Employer-Sponsored Health Insurance: Recent Trends and Future Directions

Health Care Coverage / Health Care Reform

Key Points From This Brief:

Employer-sponsored health insurance (ESI) continues to be the bedrock of coverage in the United States, but long-term trends reflect a steady decline in offer rates among smaller employers, lower enrollment rates among workers offered insurance, and a move away from coverage for dependents. As a result, the number and proportion of non-elderly people receiving insurance through an employer has trended downward for at least the past decade.
These changes have occurred as escalating medical costs push health insurance premiums ever higher. By 2012, health insurance expenses amounted to nearly 8 percent of the overall private-sector payroll and were nearly 12 percent for public-sector employers.
In the face of these rising costs, employers and health insurers have already been taking numerous steps to curtail spending growth. These initiatives include requiring greater cost sharing from plan enrollees, restricting eligibility for spouses, modifying benefit designs and making more wholesale changes to the types of plans offered, adding wellness and health management programs, and strengthening incentives for enrollees and providers to seek and deliver high value care.
Against this backdrop, the ACA introduces sweeping changes to the U.S. health insurance system. While smaller firms and those with predominantly low-wage workforces may have less incentive to offer or retain coverage, any coverage losses will be modest because fewer workers in these firms currently have health benefits. Large employers, who provide most ESI currently, appear poised to stay in the game even with the one-year delay in the employer mandate but will continue changing the benefits they offer.
It is all but certain that employers will continue to shift a greater portion of health benefit costs to employees and tighten eligibility rules for dependents. Increasing reliance on high-deductible health plans with savings options (HSAs and HRAs) within the ESI market also appears quite likely.
Private exchanges are emerging very quickly as new insurance distribution channels and employers express high interest in moving to these markets in the next few years, most often providing a defined contribution that employees can use to purchase coverage of their choice on the private exchange. Some experts predict that private exchanges will soon be the dominant distribution channel for employerprovided coverage despite the availability of the public SHOP exchanges.
Wellness and health management programs are widespread and growing in sophistication, with employers increasingly relying on financial rewards that require progress toward specific biometric goals. ACA provisions that permit even larger incentives have the potential to affect both the structure and cost of health benefits for millions of U.S. workers.
Other strategies already being adopted by employers and insurers seeking to promote value in health care spending include high performance networks and centers of excellence, differential cost-sharing based on the value represented by the provider or the service, reference pricing, and improved transparency around cost and quality. Significant movement along these lines is expected to continue in the future.
The ESI world is far from settled. The evolution of ongoing market trends and the impact of the new changes brought by the ACA both may be affected by larger environmental factors. Critical among these factors are trends toward self-insurance by smaller employers, the long-term viability of the public exchanges, state decisions about Medicaid expansion, legal challenges to the payment of subsidies on certain public exchanges and possible changes to the tax treatment of ESI premiums.