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Public Employees’ Health Benefits Survive Major Threats, So Far

Abstract

 
Previous studies of public employees’ health benefits indicate that they have been spared many of the changes evident in the private sector. But the recession and plunging state revenues in the early 2000s presented growing challenges to trying to preserve these benefits. Findings from the Round Five site visits of the Community Tracking Study (2005) reveal that benefits have still witnessed surprisingly few major modifications. But a growing gap between public- and private-sector benefits and new accounting requirements for government entities’ retirement costs raise new threats to this protected status.

The Community Tracking Study (CTS) documents multiyear trends in the public sector and puts them into a broader context to contrast with developments in private employee benefits. The community focus (including five state capitals with large complements of state employers) permits examining trends in public employees’ benefit designs, contribution strategies, and changes within local labor markets. This paper examines pressures faced by public employers during the past few years in maintenance of health benefits for their employees and retirees, describes how and why public employers have responded to the stresses as they have, and discusses the constraints they face in becoming market leaders.

Background

Top Background Study Data And Methods Study Findings Discussion NOTES

 
In 2000 there were about twenty-one million government employees in the United States—about one in seven U.S. workers.¹ Despite the size of this workforce and the public visibility of design and financing of its benefits, far more research has been focused on the purchase of health benefits by the private sector.² Public employers’ role in local markets is of special interest because these employers typically are among the largest purchasers in their communities and, unlike many large private employers, their entire workforce is often concentrated in a single market area. Although this status confers opportunities to be market leaders, public employers’ capacity to innovate might be constrained because they are more politically sensitive than private employers are to general community concerns and to the impact of benefit design and financing on local residents and community-based providers.

Two prior studies provide a foundation for recent work. Carolyn Watts and colleagues explored the experience of twenty-five public employers in the CTS markets in 1999–2000.³ By 2000, they found, there had been few changes in cost sharing for public employees (even less than for large private-sector firms’ workers) and virtually no changes in contribution strategies, and although drug copayments were starting to rise, most public employers had yet to adopt tiered systems, unlike their private-sector counterparts.

James Maxwell and colleagues completed a national study in 2002 comparing purchasing practices of all fifty state employee benefit programs with a 2000 survey of programs in Fortune 500 companies.⁴ This study, conducted roughly two years after the study by Watts and colleagues, as the recession was deepening and state tax revenues were plummeting, still detected few changes in design. However, many respondents portrayed cost control as their central concern and speculated that public employers could be on the verge of changing benefits in the face of increasing cost pressures. The authors further suggested that unions might have somewhat greater influence in the public sector, where they are still growing instead of declining as they are in the private sector. Moreover, they described a "culture of public employment" characterized by lower salaries and richer benefits. Public employers were nearly twice as likely as Fortune 500 firms to offer some retiree health benefits.

Recent national surveys indicate that both public and private employers continue to try to gain control of benefit costs.⁵ However, there are key differences between public and private employers’ changes that reveal important variations in compensation philosophies. Offer rates, take-up rates, and premium contribution levels for public employers exceeded those of private employers in 2003 and 2005 by sizable margins, while total benefit costs were comparable between sectors (Exhibit 1). The percentage of public-sector workers offered health maintenance organizations (HMOs) was also higher than offers among private-sector employers and actually grew between 2003 and 2005. Copayment levels across drug tiers were consistently lower for public-sector employees. Availability of retiree health benefits was much higher among public employers, in part because the private firms include many small employers. Public employers offered health benefits to early retirees at a much higher rate as well, although the gap narrowed between 2003 and 2005.

Top Background Study Data And Methods Study Findings Discussion NOTES

CTS researchers interviewed a range of respondents at the state and local levels in each market regarding changes made in public employees’ health benefits, including coverage, benefit design, product offerings, employee cost participation, and retiree coverage. Respondents were asked about budgetary and other pressures, factors influencing changes, and priority initiatives. Protocol-based interviews were conducted with 104 respondents, including 28 public agency employers (state and local government entities, universities, and school districts), as well as elected officials, union representatives, benefit consultants, and others with a perspective on the market. The site-visit design allowed in-depth data collection on public employers’ behavior, including the pressures they face, types of and rationales for changes they make to employee benefits, and future actions under consideration.

Study Findings

Top Background Study Data And Methods Study Findings Discussion NOTES

 
The 2005 CTS site visits found that public employers have faced budget pressures threatening the health benefits for their employees. Public employers are responding with a range of noteworthy, yet relatively modest, changes in cost sharing, product offerings, and benefit design. At the same time, a number of policy and market factors, including union influence and strategic budget maneuvering, have helped protect public employees’ benefits during the past few years. Despite their prominence in local markets, public employers’ influence on local health care purchasing and delivery has been muted.

As anticipated, budget pressures, especially on state governments, worsened after 2003 and began to abate only in early 2005. Several public employers reduced their workforces through layoffs and attrition, eliminated unfilled positions, and offered early retirement initiatives to reduce personnel expenses. Many employers also responded by freezing wages, including, in some cases, traditional annual cost-of-living adjustments. The financial squeeze was intensified by near double-digit increases in health care premiums, with pharmaceutical costs garnering special concern.

Human resource managers noted that in the depths of the recession, many public employees feared for their jobs and expected to forgo wage increases to save their employment and health coverage. The high average age of many public-sector workers—estimated to be forty-six years in Indiana, for example—suggests that health benefits are particularly salient. Benefit managers, and elected officials who fund their agencies, avoided raising health care contributions for workers while denying wage increases. Even some of the most financially strapped public employers placed a high priority on preserving health coverage for their workforces.

Health benefit–related responses. How much change was made in health benefits? The findings indicate not nearly as much as the severity of the fiscal crisis might have suggested. Most public employers interviewed reported strong budgetary pressures to make changes to public employee benefits; however, modifications to benefits—including levels of cost sharing and coverage, and types of products offered—have been modest. Where changes were more major, such as launching consumer-directed products, steps were taken cautiously. Some employers bluntly characterized their benefit designs as "antiquated," offering overly rich benefits relative to employee cost participation, resulting in employers’ bearing the brunt of increases. They further claimed that many workers seemed unaware of the substantial changes experienced by private employees in the same markets.

Premium contributions. Despite sharp increases in the cost of medical coverage, few public employers have put in place substantial increases in the amounts their workers contribute to premiums. A public employer in New Jersey noted ruefully, "You’d think that the budget pressures would push changes to sharing of costs, but they haven’t." Many public employers continue to subsidize premiums at 90 percent or higher, consistent with national data (Exhibit 1), and some still offer at least one option requiring no premium contribution, although typically this is a less comprehensive product. The University of California (UC), Irvine, in Orange County was the only employer interviewed that has developed a policy of setting graduated premium contributions based on four salary/wage ranges for university employees (introduced in 2004 in the statewide UC system), although some other employers believe that such a tactic might become necessary if premiums continue to grow disproportionately to wages.

Several employers acknowledged absorbing more of the premium increase than they are sharing with workers, in part because of concern about lack of pay increases in recent years. Some recycled salary savings from attrition and unfilled positions to shield workers from the full impact of cost inflation. Others increased dependent coverage premiums or tried to encourage spouses to obtain coverage elsewhere. However, because of large premium subsidies in the public sector, this latter strategy is seldom successful.

Copayments. Adoption of copayment increases was more readily apparent than changes in premium contributions, although again, increases were more modest than those among private employers in the same markets (Exhibit 1). Almost half of the employers interviewed reported increasing copayments over the past two years. Most increased prescription drug copayments, most commonly for brand-name drug tiers. Public employers with relatively low copayments across tiers also raised copayments for generic drugs (for example, a copayment of $1.50 or $3 for a generic drug was raised to $5 or $10). Copayments for emergency department (ED) use and physician office visits were also targeted, with a typical primary care copayment now at $10–$15. Some employers indicated that increases in copayments were permissible under existing labor agreements, so such modifications were favored because they would not have to await expiration of current contracts, as premium contribution changes would. Others noted that workers seem aware that private-sector employees’ copayments have risen and so were expecting the same.

Benefit-design changes. Disproportionate growth rates in price and use of prescription drugs, and absence of incentives to promote cost-conscious use, triggered a focus on drug benefit design. By 2005 more than half of the public employers interviewed had two or more tiers within their drug benefits, and several had added tiers within the past two years. However, public employers are still using fewer tiers than is typical among private employers, and most copayments and differentials among the tiers are still relatively low, consistent with national data (Exhibit 1).

Bringing drug benefits into line with those of large private-sector employers is a priority for many public employers’ benefit managers. The Arkansas Public Employees Insurance Board, which purchases on behalf of both state employees and local teachers, has engaged its own pharmacy benefit consultant to help make refinements in coverage to promote greater use of generics and over-the-counter products. Other employers have looked to expanding disease management programs (DMPs) as another mechanism to address drug cost increases. DMPs appear to be in vogue because of their focus on chronic conditions such as asthma, diabetes, and high blood pressure, which are common among long-term government employees. Like their private-sector counterparts, public benefit managers are eager to see whether these programs generate acceptable returns on investments.

In addition, several public employers added deductibles or required contracted plans to offer products with deductibles to "buy down" benefit packages to keep premiums within reach. Others have made modest increases to their existing deductibles. For employers intent on keeping at least one zero-premium product available, adding a high-deductible offering might be the only means to do so, but these products often have few takers.

Product offerings. Most public employers continue to provide a broad range of products—including HMO, preferred provider organization (PPO), point-of-service (POS) plans, and even traditional indemnity options—usually with multiple carriers. A number of public employers have trimmed options in recent years, but most public employers we interviewed still offer a choice of carriers. The menu of carriers narrowed, in part because of employers’ decisions to limit options and because of health plan market consolidation. In fact, several employers decried the loss of competing plans; in some of the smaller markets, such as Lansing, Little Rock, and Greenville, the limited number of plans is becoming a real concern. In some markets, unions have pressured employers to maintain a broad range of options even when employers contend that they could curb cost increases by reducing the number of product options or carriers, or both.

Contrary to trends evident in the private sector, HMOs have retained sizable public employee memberships, attracted by comprehensive benefits and still low but rising out-of-pocket expenses (Exhibit 1). This is especially true in markets where HMOs retain a cost advantage over other products. To help moderate premium increases, employers might attempt to steer employees to certain product offerings. One public employer in Indiana acknowledged that it has tried to wean employees away from costly HMO benefit designs by making available a less costly option with lower premiums but higher cost sharing as a way to pass more of the costs to the employee.

New products. Most public employers have not sought out or promoted narrow network products to moderate premium increases—with the exception of a few in the Boston, Orange County, and Seattle markets, where tiered products have a foothold. Some hesitancy to promote these options reflects local public employers’ concerns that they would, in effect, be "choosing sides" among local provider systems if they were to promote enrollment in one to the exclusion of others. In Cleveland, which has two dominant, competing health care systems, public employers typically offer plan options that ensure employees’ access to their preferred system.

The high level of premium subsidy and the comprehensive benefit package available to public-sector employees, as well as opposition from their unions, suggest an inhospitable climate for consumer-directed products. Moreover, few public benefit managers seem convinced of such products’ cost containment prospects. Some public employers, including state governments in South Carolina and Arkansas, have ventured into the realm of high-deductible products, incorporating health savings accounts (HSAs) into the menu of options. In South Carolina, a market with little union presence in either the public or the private sector, this move might reflect the prevalence of already high deductibles and coinsurance in the market. Take-up of these options remains very modest—fewer than 100 of the eligible 30,000 workers in Arkansas, for example. Whether the limited participation reflects lack of interest among employees or hesitancy among public employers to promote such designs is unclear. Meanwhile, other employers are taking "baby steps" toward consumer-directed products. For example, a local employer in Phoenix added a prescription drug option in the form of a health reimbursement arrangement (HRA) to test a consumer-driven model before attempting major changes to comprehensive medical products.

Retiree coverage. Most public employers interviewed offer health insurance coverage for their retirees; many subsidize the premium for all or some retirees, depending on, for instance, length of service or position. Public employers have made few substantive changes to retiree benefits during the past two years, despite erosion evident in private-sector retiree coverage. The State of Michigan, for example, has a differential retiree benefit commitment to workers hired after a designated date compared with those hired before it. A few employers moved to create a separate risk pool for retirees that had the effect of sharply raising retiree contributions, rather than maintaining them in the active employee pool. Other employers indicated a desire to make such a change but are not permitted to do so by current law or regulation.

Much more typical was a continuation of retiree coverage as currently designed, with modest changes in cost sharing or other components. Just as health benefits are seen as a key factor in workforce retention, so too are retirement benefits, including pensions and subsidized health care coverage. Employee benefit managers—themselves often long-term public employees—reported great reluctance among public-sector managers and elected officials to tamper with retiree programs. This was an issue that generated considerable hostility for the governor of California, who had attempted to make changes in the year before the interviews. In Massachusetts, state legislation mandates that municipalities provide health care coverage for retired workers who had coverage while active.

Notwithstanding strictures on flexibility to modify retiree health benefits, these benefits are a source of growing concern among public employers. Concern has been brought into sharper focus because large numbers of workers under age sixty-five and not yet eligible for Medicare are taking early retirement. For uniformed workers (police and fire), retirement before age sixty-five is a common expectation. Many early retirees receive health benefits comparable to those of active workers, and, as noted above, employers might not even require higher premium contributions or cost sharing, despite much higher expected cost for them than for active workers.

The Government Accounting Standards Board (GASB) Statement no. 45, issued in August 2004 and effective for most employers in 2006 and 2007, has cast a bright light on retiree health benefits offered by public-sector employers.⁷ The pronouncement requires recording a long-term liability for expected costs of health benefits that employers have promised current and future retirees. In essence, this is the public-sector version of the Financial Accounting Standards Board (FASB) Statement no. 106, issued in the early 1990s, to which many attribute the subsequent steep decline in private-sector retiree health care coverage.⁸ At the time of the 2005 visits, many employers were still digesting the implications of this pronouncement and were reluctant to speculate on either the size of the liabilities they would need to record or what kinds of policy-maker responses might be triggered by cost recognition.⁹ As the director of one state employee benefit program graphically put it: "When I wake up in the morning and think of what this number [the liability] might look like, I just want to pull the covers over my head and go back to bed."

Factors contributing to maintenance of public-sector benefits. Several policy and market factors have prevented dire consequences for public employee benefits during this challenging period, including public budget maneuvering, a reaffirmed commitment to maintenance of benefits for public-sector workers, direct and indirect effects of public-sector unions, and political sensitivities.

Budget maneuvering. As the economic environment began to improve during the 2005 site visits (January–June 2005), many benefit managers felt that the greatest near-term threats to public benefits had passed. Postmortems conducted on how states weathered the "perfect storm" of declining revenues and sharply rising health care costs have documented strategies used to achieve one-time savings or defer spending commitments to live within balanced budget constraints during recessionary periods.¹⁰ In some cases, workforce reductions provided the resources needed to continue to fund benefits for remaining workers. In other instances, recycling benefit dollars that had been committed to unfilled positions cushioned the effects of rising costs. Some localities and school districts obtained supplementation from states to help meet personnel expenses during periods of severe financial distress. In a few cases, tax increases were enacted to forestall reductions in services. And, as noted earlier, some state and localities resorted to increased worker contributions for premiums and copays to defray some added benefit costs.

Union impact. Public employee unions and associations play a prominent role in nine CTS markets (all but Phoenix, Little Rock, and Greenville). Unions’ direct impact is particularly strong through collective bargaining agreements that preclude major benefit changes except at renegotiation, which could be at two- and three-year intervals, locking in benefits for extended periods of time. Also, most public employers have multiple unions, often with staggered renewal dates, which further limits employers’ capacity to engineer substantial and abrupt modifications. For example, Cleveland contracts with thirty unions, and King County (Seattle) does so with twenty-nine. Even though many unions were characterized as cooperative and far from militant, proposing and negotiating dramatic changes in this complex environment is very difficult.

Public employees’ unions also have powerful indirect effects on employee benefits through political activities in states such as New York, New Jersey, Ohio, Michigan, and California. They give a strong voice for public employees’ concerns when benefits are threatened or cost increases for workers are under consideration by elected officials. The recent success of these unions in fending off changes might be attributable to their greater success in retaining and growing membership compared with traditional industrial unions.

Political sensitivities. State and local elected officials have shown much restraint in their approach to modifying public employees’ benefits. Despite budget pressures, few public employers indicated that they felt political pressure to make deep cuts in health benefits. Many elected officials value the contributions of public workers and expressed great concern about not making major reductions in the workforce, given the responsibilities borne by state and local government agencies. Likewise, officials themselves often have a personal stake in the benefits, including health care coverage, so preservation might be a matter of self-interest. Public employers’ ability to sustain relatively rich benefits for their workers also is an investment in the financial well-being of health care providers in local communities. As other large employers move their plants or headquarters out of localities, the large public-sector workforce contingents take on added importance, particularly in the five state capitals represented among the CTS sites. And votes of public employees are important, as is support of their unions, to officials seeking election and reelection.

Sustained commitment to public-sector workforce. Benefit managers at all levels consistently believe that benefits—health benefits in particular—are a major factor in attracting and retaining public-sector workers. Because public employees’ wages are more highly constrained than those of their private-sector peers, relatively rich benefits are seen as compensating workers who have accepted a wage-benefit trade-off as a condition of employment. This conveys a dual commitment: Benefits will be maintained and will remain affordable for workers and dependents. Sheltering workers to the extent possible through high levels of subsidy is part of the employee-employer compact. During periods when little or no wage increases were forthcoming, increased cost sharing for health benefits was seen as undesirable, although not always avoidable. At the same time, there is a rising concern among many public employers that keeping this commitment will become more difficult if health care cost increases continue to exceed the ability of public-sector employers to grant commensurate wage increases.

Pockets of innovation. Despite the size and geographic concentration of their work-forces, most public employers have not tapped into their potential to influence broader market changes to try to sustain benefits over the longer term. Continuing industry consolidation has centralized decision making for private employers’ benefits to the regional or national level, creating gaps in local leadership that public employers might fill. But the majority of public employers interviewed frankly acknowledged the limited leadership roles they felt they could or should play in the health benefit realm. Many of them have chosen not to become involved with large private purchaser-driven initiatives related to quality, public reporting of provider performance, or joint purchasing because of various concerns.

Yet our findings indicate that a few public employers are playing prominent roles in innovative strategies to improve quality and contain costs. In Boston, the Group Insurance Commission (GIC)—the state employees’ benefit program—was widely seen as the one of Boston’s most aggressive purchasers, which market observers attribute primarily to a strong executive director who is not encumbered by collective bargaining constraints. The GIC is spearheading an initiative to collect and analyze physician performance data from its major health plans and to then share the cross-plan data with the plans to develop benefit products that include tiered provider networks.

In Seattle, King County has been a leader in developing the Puget Sound Health Alliance, an ambitious attempt to bring major public and private purchasers together to promote initiatives to collect and disseminate data on providers’ performance, systematically promote quality improvement, and encourage providers’ adherence to evidence-based practice. The county is also developing financial incentives to encourage employees to complete health risk assessments and enroll in health promotion and disease prevention initiatives.

Other public employers are promoting innovative "demand-side" strategies to begin to address longer-term cost concerns. Onondaga County (Syracuse) launched a medical record initiative that provides county employees with privacy-protected access to medical and benefit information such as medications, allergies, and family history, hoping that this will reduce costs and improve quality. Several employers are trying to counter typically low enrollment in health promotion activities by offering incentives for participation. Employers and union officials jointly tout these strategies as preferable to continuing to trim back benefits or increase cost sharing, and they see them as particularly appropriate, given public employees’ long tenure.

Discussion

Top Background Study Data And Methods Study Findings Discussion NOTES

 
Distinguishing characteristics of public employers noted in earlier research continue to be evident and to play a major role in attenuating change and shielding workers from more substantial benefit reductions and cost increases. Given the severity of budget crises experienced by states and many local governments during the past few years, the lack of change has made health benefits for public workers even more attractive relative to those of private employers than they already were.

The absence of major changes is not a function of public employee benefit managers’ being out of touch with or unaware of trends in the private sector. Rather, in many instances, public employers have concluded that a number of such changes are neither feasible nor appropriate for their workers. Looking to the future, public employers do not anticipate making major alterations to employee benefits, but rather more of the same types of moderate, measured changes implemented during the past few years. And some public employers are attempting to address longer-term cost concerns through means other than cutting back on benefits, such as health promotion and disease management. But it remains to be seen whether the general economic climate and further erosion in private health benefits will permit this judicious pace to continue.

While public employees’ benefits have survived several challenges thus far, public employers and benefit consultants most familiar with GASB Statement no. 45 are concerned that this pronouncement could have ominous long-run implications. Initially, GASB will entail only an accounting treatment that will add staggering liabilities to public entities’ balance sheets.¹¹ But in the longer term, it might bring into sharper focus for both the electorate and elected officials the fact that massive financial commitments have been made to public employees that will be progressively more difficult to meet. Moreover, these commitments might represent benefit packages that are far removed from the kinds of benefits that private-sector workers (and voters) have access to or are paying considerably more to obtain.

Editor's Notes

 
Bob Hurley (rhurley{at}hsc.vcu.edu) is an associate professor in the Department of Health Administration, Virginia Commonwealth University, in Richmond, and a senior consulting researcher at the Center for Studying Health System Change (HSC) in Washington, D.C. Also at HSC, Laurie Felland is a health researcher, Anneliese Gerland is a health research assistant, and Jeremy Pickreign is a statistician.

This research was conducted as part of the Center for Studying Health System Change’s Community Tracking site visits, funded by the Robert Wood Johnson Foundation. The authors thank Paul Ginsburg, Cara Lesser, and Sally Trude for their comments on an earlier draft.

NOTES

Top Background Study Data And Methods Study Findings Discussion NOTES

 

1. C. Watts et al., "The Role of Public Employers in a Changing Health Care Market," Health Affairs 22, no. 1 (2003): 173–180.[Abstract/Free Full Text]
2. J. Maxwell, P. Temin, and T. Petigara, "Private Health Purchasing Practices in the Public Sector: A Comparison of State Employers and the Fortune 500," Health Affairs 23, no. 2 (2004): 182–190.[Abstract/Free Full Text]
3. Watts et al., "The Role of Public Employers."
4. Maxwell et al., "Private Health Purchasing."
5. J. Gabel et al., Employer Health Benefits: 2005 Annual Survey, September 2005, http://www.kff.org/insurance/7315/index.cfm (accessed 26 October 2005).
6. P. Kemper et al., "The Design of the Community Tracking Study: A Longitudinal Study of Health System Change and Its Effects on People," Inquiry 33, no. 2 (1996): 195–206.[Web of Science][Medline]
7. Government Accounting Standards Board, "Summary of Statement no. 45, Financial Reporting for Post-Employment Benefits Plans Other than Pension Plans (Issued 6/04)," June 2004, http://72.3.167.244/st/summary/gstsm45.html (accessed 20 March 2006).
8. S. Trude et al., "Employer-Sponsored Health Insurance: Pressing Problems, Incremental Changes," Health Affairs 21, no. 1 (2002): 66–75.[Abstract/Free Full Text]
9. More recent information (M. Freudenheim and M.W. Walsh, "The Next Retirement Time Bomb," New York Times, 11 December 2005) provides some estimates of the size of the retiree liabilities that state and local governments are facing. For example: "Michigan says it has made unfunded promises that are now valued at $17 billion for teachers, part of a possible $30 billion total for all public agency retirees."
10. T.A. Coughlin and S. Zuckerman, "Three Years of State Fiscal Struggles: How Did Medicaid and SCHIP Fare?" Health Affairs 24 (2005): w385–w398 (published online 16 August 2005; 10.1377/hlthaff.w5.385).[Abstract/Free Full Text]
11. Freudenheim and Walsh, "The Next Retirement Time Bomb."

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