CHAPTER 4 - EMPLOYER-SPONSORED HEALTH COVERAGE
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Originally written by Paul Fronstin, Ph.D., Employee Benefit Research Institute, and updated by Paul Fronstin of EBRI and Bill Erwin of the Alliance for Health Reform. Updated on November 6, 2012 by Marilyn Werber Serafini of the Alliance for Health Reform.
- Over 170 million individuals were covered by employment-based health benefits in 2011.1
- The percentage of individuals with such coverage was 55.1 percent in 2011, down from 55.3 percent in 2010, 56.1 percent in 2009, and 65.1 percent in 2000.2
- Due to the ACA, about 3 million to 5 million fewer people will obtain employer-sponsored coverage each year from 2019 through 2022 than would have been the case under prior law.3
- Sixty-one percent of firms offered health benefits to their workers in 2012 – similar to the 60 percent that offered them the year before. That’s a significant reduction from the 69 percent that reported offering benefits in 2010, but much more in line with the levels for years prior to 2010.4 The health reform law provides subsidies to help certain small employers pay for their employees’ coverage.
- The percentage of larger employers offering health benefits has held steady since 2000 at 98 to 99 percent.5
- 14.1 million individuals age 65 and older had some form of employment-based health benefits in 2011, up from 12.9 million individuals in 2010 – either as an active worker, retiree, or dependent.6
- Retiree coverage has been shrinking. In 2012, among employers with 200 or more workers that offered health coverage to active workers, 25 percentalso offered health benefits to retirees, down from 35 percent in 2000 and 66 percent in 1988.7
- In 2012, annual premiums for employee-only coverage averaged $5,615 ($951from the worker, $4,664 from the employer).8 For family coverage, the average annual premium was $15,745 ($4,316from the worker, $11,429 from the employer).9
- Workers paid an average of 18 percent of the total cost of employee-only coverage in 2012 and 28 percent for family coverage (similar to 2011.)10
Health coverage on the job has long been the backbone of the U.S. health insurance system. Nearly six out of every 10 individuals in the United States had some form of health insurance coverage through an employer in 2011.11 This is a major contrast to most other developed countries, where people typically obtain coverage through government programs.
One of the earliest examples of job-based coverage began in Dallas in 1929. Baylor Hospital had a large number of unpaid bills, many for care delivered to Dallas school teachers. So the hospital developed a plan whereby teachers could prepay -- at 50 cents per month or $6 per year – for 21 days of hospital care at Baylor. The plan kicked in after the patient’s first week in the hospital.
Within two years, employees of the Dallas Morning News and radio station WFAA joined in. The lumber and railroad industries had similar prepayment plans even earlier.12
The Dallas school system didn’t contribute to the teachers’ health plan in 1929. Today, most employers offering health plans do contribute a hefty portion of the premium (82 percent on average for single coverage in 2012).13
They do this because, in their view, there is a business case for doing so.14 These employers think that they must offer health benefits in order to recruit and retain workers in a competitive labor market.They also think that offering health benefits has a positive effect on worker health status and therefore on productivity (a proposition backed up by research).15
In addition, there are tax benefits for both the employer and the employee. Health benefits are a tax-deductible expense for employers and they are excluded from taxable income to employees. This exclusion is the nation’s largest tax expenditure, totaling $177 billion in federal revenue in FY 2011.16 (Some small firms get an additional tax incentive through the Patient Protection and Affordable Care Act of 2010, discussed below.)
In 2009, overall, employer-sponsored health insurance was projected to pay 31 percent of the nation’s total health care bill. This share is projected to shrink to 27 percent in 2019 if the Patient Protection and Affordable Care Act (ACA, for short) is implemented on schedule, as public funds pay for a greater portion of care.17
However, even in firms that offer health benefits, not all workers are covered. Some workers cannot enroll due to waiting periods or minimum work-hour rules. Others are prevented by coverage costs, or have access to coverage through a spouse.18 According to the 2012 Kaiser Family Foundation Employer Health Benefits Survey, “among firms that offer coverage, an average of 77% of workers are eligible for the health benefits offered by their employer.”19 Of the eligible workers, 81% use their employer’s coverage, which leads to 62% of workers in firms that offer coverage obtaining employer health benefits.20 Between firms that provide and do not provide health coverage, 56% of workers are covered by health insurance offered by their employer, similar to the percentage in 2011.21
Cost-sharing for medical services can include deductibles, which are amounts that the insured must pay before some or all services are covered.22 For family coverage, the majority of workers with general annual deductibles have an aggregate deductible. This means that all family members’ out-of-pocket expenses count toward meeting the deductible amount.23 For each plan type (HMO, PPO, and POS) there was no statistically significant change in deductible amounts from 2011 to 2012 for family or single coverage.24 However, since 2006, the average annual deductible for workers with PPOs has increased from $1,034 to $1,770 in 2012 for aggregate family deductibles and from $473 to $733 in 2012 for single coverage.25
General annual deductibles vary by plan type and firm size. According to the Kaiser Family Foundation 2012 Employer Health Benefits Survey, “Over the last five years, the percentage of covered workers with a deductible of $1,000 or more for single coverage has increased from 12% to 34%.”26 In addition, for individual coverage, workers in small firms (3–199 workers) are more likely to have a general annual deductible of $1,000 or more than workers in large firms with 200 or more workers (49% vs. 26%)27
The number and percentage of people with employment-based health benefits has fallen considerably from the peak year of 2000. More than 170 million individuals were covered by employment-based health benefits in 2011, 11.8 million fewer than in 2000 and 7.4 million less than in 2008.28 The portion of the population covered through employment dropped to 55.1 percent in 2011, down from 55.3 percent a year earlier and 65.1 percent in 2000.29
There are many varieties of employer-sponsored health coverage. Health maintenance organizations (HMOs) combine the functions of insurer and provider; members are typically required to select a primary care physician through whom all care must be coordinated. In preferred provider organizations (PPOs), a number of health care providers contract with one or more health plans to serve enrollees on a fee-for-service basis at discounted fees. See the glossary for details.
A recent survey conducted by the National Association of Health Underwriters found that employers provide a comprehensive level of health benefits to employees.30 According to the survey, employees with such plans receive emergency care and hospital care.31 In addition, “follow-up care, such as in-patient rehab, nursing facilities and hospice care are also covered by 97, 93 and 90 percent of small-group plans respectively.” 32
ADVANTAGES AND DISADVANTAGES OF EMPLOYMENT-BASED COVERAGE
There are a number of advantages associated with using employment-based coverage as the primary means for providing health benefits.It is generally cheaper for a worker to receive the same covered services through employment-based benefits than to shop for coverage on his or her own. An employer, representing many workers, naturally has more clout in negotiating prices with insurers than any individual does. Also, health insurance premiums paid by employers are not considered income to workers and therefore are not subject to income taxation, which reduces the cost of purchasing insurance through employers.33
Insuring a group of employees also represents less overhead cost per person for health plans than insuring an individual.
Buying coverage for a group of workers spreads the insurer’s financial risk. Most people in the group will have minimal medical expenses, balancing the small number who will need expensive care. This generally leads to lower insurance rates for groups. (And, of course, the same risk sharing helps lower per-beneficiary costs for self-funded employers paying for employee health expenses directly.)
But there are disadvantages to employer-sponsored coverage as well. Because employers are not currently required to offer coverage, not all workers have access to it. Employer-sponsored health coverage can affect an individual’s employment decision in terms of how many hours to work and what type of a job to hold.34 Losing a job or deciding to start one’s own business has in the past also resulted in loss of coverage for some, as has retirement or a shift to part-time status. Other disadvantages are that the tax exemption of premiums can lead to higher health spending.35 According to the National Bureau of Economic Research, the benefits from the tax exemption flow unequally to “high-income workers, who have higher marginal tax rates and more generous plans.”36
Some of the disadvantages will go away in 2014, however, when major provisions of the ACA go into effect (see details below). Employers with more than 50 workers who do not provide qualifying health coverage will be required to pay $2,000 per full-time worker (the first 30 workers are excluded). The penalty applies only if one or more workers receives subsidized coverage through a health insurance exchange.
This will encourage employers to offer coverage (although some will decide to pay the penalty, judging this to be less expensive than the employer portion of the insurance premium for enrolled workers). Also, people not offered coverage on the job will be able to purchase it through state or regional health insurance exchanges, described below.
RESPONSES TO PREMIUM INCREASES
Premiums have been increasing faster than inflation, workers’ earnings and the gross domestic product. (See charts, “Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Single Coverage, 1999-2011” and “Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage, 1999-2011”)
The average annual premium of $15,745 in 2012 is 30 percent higher than in 2007, and 97 percent higher than in 2002.37
As premiums have risen over the years, employers have tried different strategies to curb the growth in their health care costs. One way is to have employees pay more out of pocket for deductibles and co-payments. (See glossary for definitions.) This means less expense for insurers (and self-insured employers) and, theoretically at least, lower premiums.
For instance, workers in preferred provider organizations having a general annual deductible for single coverage saw their yearly deductible increase from $473 in 2006 to 733 in 2012. 38
Between about 2002 and 2008, workers paid about 16 percent of the premium for single coverage, and between 26 and 28 percent for family coverage. In 2012, workers contributed on average 18 percent of the premium for individual policies and 28 percent of the premium for family coverage. 39 (See Average Percentage of Premium Paid by Covered Workers for Single and Family Coverage, 1999-2012)
Employees could pay even more in the future. A 2010 study by PricewaterhouseCoopers found that among 700 employers surveyed, 42 percent of respondents said they intend to increase employee contributions in the future.40
To help reduce costs, employers have also shown interest in a relatively new type of health plan. Frequently referred to as consumer-directed health plans or high deductible health plans, these plans combine higher deductibles with tax-preferred accounts that can be used for out-of-pocket health care expenses.
The plans encourage employees to be more cost conscious about their health care spending, since they feel they are spending their own money for expenses up to the deductible amount. For 2012, minimum deductibles of $1,200 for self-only coverage and $2,400 for family coverage are required for an individual to be eligible to make tax preferred contributions to their health savings account (HSA).41
Among firms that offer health benefits, 31 percent offer high deductible health plans.42 Ninteen percent of covered workers enrolled in such plans in 2012. 43 That was similar to 2011, but enrollment has risen significantly from 8 percent in 2009. 44
One reason for this growth may be lower premiums. A report from the Employee Benefit Research Institute noted an average savings of 4.8 percent in premiums compared to other types of health plans, due in part to younger, healthier workers choosing them.45
EMPLOYMENT RETIREMENT INCOME ACT (ERISA)
The Employee Retirement Income Security Act of 1974 (ERISA) is the primary federal law governing employment-based health benefits in the private sector.46 Under ERISA, the regulation of employment-based health benefits has evolved into a system in which both federal and state laws play important roles.
ERISA relieves employers of the need to meet state-imposed mandates governing health benefits, so long as the benefits are “self-funded.” Self-funded employers pay for employees’ health expenses directly, rather than buying insurance to cover these expenses.
ERISA has been seen as a barrier to state-level health reform that would, for example, require employers to help pay for coverage for their workers. However, the Affordable Care Act imposed additional federal requirements on ERISA plans, such as coverage for certain preventive services without any out-of-pocket payments by those covered.47
IMPACT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 (ACA)
The Patient Protection and Affordable Care Act ("the ACA") has major implications for employment-based health benefits. The law provides some immediate benefits, such as subsidies to help small employers provide health coverage and allowing dependents up to age 26 to stay on a worker’s health plan. In later years, the law carries penalties, such as the requirement that employers with 50 or more workers must offer health coverage or pay a $2,000 fee per full-time employee (with the first 30 employees excluded).48
Here is a timeline of provisions in the ACA as they may affect employment-based health plans.49
- Temporary reinsurance program for retiree health benefits: The law enabled employers to apply for a subsidy to cover 80 percent of the cost of claims between $15,000 and $90,000 for retirees ages 55 and older who were not yet eligible for Medicare. $5 billion was set aside for use until Jan. 1, 2014. However, on Dec. 9, 2011, the Department of Health and Human Services (HHS) announced that the program would end early due to a depletion of funds.50
- Subsidies to employers: Employers with fewer than 25 employees and average annual earnings below $50,000 are eligible for a tax credit to cover part of their cost of providing health insurance. Until 2013, a tax credit of up to 35 percent of the employer’s costs is available for employers contributing at least 50 percent of the premium. Tax-exempt small businesses meeting these requirements are eligible now for tax credits of up to 25 percent of the employer’s contribution. In 2014 and beyond, a 50 percent tax credit is available, but only for two years. Tax-exempt organizations can claim a 35 percent credit starting only in 2014.
- Ban on lifetime limits for covered expenses and restrictions on annual limits.
- Dependents up to age 26 are allowed to participate in their parents’ plan.
- No refusing coverage to dependent children under age 19 because of pre-existing conditions.
- Cost-sharing (i.e. out-of-pocket dollars) is prohibited for certain preventive services.
- Emergency care outside a plan’s network must be provided at in-network cost sharing levels.
- Internal/external appeal processes were to be established.
- Insured plans cannot discriminate in favor of highly compensated workers (similar requirements already apply to self-insured plans).
- OB/GYN or pediatrician can be designated as a primary care physician
- Tax penalty on nonqualified HSA withdrawals doubled to 20 percent.
- Over-the-counter medicine is not eligible for reimbursement from Flexible Spending Accounts and other tax-favored arrangements unless obtained with a prescription.
- Health plans are required to pay, in FY 2013, a comparative effectiveness/patient-centered outcomes fee of $1 multiplied by average number of covered lives in the plan. The fee goes up to $2 for plan years ending after Sept. 30, 2013
- Uniform benefit summary must be provided.
- Employers are required to report the value of health coverage on W-2 forms (covering the year 2012).
- FSA contributions capped at $2,500.
- Federal subsidy to employers for Medicare-eligible retiree drug expenses becomes taxable.
- Employers who do not provide qualifying health coverage are required to pay $2,000 per full-time worker (first 30 workers are excluded). Employers with 50 or fewer workers are excluded from penalty. Penalty applies only if one or more workers receive subsidized coverage through a health insurance exchange.
- Employers with fewer than 100 workers are eligible to provide health benefits through state-based health insurance exchanges. (See more on exchanges below.)
- Employers required to offer a “free choice voucher” to employees with incomes less than 400 percent of federal poverty level whose share of the premium exceeds 8 percent but is less than 9.8 percent of their income and who choose to enroll in a plan in the health insurance exchange. The voucher is equal to the employer portion of the premium.
- Automatic enrollment required by employers with 200 or more workers.
- States may allow employers with 100 or more workers to buy health benefits through health insurance exchanges.
- Excise tax on high cost health plans. A 40 percent excise tax is imposed on plans with an aggregate value exceeding $10,200 for individual coverage or $27,500 for family coverage. The tax is applied to the value of the plan above those thresholds.51
As mentioned above, the ACA offers a tax credit for some small employers to offer health coverage or continue their existing coverage. The portion of businesses with three to nine workers offering coverage increased from 48 percent in 2011 to 50 percent in 2012.52 Increases were seen as well among firms with 10 to 24 workers, and 25 to 49 workers.
Analysts have wondered whether employers with more than 50 workers will choose to pay the $2,000 per employee penalty rather than offer coverage beginning in 2014. Since 96.5 percent of firms this size already offer coverage,53 this provision in the law has not been particularly controversial. Nonetheless, some firms could decide that paying the penalty is less burdensome than the cost of coverage.
Some people look to Massachusetts to see whether an employer mandate causes firms to drop coverage. In that state, a health insurance mandate went into effect in mid-2007, affecting both individuals and employers. Based on the 2009 Massachusetts Health Insurance Survey (MHIS), the overall uninsurance rate in the state was estimated to be 2.7 percent.54 In 2010, the uninsurance rate in Massachusetts was estimated to be 1.9 percent, a significant decline from 2008 and 2009, when the uninsurance was at 2.6 percent and 2.7 percent, respectively.55 This decrease can be attributed to a decrease in uninsurance among children.56 Furthermore, employer sponsored insurance in Massachusetts was 66.3 percent in 2008, 67 percent in 2009, and 65.1 percent in 2010.57
For more details on provisions in the ACA affecting employers, see the Alliance for Health Reform issue brief, “Implementing Health Reform: Employer & Consumer Issues” at www.allhealth.org
HEALTH INSURANCE EXCHANGES
Beginning in 2014, each state will have a health insurance exchange available where qualified individuals can buy coverage.58 Each state will also have a small business exchange available, where firms with up to 100 employees can buy coverage for their workers, unless the state decides to allow only firms with up to 50 employees to take part (an option that states have). These will be called Small Business Health Option Programs (SHOPS).
Businesses with more than 100 employees will be able to purchase coverage through the small business exchange beginning in 2017, at state option. States can join together to create regional exchanges. They can combine the individual and small group exchanges. They can also create more than one exchange within a state, as long as each serves a defined geographic area.
All policies offered through exchanges will have a minimum benefit package. Given that, consumers will be able to choose from among four levels of policies, with the bronze level as the least expensive and platinum level as the most expensive. (The intermediate levels are silver and gold.) Within each level, states can determine the combination of benefits and consumer cost-sharing to be offered. 59
Exchanges are intended to increase competition among private insurers, thereby perhaps lowering costs. By pooling together many purchasers, they also aim to give small businesses the buying power that larger businesses now enjoy.60
In January 2013, the federal government will evaluate state exchanges to identify if they have made sufficient and meaningful progress in preparing to set up state marketplaces.61 If approved by the federal government, the state will start accepting applications for coverage in October of 2013 so that individuals will be able to obtain coverage by January 1, 2014. If a state is not approved, it will have to rely on federal fall-back exchanges, which are currently undergoing their own technical, political, and financial challenges to meet the same deadlines. 62
(For more information on exchanges, see Timothy Stoltzfus Jost (2010). “Health Insurance Exchanges and the Affordable Care Act: Eight Difficult Issues.” The Commonwealth Fund, September 30. http://goo.gl/cUTp.)
TIPS FOR REPORTERS
- The Affordable Care Act and its provisions affecting employer-sponsored coverage are rich with story possibilities. For a good summary of the law and an implementation timeline by the Kaiser Family Foundation, including provisions affecting businesses, go to www.kff.org/healthreform/upload/8061.pdf
- For experts on employer-sponsored coverage and the reform law, sign up for the Alliance for Health Reform’s Find-an-Expert Service for reporters -- www.allhealth.org/reporter_enroll.asp
- Keep in contact with state business groups (Chamber of Commerce, National Federation of Independent Business), health consumer groups and other groups active in coverage issues.
- Remember that AARP has an interest in employment-based health benefits as well as in Medicare. State chapters can be helpful in providing reaction to private-sector or government health proposals.
- Don’t overlook your state insurance department as a source of data, expert comment and story ideas.
- Take an insurance agent to lunch. Ask how the agent expects his or her role to change after health insurance exchanges become active in all states by 2014. Also, get to know the leaders of your state’s chapter of the National Association of Health Underwriters -- www.nahu.org/about/chapters.cfm
- Build and update a data resource bank for your state with the number of insured/uninsured, sources of coverage, recent trends, etc. Statehealthfacts.org , a service of the Kaiser Family Foundation, has a wealth of information for your state.)
- State officials have some key responsibilities under the reform law, and some key decisions to make on how (and whether) to set up a health insurance exchange for your state.
- Keep in touch with the relevant officials. Keep an eye on the docket for the Supreme Court in your state for health issues that may result in important judicial opinions.
- How many small businesses in your area are applying for the federal tax credits available now to help them pay for their workers’ coverage?
- Many states are well into their planning for the health insurance exchanges that begin in 2014. What’s happening in your state? If your state plans to “opt out” and allow the federal government to set up an exchange for your state’s citizens, what is the federal government doing to get ready? Will your state share responsibilities with the federal government? If so, who will do what?
- Find local people who are employed but who do not have employment-based health benefits, and explain the reasons why they do not. Will their situation change after full phase-in of the ACA?
- Do the same with the so-called “underinsured,” those who have skimpy coverage. Will their situation improve as a result of the health reform law? How popular are so-called “mini-med” plans in your area – plans with bare-bones benefits for a small monthly premium? Has any of these plans received a waiver from the federal Health and Human Services Dept. allowing them to be sold despite their relatively thin coverage?
- Be on the lookout for two key reports each year on trends in employer-sponsored coverage: the Kaiser/HRET Annual Employer Health Benefits Survey (http://ehbs.kff.org/pdf/2012/8345.pdf), usually released in September, and the annual report on health benefits from Mercer Consulting (www.mercer.com), usually released in November. Both give you a hook for stories about local trends.
- What are local businesses and business groups doing to control the cost of health coverage?
- What do local people who now have coverage through their job think of getting health coverage through an insurance exchange instead?
- Talk to local businesses to find out whether they might consider paying the penalty and dropping health insurance. What factors are they considering when making their decisions?
- What provisions in the Affordable Care Act do business groups in your area want to see repealed? Would they like to see such provisions gone entirely, or replaced with something else?
- The federal fallback exchanges are currently in the process of being designed.
Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage, 1999-2011
Average Percentage of Premium Paid by Covered Workers for Single and Family Coverage, 1999-2011
1 U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011 http://www.census.gov/prod/2012pubs/p60-243.pdf
2 U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011.” http://www.census.gov/prod/2012pubs/p60-243.pdf
3 “The Effects of the Affordable Care Act on Employment Based Health Insurance.” CBO, March 2012; http://www.cbo.gov/publication/43090
4 Kaiser Family Foundation and Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345-Chartpack.pdf
5Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345-Chartpack.pdf
6 U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011.” http://www.census.gov/prod/2012pubs/p60-243.pdf
7 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345-Chartpack.pdf
8 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
9 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
10 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
11U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011.” http://www.census.gov/prod/2012pubs/p60-243.pdf
12 Texas State Historical Association. “Kimball, Justin Ford.” (www.tshaonline.org/handbook/online/articles/fki09)
13 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
14 Fronstin, Paul (2007). “The Future of Employment-Based Health Benefits: Have Employers Reached a Tipping Point?” Employee Benefit Research Institute. December, p. 13. (www.ebri.org/pdf/briefspdf/EBRI_IB_12-20073.pdf ).
15 North Carolina Institute of Medicine (2006). “The Business Case for Providing Health Insurance.” April. (www.nciom.org/projects/uninsured/businesscase.pdf ).
16 Office of Management and Budget. “Analytical Perspectives, Budget of the United State Government, Fiscal Year 2011.” p 211. http://goo.gl/rC5cb
17 Andrea M. Sisko and others (2010). “National Health Spending Projections: The Estimated Impact of Reform Through 2019.” October, Table 1. (www.healthaffairs.org)
18 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
19 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
20 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
21 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
22 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
23 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
24 Health Research and Education Trust (2012). “2012 Employer Health Benefits Survey.” http://ehbs.kff.org/pdf/2012/8345.pdf
25 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." Exhibit 7.5. http://ehbs.kff.org/pdf/2012/8345.pdf
26 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." Page 107. http://ehbs.kff.org/pdf/2012/8345.pdf
27 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." Page 107. http://ehbs.kff.org/pdf/2012/8345.pdf
28 U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011.” http://www.census.gov/prod/2012pubs/p60-243.pdf
29 U.S. Census Bureau (2012). “Table C-3. Health Insurance Coverage by Age: 1999 to 2011.” http://www.census.gov/prod/2012pubs/p60-243.pdf
30 “Survey Demonstrates Americans Receive Comprehensive Health Benefits through Employer Plans,” National Association of Health Underwriters.5 Jan 2012; http://www.nahu.org/media/releases/2012/Survey_NAHU_Members.pdf
31 “Survey Demonstrates Americans Receive Comprehensive Health Benefits through Employer Plans,” National Association of Health Underwriters.5 Jan 2012; http://www.nahu.org/media/ releases/2012/Survey_NAHU_Members.pdf
32 “Survey Demonstrates Americans Receive Comprehensive Health Benefits through Employer Plans,” National Association of Health Underwriters.5 Jan 2012; http://www.nahu.org/media/ releases/2012/Survey_NAHU_Members.pdf
33 “Employer-Sponsored Health Insurance and Health Reform” The National Bureau of Economic Research. Feb 2012. http://www.nber.org/aginghealth/2009no2/w14839.html
34 “Employer-Sponsored Health Insurance and Health Reform” The National Bureau of Economic Research. Feb 2012. http://www.nber.org/aginghealth/2009no2/w14839.html
35 “Employer-Sponsored Health Insurance and Health Reform” The National Bureau of Economic Research. Feb 2012. http://www.nber.org/aginghealth/2009no2/w14839.html
36 “Employer-Sponsored Health Insurance and Health Reform” The National Bureau of Economic Research. Feb 2012. http://www.nber.org/aginghealth/2009no2/w14839.html
37 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." Page 107. http://ehbs.kff.org/pdf/2012/8345.pdf
38 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2012 Annual Survey." Exhibit 7.5. http://ehbs.kff.org/pdf/2012/8345.pdf
39 Kaiser Family Foundation and Health Research and Educational Trust (2012). “2012 Employer Health Benefits Survey.” Exhibit 6.1, http://ehbs.kff.org/pdf/2012/8345.pdf
40 PricewaterhouseCoopers (2010). “Health and Well-Being Touchstone Survey. Executive Summary.” June. www.pwc.com/en_US/us/hr-management/assets/health-wellness-touchstone-survey.pdf
41 U.S. Office of Personnel Management “High Deductible Health Plans (HDHP) and Health Savings Accounts (HSA)” (http://www.opm.gov/insure/health/hsa/faq.asp)
42 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey, Exhibit 4.3." http://ehbs.kff.org/pdf/2012/8345.pdf
43 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." http://ehbs.kff.org/pdf/2012/8345.pdf
44 Kaiser Family Foundation and Health Research and Educational Trust (2012). "Employer Health Benefits: 2011 Annual Survey." http://ehbs.kff.org/pdf/2012/8345.pdf
45 Employee Benefit Research Institute (2010). “What Do We Really Know About Consumer-Driven Health Plans?” Issue brief, August. (www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=4612)
46 Pierron, William; and Fronstin, Paul (2008). “ERISA Pre-emption: Implications for Health Reform and Coverage.” EBRI Issue Brief no. 314 (Washington, DC: Employee Benefit Research Institute), February.(http://www.ebri.org/pdf/briefspdf/EBRI_IB_02a-20082.pdf ).
47 Healthcare.gov. “Preventive regulations.” (www.healthcare.gov/center/regulations/prevention/regs.html)
48 Kaiser Family Foundation (2010). “Summary of the New Health Reform Law.” (www.kff.org/healthreform/8061.cfm)
49 H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 1311. (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).
50 "HHS Announces End of Early Retiree Reinsurance Program," Arvak Insurance Group, Dec 14, 2011; http://www.arvakinsurancegroup.com/business/hhs-announces-end-of-early-retiree-reinsurance-program/
51 The threshold amounts will be increased for retired individuals age 55 and older who are not eligible for Medicare and for employees engaged in high-risk professions by $1,650 for individual coverage and $3,450 for family coverage. The threshold amounts may be adjusted upwards if health care costs rise more than expected prior to implementation of the tax in 2018. The threshold amounts will be increased for firms that may have higher health care costs because of the age or gender of their workers. Source: Kaiser Family Foundation. “Summary of the New Health Reform Law.” (http://www.kff.org/healthreform/upload/8061.pdf)
52 Kaiser Family Foundation and Health Research and Educational Trust (2012). Employer Health Benefits: 2012 Annual Survey, Exhibit 2.2 . http://ehbs.kff.org/pdf/2012/8345.pdf
53 Kosali Simon, Center for American Progress (2010), “Implications of Health Reform for Employers,” May, p. 2 http://www.americanprogress.org/issues/2010/05/pdf/health_employers.pdf
54 Long, Sharon K. and Phadera, Lokendra. Estimates of Health Insurance Coverage in Massachusetts from the Massachusetts Health Insurance Survey: An Update for 2010. Urban Institute, www.urban.org/sharonklong
55 Long, Sharon K. and Phadera, Lokendra. Estimates of Health Insurance Coverage in Massachusetts from the Massachusetts Health Insurance Survey: An Update for 2010. Urban Institute, www.urban.org/sharonklong
56 Long, Sharon K. and Phadera, Lokendra. Estimates of Health Insurance Coverage in Massachusetts from the Massachusetts Health Insurance Survey: An Update for 2010. Urban Institute, www.urban.org/sharonklong
57 Long, Sharon K. and Phadera, Lokendra. Estimates of Health Insurance Coverage in Massachusetts from the Massachusetts Health Insurance Survey: An Update for 2010. Urban Institute, www.urban.org/sharonklong
58 “Qualified individuals” will be U.S. citizens and legal immigrants who are not incarcerated. Kaiser Family Foundation (2010). “Summary of the New Health Reform Law.” (www.kff.org/healthreform/8061.cfm)
59 State Health Access Data Assistance Center (2010). “Health Insurance Exchanges: Implementation and Data Considerations for States and Existing Models for Comparison.” October. (www.rwjf.org/files/research/70588.pdf)
60 HealthCare.gov. “Health Insurance Exchanges: State Planning and Establishment Grants.” (www.healthcare.gov/news/factsheets/esthealthinsurexch.html)
61 “Health Exchanges” American College of Physicians. http://www.acponline.org/advocacy/state_policy/hottopics/exchanges.pdf
62 Laszewski, Bob. “Will the Feds Be Ready With the Fallback Insurance Exchanges by October 2013?” Health Care Policy and Marketplace Review. Jan 18 2012; http://healthpolicyandmarket.blogspot.com/