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Health Benefits In 2003: Premiums Reach Thirteen-Year High As Employers Adopt New Forms Of Cost Sharing

Abstract

 
This paper reports changes in job-based health insurance from spring 2002 to spring 2003. The cost of health insurance rose 13.9 percent, the highest rate of increase since 1990. Employers required larger contributions from employees for the monthly cost of health insurance. Separate copayments and deductibles for hospital services have become commonplace, and provider networks have broadened. There was no change in the percentage of employers offering health plans to their workers. Employers indicate little confidence in any future strategies for controlling health care costs.

Job-based insurance covers nearly 175 million Americans, including 160 million active workers and their dependents, three million early retirees, and twelve million Medicare-eligible retirees.² Employer-sponsored insurance is intertwined with the problems of uninsurance in America, since approximately 80 percent of the uninsured are from families whose head of household works full or part time.³

This paper reports on the state of job-based health benefits in 2003 and how they have changed over the past year, as well as the past fifteen years.⁴ We review many features of health benefits in the workplace, including the cost of coverage; employee contributions for insurance; employee cost sharing; plan enrollments; changes in the percentage of employers offering coverage; retiree coverage; consumer-driven health care; and attitudes of employers toward controlling costs.

Study Methods

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 
In the fifth year of the annual Henry J. Kaiser Family Foundation/Health Research and Educational Trust (KFF/HRET) Employer Health Benefits Survey, core elements of the survey remain a continuation of earlier surveys conducted by the Health Insurance Association of America (HIAA) from 1987 to 1991 and KPMG Peat Marwick from 1991 to 1998. The survey questionnaire requests information about the employer’s largest conventional, health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service (POS) plans.

Using computer-assisted telephone interviewing, National Research LLC conducted telephone interviews with employee benefit managers from January to May 2003. The 2003 national survey includes 1,856 randomly selected public and private firms, of which 1,359 participated in the survey in 2001 or 2002, or both. Firm size ranges from three to hundreds of thousands of workers. The KFF/HRET survey sample comes from a listing of the nation’s employers compiled by Dun and Bradstreet. The sample is stratified by firm size (number of workers) and industry. The overall response rate was 50 percent, identical to the 2001 and 2002 figures.

Because firms in the sample are chosen randomly, statistical weights are used to extrapolate results to national as well as firm-size, regional, and industry figures. We calculate weights by determining the basic weight, applying a nonresponse adjustment, and then applying a post-stratification adjustment.

This year we made several changes to our methodology to strengthen the reliability of the results. In previous years we used Dun and Bradstreet’s listing of the nation’s firms as the basis of calculating employer weights. Each firm’s weight was the inverse of its probability of appearing in the Dun and Bradstreet sample. For the 2003 survey we used the recently released Statistics of U.S. Businesses, from the U.S. Census Bureau, as the basis of a post-stratification adjustment. Census data indicate that 59 percent of the nation’s firms have three to nine workers, not 74 percent as in earlier Dun and Bradstreet samples.⁵ This change, however, has little impact on worker-based estimates, since firms with three to nine workers accounted for less than 10 percent of the nation’s workforce. For all statistics from surveys conducted in 1999 and after, we used the new set of census weights to recalculate the figures, to assure comparability.

While most of the data in the KFF/HRET survey are employee-based, offer-rate statistics represent the percentage of employers offering health benefits or retiree benefits, respectively, for different firm-size categories. Because a lower proportion of firms with three to nine workers offer health benefits as compared with other firm-size categories, reducing the influence of this subset of firms in the sample has the effect of raising the offer rate by around four percentage points over what we have previously reported.

Our second major change concerns a nonresponse adjustment made to the one question that we ask firms that decline to participate in the full survey, "Does your company offer or contribute to a health insurance program as a benefit to your employees?" Our experience from prior-year surveys indicated that firms not offering health benefits are less inclined to participate in the full survey, and there is reason to believe the same might be true for the single-offer question. In 2003 we conducted a nonresponse analysis by recontacting all firms with three to forty-nine workers that were not participating in the survey. Of the 1,744 non-responding firms, 1,119 addressed this question. Respondents who answered the offer question twice were evaluated in statistical tests showing that both approaches yield similar results (p < .01), and a subsequent adjustment to the weights for these small firms is applied to the remaining firms.

Study Findings

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 
Health insurance premium increases. Premium growth of 13.9 percent in 2003 signifies the third consecutive year of double-digit increases (Exhibit 1). Premium increases were more than six times the economywide rate of inflation and ten percentage points more than the annual increase in wages of nonsupervisory workers.

View larger version (32K): [in this window] [in a new window]   EXHIBIT 1 Premium Increases Compared With Other Indicators, 1988–2003 SOURCES: Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits, 1999–2003; KPMG Survey of Employer-Sponsored Health Benefits, 1988–1998; and Bureau of Labor Statistics, 1988–2003. NOTES: The graph line for insurance premiums represents data for both large and small firms, except for the years 1991, 1992, 1994, and 1997, for which large-firm data only are shown. Premium estimates are statistically different from the previous year for 1998–1999, 1999–2000, 2000–2001, and 2001–2002 (p < .05) and for 2002–2003 (p < .10). No tests were done on years prior to 1998 or for employees’ earnings or overall inflation. Sample included firms with 200 or more workers only.

Premium increases outpaced estimated increases in claims expenses. Data from Milliman USA reported in this journal show that claims expenses rose 9.6 percent in calendar year 2002 (down from 10 percent in 2001).⁶ Premiums for fully insured plans grew nearly three percentage points faster than premium equivalents in self-insured plans.⁷ It would appear, therefore, that insurers have increased their underwriting profits (profits before investment income) over the past year.

Cost of coverage. The average monthly cost for single coverage was $282 ($3,391 annually), while the average monthly cost of family coverage was $756 ($9,075) (Exhibit 2). Differences in monthly costs across regions and by firm-size categories are surprisingly modest. Despite recent increases, HMOs remained the least costly type of coverage, and indemnity single coverage was the most expensive; however, the difference in cost is less than 10 percent. However, the above comparisons are unadjusted for differences in benefits, cost sharing, area cost of living, health status of the covered population, and other factors.

Separate hospital deductibles and copayments. An important recent change in patient cost sharing could be the imposition of separate cost-sharing requirements for inpatient hospital care. We are unaware of prior surveys capturing this type of data, most likely because these deductibles are a recent phenomenon in employer-sponsored plans. In 2003, 36 percent of all employees with job-based insurance faced a separate deductible or copayment when admitted to the hospital, averaging $202 (Exhibit 4). Half of HMO enrollees faced separate hospital deductibles or copayments, a figure exceeding that for other plans. An additional 12 percent of covered workers had to pay coinsurance when hospitalized, with an average coinsurance rate of 16 percent.

To control expenses, employers continue to redesign their drug benefits, although the pace of change might have slowed. The percentage of workers enrolled in a plan using a formulary grew slightly, from 70 percent in 2002 to 71 percent in 2003, up from 46 percent in 2000. Three-tier cost-sharing formulas, where the patient’s copayment or coinsurance is dependent on the type of drug prescribed, grew to 63 percent in 2003, up from 55 percent in 2002 and 26 percent in 2000. Consequently, employees have stronger financial incentives to use generic or "preferred brand-name" drugs to obtain lower cost sharing. The average copayment for a brand-name drug (when a generic is available) grew from $20 in 2000 to $25 in 2002 and $29 in 2003. Copays for generic drugs, in contrast, remained unchanged at $9 over the past year. Unlike hospital services, few employees (8 percent) faced a separate deductible for use of prescription drugs.

Covered benefits. Four-fifths of employees worked for firms reporting that their level of benefits remained the same over the past year. However, when firms changed their benefits, they were about twice as likely to reduce benefits as increase them. Nine-tenths of firms with 5,000 or more workers provided dental benefits, whereas only 28 percent of firms with three to nine workers did so. Coverage for preventive benefits remained high, with 93 percent of employees covered for adult physical exams, 97 percent for well-baby care, and 99 percent for prenatal care. The percentage of workers with coverage for sterilization (87 percent) was nearly double that covered for abortion (46 percent).

Plan enrollments. The shift from heavily managed care, characterized by limited provider networks, capitated payment of providers, and extensive use of prospective utilization management, continues.⁹ Over the past two years PPO plan enrollment has grown from 46 percent to 54 percent of employees; it has nearly doubled since 1996, the high-water mark of heavily managed care. HMO enrollment remained statistically unchanged in 2003 (Exhibit 5).

View larger version (25K): [in this window] [in a new window]   EXHIBIT 5 Health Plan Enrollments Among Covered Workers, By Type Of Plan, Selected Years 1996–2003 SOURCES: Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits, 1999–2003; and KPMG Survey of Employer-Sponsored Health Benefits, 1996 and 1998. NOTE: HMO is health maintenance organization. PPO is preferred provider organization. POS is point-of-service plan.

Employer purchasing and quality of care. Employers actively considered new plan options during the past year. Nearly two-thirds of small firms and half of large firms responded that they had shopped for a new plan. When employers seek new plans, however, their understanding of quality of care is limited. Advocates of new approaches to improve quality and expand consumer choice agree that quality measures are important, but the majority of small and large U.S. employers are unfamiliar with organizations that measure health plan quality. Only 5 percent of small (3–199 workers) and 18 percent of large (200 or more workers) employers were familiar with the Leapfrog Group, for example; half of "jumbo" employers (5,000 or more workers) were.¹⁰ Similarly, only 14 percent of small employers, 43 percent of large employers, and 71 percent of jumbo employers were familiar with National Committee for Quality Assurance (NCQA) or URAC accreditation.¹¹ Only 6 percent of small, 24 percent of large, and 62 percent of jumbo firms were familiar with Health Plan Employer Data and Information Set (HEDIS) data.

Given the lack of familiarity with organizations that measure quality, employers’ most important criterion for selecting health plans is price, while NCQA and URAC accreditation and HEDIS scores are the least important factors. Thus, 79 percent of small firms and 87 percent of large firms considered the cost of the plan to be a "very important" factor in plan selection in 2003. Less than 5 percent of small and large employers regarded NCQA/URAC accreditation or HEDIS scores as "very important." After price, the number of physicians in the network was the second most important criterion.

Availability of coverage. Despite the continuing slow economy and a third straight year of double-digit premium increases, the percentage of employers offering health benefits remained statistically unchanged in 2003 (Exhibit 6). The offer rate for small employers also remained steady, although it is significantly lower than its prerecession high in 2000. Virtually all large businesses (200 or more workers) continued to offer coverage, while just over half of the smallest companies (three to nine workers) did so. As in previous years, the firms least likely to offer coverage were those with lower-wage workforces, greater turnover, no unions, and a large proportion of part-time employees.

View larger version (37K): [in this window] [in a new window]   EXHIBIT 6 Percentage Of Firms Offering Health Benefits, By Firm Size, Selected Years 1996–2003 SOURCES: Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits, 2000–2003; and KPMG Survey of Employer-Sponsored Health Benefits, 1996 and 1999. NOTES: Estimates are statistically different from the previous year for 1996–1999 (all large firms), 1999–2000 (25–49 workers), and 2002–2003 (10–24 workers) (p < .10). Estimates are statistically different from the previous year for 1999–2000 (3–9 workers, 10–24 workers, all small firms), 2000–2001 (all large firms), and 2001–2002 (10–24 workers) (p < .10). Small firms are those with 3–199 workers. Large firms are those with 200 or more workers.

Although employers overwhelmingly cite costs as a very important reason for not offering health benefits, it appears that their decision not to offer also could reflect their views about their employees’ preferences for wages over health benefits. We asked non-offering employers whether, if they were able to increase compensation by an additional $2 an hour (approximately $4,000 per year), they felt that their employees would prefer higher wages or health benefits. Seventy-nine percent answered that their employees would prefer higher compensation. This suggests that even an improving economy might not encourage many more employers to begin offering health benefits.

When employers do offer coverage, often not all workers are eligible to take advantage of the benefit. For example, among firms offering health coverage, 46 percent extend eligibility to part-time workers, and only 8 percent make it available to temporary employees. Overall, 81 percent of workers in firms offering health benefits are eligible for coverage, and 83 percent of eligible workers take up coverage. This means that one-third of workers in firms offering insurance are not enrolled in the employer’s plan, because they either are not eligible or do not take it up (likely because of its cost or because they have other coverage available through a spouse or second job).

Retiree coverage. The percentage of large firms offering retiree benefits remained statistically unchanged in 2003 at 38 percent. More than 93 percent of large firms offering retiree benefits provided coverage to early retirees, while 78 percent covered Medicare-age retirees.

Employers’ Views Of The Future

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 
Given years of rapidly rising costs, it is not particularly surprising that employers do not have confidence that current market strategies can reduce premium growth. When employers were asked what they see for the future and which strategies might be effective in addressing rapidly rising costs, none of the approaches was identified as likely to be very effective. The most commonly identified approach was disease management, which 21 percent of employers said would be very effective in addressing cost increases. The irony here is that there is little evidence from the scientific literature that disease management programs save money.¹² Other approaches that were not perceived to be potentially effective included consumer-driven health plans (identified as "very effective" by 14 percent of employers); higher cost sharing (10 percent); and tighter managed care networks (6 percent). However, substantial percentages of employers viewed these approaches as somewhat effective as a future cost-control strategy.

Looking to the future, how should we expect employers to respond to steadily rising costs? Our survey suggests that many employees will face higher premium contributions and cost sharing next year but that few employers will drop coverage or reduce eligibility for benefits. Four-fifths of large employers said that they were very or somewhat likely to increase employee contributions, almost half said that they were very or somewhat likely to increase deductibles and office visit copayments or coinsurance, and 57 percent said that they were very or somewhat likely to increase employee cost sharing for prescription drugs.

Similar to 2002, far lower percentages of small employers indicated that they intended to increase employees’ costs, with 46 percent saying that they were very or somewhat likely to increase employee contributions, less than 40 percent saying that they were very or somewhat likely to increase deductibles on office visit copayments or coinsurance, and 38 percent saying that they were very or somewhat likely to raise employee cost sharing for prescription drugs. Why smaller firms are relatively less inclined to shift costs to employees is unclear; it could be because they already offer fewer benefits and have less margin for making changes, or it could be that insurers’ rules (minimum offer rates or contribution levels) constrain their ability to make changes.

In addition, we are beginning to see some interest by employers in alternative approaches to health benefits. While overall penetration of high-deductible health plans (defined in the survey as having a deductible of more than $1,000) is negligible, 17 percent of employers with more than 5,000 employees reported offering such a plan in 2003. Further, about 8 percent of all employers, and about 16 percent of the largest employers (those with more than 5,000 employees), reported that they were very likely to offer a high-deductible plan next year.

Employers also indicated an interest in tighter managed care networks as a way of reducing cost growth. Almost 42 percent of employers said that they would be interested in such an approach, and 68 percent believed that such networks would be at least somewhat acceptable to their employees. Employers have been moving away from HMOs and tightly managed care in recent years, but unrelenting premium increases could be awakening a renewed interest in managed care, at least as an alternative to increasing costs and cost sharing.

Outlook For The Future

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 
In 2002 we noted the unhappy confluence of accelerating premiums, sharply increased cost sharing, and declining coverage, and we suggested that these trends could continue for some time.¹³ Unfortunately, this prediction has proved largely true: Premiums rose in 2003 at an even higher rate than in 2002, and cost sharing continued to rise. One piece of good news from the 2003 survey is that the percentage of employers offering coverage remained steady, despite a continuing economic slump and unrelenting premium increases.

Despite rapidly rising premiums, however, purchasers have moved away from more tightly managed plans and into less managed and more expensive plan types in the past few years. Now, after three years of double-digit premium increases, the health care marketplace appears to be in a state of transformation: Health plans are moving away from their role as care managers and becoming the conduits by which purchasers can shift more responsibility to employees. It remains to be seen whether the continued growth in cost sharing and new consumer-driven models will be more palatable to consumers than traditional HMOs have been, and there may still be an opportunity for tighter managed care plans to arise as lower-cost (or, from an enrollee’s perspective, lower-cost-sharing) alternatives. In the short term, however, the prognosis for working families is that their health plans will change and that they are likely to pay more out of pocket for their health care.

Editor's Notes

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 
Jon Gabel is vice-president, Health Systems Studies, at the Health Research and Educational Trust (HRET) in Washington, D.C. Gary Claxton is vice-president of the Henry J. Kaiser Family Foundation, also in Washington. Erin Holve is a senior policy analyst there. Jeremy Pickreign is a statistician with the HRET, where Heidi Whitmore is a senior research associate; Kelley Dhont, a research associate; and Samantha Hawkins, a research assistant. Diane Rowland is executive vice-president of the Kaiser Family Foundation.

The authors thank Ben Finder at the Kaiser Family Foundation for his helpful research assistance and Jenna Rabbideaux at the Health Research and Educational Trust for her administrative assistance.

NOTES

Top Study Methods Study Findings Employers’ Views Of The... Outlook For The Future Editor's Notes NOTES

 

1. The most recent year change is significant only at p < .10.
2. P.Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2001 Current Population Survey, EBRI Issue Brief no. 240 (Washington: Employee Benefit Research Institute, December 2001).
3. Kaiser Commission on Medicaid and the Uninsured, Health Insurance Coverage in America: 2000 Data Update (Menlo Park, Calif.: Kaiser Family Foundation, February 2002), 8.
4. J.Gabel et al., "Job-Based Health Benefits in 2002: Some Important Trends," Health Affairs (Sep/Oct 2002): 143–151; J.Gabel et al., "Job-Based Health Insurance in 2001: Inflation Hits Double Digits as Managed Care Retreats," Health Affairs (Sep/Oct 2001): 180–186; and J.Gabel et al., "Job-Based Health Insurance in 2000: Premiums Rise Sharply while Coverage Grows," Health Affairs (Sep/Oct 2000): 144–151.
5. The explanation for this discrepancy is that Dun and Bradstreet was slow in purging firms from its database that had gone out of business or had been acquired by other firms.
6. B.C.Strunk and P.B. Ginsburg, "Tracking Health Care Costs: Trends Stabilize but Remain High in 2002," 11 June 2003, www.healthaffairs.org/WebExclusive/Strunk_Web_Excl_061103.htm (27 June 2003).
7. Increases in premium equivalents for self-insured plans can be viewed as a proxy for what actuaries believe will be the increase in claims expenses. In contrast, premiums in fully insured plans reflect actuaries’ expected increases in claims expenses but also an element of the underwriting cycle—catch-up pricing when there is little market entry, and underpricing when new insurers enter the market and fight to gain market share.
8. Strunk and Ginsburg, "Tracking Health Care Costs."
9. C.Lesser, P. Ginsburg, and K. Devers, "The End of an Era: What Became of the Managed Care Revolution in 2001?" Health Services Research (February 2003): 337–355; and C.Lesser and P. Ginsburg, Health Care Cost and Access Problems Intensify: Initial findings from HSC’s Recent Site Visits, Issue Brief no. 63 (Washington: Center for Studying Health System Change, May 2003).
10. The Leapfrog Group, founded by the Business Roundtable, comprises 135 organizations that provide health benefits. The Leapfrog Group seeks to identify problems and propose solutions that it believes will improve hospital safety.
11. The National Committee for Quality Assurance (NCQA) is an independent nonprofit organization that aims to improve health care quality. It accredits health plans and measures plan performance through the Health Plan Employer Data and Information Set (HEDIS). More than half of the nation’s HMOs voluntarily participate in NCQA accreditation. URAC, also known as the American Accreditation HealthCare Commission, accredits PPO plans and utilization management programs.
12. B.Wheatley, Disease Management: Findings from Leading State Programs, State Coverage Initiatives Issue Brief no. 3 (Washington: Academy Health, 2002).
13. Gabel et al., "Job-Based Health Benefits in 2002."

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