Self‐Funding of Health‐Care Plans by Small Firms: Risks and Reforms

Small employers that offer health insurance have usually offered fully insured products through traditional health plans. Recently, the Patient Protection and Affordable Care Act (ACA) has created new requirements for fully insured products that will entice more small firms to fund their own health‐care benefits. However, self‐funding poses significant risks to these small firms, their employees, and state exchanges. To mitigate some of these risks within current political realities, we recommend advance disclosures—to small firms of material changes in their stop‐loss policies, and to their employees that premium subsidies are available only on ACA exchanges. We also suggest strengthening Small Business Health Options Program exchanges by broadening the availability of subsidies and building partnerships with brokers. Finally, we recommend an expanded role for brokers and third‐party administrators in helping small firms improve their choice of health‐care insurance.     

Whole Farm Income Insurance

This article employs a mathematical programming model to investigate farmers’ optimal crop choices under gross revenue insurance, whole farm income insurance (WFI), the Canadian Agricultural Income Stabilization (CAIS) program, and its modified 2008 program AgrInvest. WFI poses a particularly interesting problem since the indemnity/premium structure is dependent upon the choice of crops, whereas the choice of crops is simultaneously influenced by the presence of the whole farm insurance program. Results indicate that farmers will alter farm plans significantly in response to the type of insurance offered and the level of subsidy.     

The Effects of Offering Health Plan Choice Within Employment-Based Purchasing Groups

Employers may offer employees a choice of health plans either to promote competition among plans or to better cater to employee preferences for different types of products. This article examines whether the relationship between the availability of choice and insurance costs and coverage are consistent with these models of employer behavior. The results indicate that employers who offer choice have lower average premiums, primarily because employees are enrolled in less generous plans, and cover a greater proportion of workers than those who do not. The results are consistent with employers offering choice to accommodate diverse worker preferences.     

How does managed care do it?

Integrating the health services and insurance industries, as health maintenance organizations (HMOs) do, could lower expenditure by reducing either the quantity of services or unit price or both. We compare the treatment of heart disease in HMOs and traditional insurance plans using two datasets from Massachusetts. The nature of these health problems should minimize selection. HMOs have 30% to 40% lower expenditures than traditional plans. Both actual treatments and health outcomes differ little; virtually all the difference in spending comes from lower unit prices. Managed care may yield substantial increases in measured productivity relative to traditional insurance.     

Price presentation and consumers’ choice

Currently, regulatory authorities and consumers ask for more cost transparency with respect to financial product components. In life insurance, for instance, the premium for products should be split in its components: A premium for death benefits, the savings premium, the cost of an investment guarantee, and the administration costs. In this regard, it is important for insurance companies and regulators to know to what extent the way of presenting the prices of an offer affects consumer evaluation of the product. Based on a paper by Huber et al. (How do price presentation effects influence consumer choice? The case of life insurance products. Working paper, 2011) as presented at the annual meeting of Deutscher Verein für Versicherungswissenschaft in 2011, this article presents the effects of different forms of presenting the price of life insurance contract components and especially of investment guarantees on consumer evaluation of this product. This is done by means of an experimental study using a representative panel for Switzerland and by focusing on unit-linked life insurance products. The findings reveal that, contrary to consumer products, there is no effect of price bundling and price optic on consumer evaluation and purchase intention for life insurance products. However, there is a significant moderating effect of consumer experience with insurance products on this relationship.     

Adverse Selection and Competing Deposit Insurance Systems in Pre-Depression Texas

In 1910, Texas instituted a unique deposit insurance program for its state chartered banks by providing a choice between two separate plans: the depositors guaranty fund, similar to insurance schemes in several other states, and the depositors bond security system, which required the procurement of a privately issued guarantee of indemnity. While, under most deposit insurance schemes, the incentive to monitor the financial condition of individual banks simply devolves from depositors to regulators, the bond security system established in Texas distinguished itself by attempting to reintroduce market discipline through the indemnity requirement. Using a probit model with heteroscedasticity, we find evidence that the choice of insurance coverage led to risk-sorting among the banks, with relatively conservative and financially secure institutions opting for the comparatively rigorous bond security system. In addition, the bank failure record indicates the risk differentials between banks in the two plans persisted over time and even possibly grew, suggesting the bond security system at least partially avoided the moral hazard incentives associated with the fixed-rate depositors guaranty plan. These findings support the general view that market discipline is effective in banking.     

Which Price is Right: Load or Premium?

This paper uses national time series data for the United States to investigate whether changes in the premium or loading fee offer a better explanation for variations in the percentage of the population with private health insurance from 1960 to 2004. The empirical results suggest that premium provides a better measure of price when estimating the demand for health insurance at the extensive margin. The empirical analysis also indicates that the aggregate short-run price and income elasticities of demand for health insurance are fairly close at ?0.19 and 0.27, respectively. One implication is that the percentage of the population with private health insurance in the United States should continue to decline in the future if real premiums persistently grow significantly faster than the overall economy.     

边远地区农业保险市场低水平均衡的原因与对策建议

一些边远地区的农业保险市场呈现有效供需不足的低水平均衡状态,其主要原因在于：农业保险较高的风险与成本、边远地区财力支持不足以及农保市场信息不对称等导致农业保险供给减少;而农保市场信息不对称导致较高的保费,保险公司过低的赔付额与部分不合理条款以及农户较低的参保能力与意愿抑制了农户对保险业务的有效需求。应采取相应措施,促进边远地区农业保险可持续发展。     

A Comparison of HMO Efficiencies as a Function of Provider Autonomy

Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to traditional fee‐for‐service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on reform, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using “game‐theoretic” data envelopment analysis (DEA) models. While other studies confirm that absolute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee‐for‐service (FFS) indemnification plans in their marketplace contentions.     

Limiting the ACA's Threats to Small Group Health Insurance Markets

We identify three threats to small group health insurance markets that may result from the 2014 implementation of certain provisions in the Affordable Care Act (ACA). First, small employers with predominantly low‐income employees may tend to opt out of small group markets because their employees will be better off with subsidized individual coverage. Second, small employers with employees of heterogeneous income levels will have strong incentives to offer coverage that is either “unaffordable” or fails to provide “minimum value” in order to preserve the availability of government subsidies for their low‐income employees. Finally, small employers that continue to offer group plans will face increased incentives to self‐insure those plans, further contracting small group markets and subjecting them to adverse selection. Collectively, these forces may destabilize small group markets and increase the ACA's fiscal cost. We therefore conclude by offering various reforms aimed at offsetting these risks and preserving the viability of small group markets.     

Medicare in the 21st century.

The authors provide an overview of the Medicare program in terms of how the current program operates, the current issues it faces that may shape possible options for reform, and the implications of these features and issues for employment-based health plans. Current issues include adoption of a premium support model, changes in the eligibility age for Medicare benefits, Medigap insurance, benefits covered and customer service.     

The Demand for Health Insurance in the Group Setting: Can You Always Get What You Want?

To what extent do health benefits obtained in the employment‐based setting reflect individual preferences? We examine this question by comparing the relationship between person‐level characteristics and the plans they obtain in a group setting to the relationship observed in the individual insurance market, using data from the 1996‐1997 and 1998‐1999 Community Tracking Study's Household Surveys. We also examine the effect of unions on group choice. Our structural models of the demand for insurance indicate that plans obtained in the group setting often reflect underlying individual preferences for insurance, but we consistently observe significantly different effects of ethnicity and unionization.     

Intergenerational Transfers and Insurance Policy Design

Abstract

Group health insurance policies offering an identical benefit package to every member of the group result in lower expected health benefits for younger cohorts than older cohorts. The dispersion in insurance benefits across age groups differs among insurance policies. Simulation results presented in this paper demonstrate that a shift from comprehensive health insurance to high-deductible health insurance decreases the share of expected benefits going to younger cohorts. An estimated 81.5% of the 23-to-32-year-old cohort is expected to receive less than $500 in health benefits during a year for one prototypical high-deductible health plan. Low expected benefits for younger relatively healthy cohorts could increase the number of younger individuals who eschew health coverage. Age-rated premiums are probably the most straightforward way to stimulate demand for high-deductible health plans among younger healthier individuals.     

Health plan termination--bankruptcy--automatic stay--COBRA. In re Health Management Limited Partnership

Even though an insurer provided telephone notice of termination of a group health plan's insurance coverage for failure to pay the required premium on the same day the employer filed a bankruptcy petition and gave written notice after the petition was filed, it did not violate the bankruptcy code's automatic stay provision. This is because a special payment plan provided for an extended grace period and automatic termination upon failure to pay the premium in full by the end of that period, and the final due date was before the debtor filed the petition. Thus, termination occurred automatically before the bankruptcy petition was filed. The insurer is not the plan administrator and is not obligated to provide COBRA notice to the debtor's employees, especially since the employees could not elect to continue coverage under a group health plan when the insurance coverage had been terminated. An employee's right to elect to continue coverage under the employer's group plan presumes there is coverage available to continue.     

The Impact of the Health Insurance Market on Small Firm Employment

Small firms that offer health insurance to their employees may face variable premiums if they hire employees with high expected health costs. To avoid expensive premium variability, small firms may attempt to maintain a workforce with low expected health costs. This results in employment distortions. I examine the magnitude of these employment distortions using the 1987 National Medical Expenditure Survey and the 1996 Medical Expenditure Panel Survey. Based on the underwriting behavior of insurance companies in 1988, I classify medical conditions into three categories: conditions that led to denial of coverage; conditions that led to exclusion restrictions; and, conditions that led to higher premiums. In 1987, I find that insured small firms were less likely to employ workers with families that had conditions that led to higher premiums than insured large firms. However, in 1996, possibly due to the passage of small group health insurance reforms that restrict insurers' ability to exclude or deny coverage, insured small firms were less likely to employ workers with denial conditions compared to insured large firms. These results suggest that the pattern of employment distortions in insured small firms is consistent with the evolving small group health insurance market.     

Why small businesses don't have health insurance: results of a Florida survey

While most of the insured population has health insurance under an employer-sponsored group plan, the majority of the working uninsured are employed by small firms. Increasing the number of small firms that provide health insurance plans to their employees is important for decreasing the number of uninsured. This article summarizes the results of a survey designed to study characteristics of the firms that do not have health insurance, the obstacles to their getting insurance, and small business owners' interest in having a group health plan.     

Health uninsurance premium and mortgage interest rates

I show that lenders charge higher interest rates on mortgage-financed houses in areas with a higher rate of health uninsurance to protect themselves against a potential future bankruptcy of the borrower caused by health uninsurance. The health uninsurance premium is higher for applicants who are more likely to file for bankruptcy and for mortgage-financed houses in areas where there are greater benefits to obtaining insurance or where there is a higher percentage of uninsured people who cannot afford insurance. The premium is lower following the implementation of the requirement to have qualifying health insurance coverage under the Affordable Care Act.     

Let's put consumers in charge of health care

Businesses spend billions on health insurance. And what do they get for their money? A lot of unhappy employees. Workers fret about the quality of the care they receive, the burden of their out-of-pocket expenses, and the gaps in their coverage. For businesses, health care has become a lose-lose proposition: They pay way too much, and they get way too little. The problem is that the health care industry has been shielded from consumer pressure--by employers, insurers, and the government. As a result, costs have exploded even as choices have narrowed. But if companies embrace a new model of health coverage--one that places control over both costs and care directly into the hands of employees--the competitive forces that spur productivity and innovation in consumer markets can be loosed upon the inefficient, tradition-bound health care system. Moving to consumer-driven health care requires that companies revamp their health benefits in six ways: Give employees incentives to shop intelligently; offer a real choice of insurance plans; charge employees prices that accurately reflect the company's costs; let providers set their own prices; adjust payments for each enrollee based on need; and provide relevant information. Putting consumers in charge of health care may seem like a radical approach. But individuals are highly motivated to educate themselves about their health, their insurance, and their care, and they want to seek the most value for their money. Promoting that economic dynamic--the same that fuels consumer markets everywhere--is the best way to enhance the health care industry's productivity and quality.     

Health insurance--a challenge in India

In India, indemnity health insurance started about 3 decades ago. Mediclaim was the most popular product. Indian insurers and multinational companies have not been enthusiastic about starting health insurance in spite of the availability of a good market because health insurers have historically incurred losses. Losses have been caused by poor administration. Because it is a small portion of their total businesses, insurers have never tried sincerely to improve deficiencies or taken special interest. Hospital management and medical specialists have the spirit of entrepreneurship and are prepared to learn quickly and follow managed care principles, though they are not currently practiced in India. Actuarial data from the health insurance industry is sparse, but data from alternative sources will be helpful for starting managed healthcare. In my opinion, if properly administered, a "limited" managed care product with appropriate precautions and premium levels will be successful and profitable and will compete with present indemnity products in India.