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The Future of Employer Sponsored Health Insurance. Michael A. Morrisey, Ph.D. Lister Hill Center for Health Policy University of Alabama at Birmingham. Alliance for Health Reform Washington, DC September 26, 2008. The Story.

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The future of employer sponsored health insurance

The Future of Employer Sponsored Health Insurance

Michael A. Morrisey, Ph.D.

Lister Hill Center for Health Policy

University of Alabama at Birmingham

Alliance for Health Reform

Washington, DC

September 26, 2008

The story
The Story

Employer sponsored health insurance (ESHI) is not going away anytime soon

… but how it is provided will change significantly

Modern insurance does two things
Modern Insurance Does Two Things

  • It reduces the financial risk of big, costly relatively rare health events

  • It negotiates lower prices for health services

    • Arguably lower prices than we can get ourselves

More catastrophic type coverage
More Catastrophic-Type Coverage

  • As premiums increase employers & employees will try to conserve on coverage – giving up the coverage they value least

    • Switch to cheaper plans

    • Drop coverage for lesser valued & routine services

    • Seek higher copays & deductibles

More different selective contracting
More & Different Selective Contracting

  • Selective contracting has a track record of effectiveness in lowering the price of health services

    • Trading volume for price

  • We will see:

    • More narrow panel managed care

    • Discounts on drugs & physician visits

Resurgence of tighter provider networks
Resurgence of Tighter Provider Networks

  • HMOs but with much less gatekeeping and less utilization management

  • …but greater reliance on selective contracting

Discounts in many forms
“Discounts” in Many Forms

  • Discount card

    • Provided by the insurer who offers ESHI

    • Provided by a health services provider

      • See the merger of Caremark and CVS

  • Aggressive pricing

    • Wal-Mart's $4 prescriptions & $9 diabetes supplies

    • Retail-outlet health services providers

      • Routine, chronic, preventive

Better tailored coverage for single two earner households
Better Tailored Coverage for Single & Two-Earner Households

  • Two-earner households don’t want two insurance plans

    • Have much larger out-of-pocket insurance premiums

    • “Gross up” wages and salaries

    • Allows workers to have both coverage & higher wages

Salience of insurance premiums
Salience of Insurance Premiums

  • Many workers view the “price of ESHI” as the amount they have to pay out-of-pocket

    • But the wages given up are based on the full premium

  • If they see the full premium as their money they will choose more carefully about what insurance coverage they value

Neoclassicists vs behavioralists
Neoclassicists vs. Behavioralists

  • When Going to the Store …

    • Neoclassicists

      • People understand that they will pay 7% sales tax and will incorporate this into the posted prices they see – and buy less

    • Behavioralists

      • It is the posted price that is salient to people and they make their decisions based on this price and overlook the sales tax

Higher wages and full price menu of health insurance options
Higher Wages and Full Price Menu of Health Insurance Options

  • If the Behavioralists are right, then the salience of the full price menu will induce people to:

    • Switch to cheaper existing plans

    • Seek higher copays & deductibles

    • Drop lesser valued & routine coverages

The future of eshi summary
The Future of ESHI - Summary

  • Short-Run

    • More catastrophic-type coverage

    • “Discount cards” – price cuts to consumers

    • Greater use of selective contracting

  • Longer-Run

    • Wages “grossed up” & higher out-of-pocket premiums

    • Salience of the full insurance premium

What can congress do
What Can Congress Do?

  • Maintain choice

    • Employers have seen that one size doesn’t fit all

  • Implement a Tax-Cap on ESHI

    • To reduce the incentive for the middle & high income to over-insure

  • Replace the Tax-Cap with a Tax Credit

    • To enhance incentives for the low income to buy coverage

    • Perhaps income or health status adjusted