likely that employer-sponsored insurance as an institution will persist for some time in the United States but that its role will steadily diminish. During the next 20 years, it seems probable that the proportion of U.S. companies offering insurance will drop below 50 percent, as will the proportion of workers and their dependents enrolled in such programs. Out-of-pocket expenditures for medical services will increase accordingly for working Americans. Among employers with fewer than 100 employees, employer-sponsored insurance may become a rarity or a very modest offering, pared of expensive benefits such as drugs, encumbered with large deductibles, or covering only essential services such as hospital care.

    If current trends persist, the decline of employer-sponsored insurance will be accompanied by incremental increases in the role of government in insuring Americans. In recent years, expansions of Medicaid and the State Children's Health Insurance Program, a related program for insuring poor children not eligible for Medicaid, have moderated the effect of declines in employer-sponsored insurance, resulting in an increase in the number of publicly insured Americans that has almost, but not fully, compensated for the loss of private coverage.13 Thus, the United States will see an increase in the role of government, but incrementally and unobtrusively, in a way compatible with Americans' abiding distrust of the public sector.

    The decline of employer-sponsored insurance seems likely to persist because of the fundamental nature of cost trends in health care. These have proved unstoppable, because they reflect a basic human desire for health, health care, and protection from the financial burden of illness. Advocates of consumer-directed health care believe that by forcing employees to face the costs of illness, they can restrain this seemingly irresistible force, but the most realistic possibility remains that even when Americans must share costs, they will demand more and better services. This tendency will lead to continuing increases in costs to employers, especially for care for chronically ill workers who exhaust their deductibles, as most of them will. Increasing numbers of employers will therefore seek relief from a burdensome and unpredictable expense that defies their control and understanding. In countries whose governments cover health care costs, politicians also face exasperating political dilemmas regarding how to manage them. But governments generally cannot jump off the health care tiger. Employers can, and because they can, many will.

    It is difficult, barring catastrophic political or economic events, to imagine a future for American health care without employer-sponsored insurance, given the firm roots of this accidental institution in the nation's psyche and its health care environment.18 But it is also difficult to imagine a future in which such plans continue to be the dominant insurers they have been historically. Perhaps one can hope for a salutary compromise, in which a diminished private insurance sector, serving a privileged minority of workers, continues to be an engine of innovation for an increasingly large public health insurance sector that is more efficient and effective as a consequence. This would be a health insurance system that provided a uniquely American — and more sustainable — solution to the nation's health care challenge.

    No potential conflict of interest relevant to this article was reported.

    I am indebted to Dr. Mandy Krauthamer for research assistance and to Dr. Joseph Newhouse and Helen Darling for reviewing the manuscript.

    Source Information

    From the Institute for Health Policy, Massachusetts General Hospital–Partners Health Care System, Boston.

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