Employer-sponsored health insurance

Transcription

1 Web First doi: /hlthaff HEALTH AFFAIRS 31, NO. 10 (2012): Project HOPE The People-to-People Health Foundation, Inc. By Gary Claxton, Matthew Rae, Nirmita Panchal, Anthony Damico, Heidi Whitmore, Kevin Kenward, and Awo Osei-Anto Health Benefits In 2012: Moderate Premium Increases For Employer- Sponsored Plans; Young Adults Gained Coverage Under ACA Gary Claxton kff.org) is a vice president and director of the Health Care Marketplace Project at the Henry J. Kaiser Family Foundation in Washington, D.C. Matthew Rae is a senior policyanalystatthekaiser Family Foundation. Nirmita Panchal is a policy analyst at the Kaiser Family Foundation. Anthony Damico is a statistical analyst at the Kaiser Family Foundation. Heidi Whitmore is a senior research scientist at NORC at the University of Chicago, in Bethesda, Maryland. Kevin Kenward is director of research at the Health Research and Educational Trust, in Chicago, Illinois. ABSTRACT Health care premiums rose moderately for single and family employer-sponsored coverage this year, the 2012 annual Kaiser Family Foundation/Health Research and Educational Trust (HRET) Survey of Employer Health Benefits found. Even with the lingering effects of the recession, cost-sharing levels remained relatively stable in Also remaining stable was the rate at which employers offered coverage, according to the survey, which was based on telephone interviews with 2,121 public and private employers contacted from January through May The average annual premiums in 2012 were $5,615 for single coverage and $15,745 for family coverage, an increase of 3 and 4 percent, respectively, from The percentage of firms offering health benefits, 61 percent, was similar to last year s, as was the percentage of workers at offering firms who were covered by their firm s health benefits, 62 percent. One noteworthy change, because of a provision of the Affordable Care Act, is that 2.9 million young adults who would not otherwise have been enrolled in a parent s employer-sponsored health insurance were covered by that insurance in Awo Osei-Anto, formerlya senior researcher and project manager at the Health Research and Educational Trust, is a health policy PhD student at Brandeis University, in Waltham, Massachusetts. Employer-sponsored health insurance is the leading source of coverage in the United States, covering 149 million nonelderly people. 1 This article presents findings from the fourteenth annual Kaiser Family Foundation/ Health Research and Educational Trust (Kaiser/ HRET) Survey of Employer Health Benefits. 2 Among the major findings, the cost of single coverage rose 3 percent and that of family coverage rose 4 percent in 2012, while average costsharing amounts remained largely unchanged. Following two years of significant increases in the percentage of covered workers enrolled in high-deductible health plans with a savings option (8 percent in 2009, 13 percent in 2010, and 17 percent in 2011), the survey found a similar level of enrollment in 2012 compared to 2011: 19 percent of covered workers are now enrolled in a high-deductible health plan with either a health reimbursement arrangement or a health savings account. There continue to be important differences between the health benefits offered by small and large firms. Workers at small firms (those with workers) face higher cost sharing, including higher copayments for office visits and higher general annual deductibles for single coverage. These workers are also responsible for a larger premium contribution for family coverage than are workers at large firms (those with 200 or more workers). Despite the economic slowdown, the percentage of firms offering coverage (61 percent) remained unchanged from Among firms offering health benefits, the percentage of workers covered by health benefits through their own employer (62 percent) was the same as last year Health Affairs October :10

2 Employers continue to offer wellness benefits to their employees: More than 94 percent of large employers offer at least one wellness program. Twenty-two percent of employers with at least 1,000 employees offer an on-site health clinic. Study Data And Methods Sample For Survey The sample for the annual Kaiser/HRET Survey of Employer Health Benefits includes private firms and nonfederal government employers with three or more employees. The sample of private firms was compiled by Survey Sampling Inc.; nonfederal government employers were sampled from the Census Bureau s Census of Governments. The sample is stratified by firm size and industry. Computer-assisted telephone interviews were conducted with employee benefit managers from January through May 2012 by National Research LLC. A total of 2,121 firms completed the full survey, 74 percent of which had participated in either the 2010 or the 2011 survey, or both. The response rate was 47 percent, both for the overall sample and for those firms offering health benefits. In an effort to increase the sample size for the estimate of the percentage of firms indicating whether they offer coverage, we asked the following question to firms that declined to participate in the full survey: Does your company offer a health insurance program as a benefit to any of your employees? A total of 1,205 firms answered only this question. These responses were used with the responses of those firms that completed the full survey to calculate the overall offer rate. The response rate for this one question was 73 percent. Methods To produce nationally representative estimates, we developed weights specific to employers, workers, covered workers, and workers within each type of health plan. The employer weight was determined by calculating the firm s probability of being selected into the sample. The basic employer weight was then adjusted for nonresponse bias and trimmed of overly influential weight values. 3 Next, the employer weights were poststratified to ensure that the sum of the weights matched the Census Bureau s 2009 Statistics of US Businesses for private-sector firms or the 2007 Census of Governments for nonfederal public-sector firms. The worker weight was calculated by multiplying the employer weight by the number of workers at the firm and then following the same weight adjustment process described above. The covered-worker weight and the plan-specific weights were calculated by multiplying the percentage of workers enrolled in each of the plan types by the firm s worker weight. These weights allow for analyses of all workers covered by health benefits and of workers in a particular type of health plan. Although most US firms are small, most workers covered by health benefits are employed at large firms: 68 percent of the covered worker weight is constituted of firms with 200 or more employees. Conversely, firms with fewer than 200 employees represent 98 percent of the employer weight. To correct for nonresponse to particular items on the survey, we imputed missing data following a hotdeck approach, which replaces missing information with observed values from a firm similar in size and industry to the firm with missing data. To account for design effects, the R statistical environment and survey library were used to calculate standard errors. 4 Differences referred to in the text use a p value of 0.05 as the threshold for significance. 5,6 Survey Questions Each year, benefit managers are asked questions about how many employees are eligible for and covered by the health benefits offered by the firm, and about the characteristics of the firm s largest health maintenance organization, preferred provider organization, point-of-service plan, 7 and highdeductible health plan with a savings option. The latter are plans that have deductibles of at least $1,000 for single coverage and $2,000 for family coverage and that offer a health reimbursement arrangement or are eligible for a health savings account. 8 Study Results The Cost Of Coverage In 2012 the average annual premium cost was $5,615 for single health coverage and $15,745 for family coverage (Exhibit 1). The average premiums were about 3 percent higher for single coverage and 4 percent higher for family coverage than in During the same period, general inflation was 2.3 percent, and wages rose by 1.7 percent. 9,10 Family health insurance premiums have nearly doubled since Average premiums for single coverage are similar for workers in small firms and large firms, but average premiums for family coverage are lower for workers in small firms than for those in large firms: $15,253 versus $15,980 (Exhibit 2). The difference in premiums between large and small firms may be partially explained by the higher cost sharing and deductibles faced by workers at small firms. Both single and family premiums for covered workers in high-deductible health plans with a savings option are lower than the average premiums for all plans, while October :10 Health Affairs 2325

3 Web First Exhibit 1 Average Annual Premiums For Single And Family Coverage, SOURCE Kaiser Family Foundation and Health Research and Educational Trust, Survey of Employer Health Benefits, NOTE All of the estimates except 1999 (both single and family) and 2009 (single) are significantly different from the estimate for the previous year shown (p < 0:05). premiums for covered workers in preferred provider organization plans are higher. Premiums for covered workers in firms with a larger share of lower-wage workers (those with annual wages of $24,000 or less) are lower than premiums for covered workers in firms with a smaller share of lower-wage workers (Exhibit 3). Conversely, covered workers at firms with a larger proportion of higher-wage workers (those with annual wages of $55,000 or more) have higher premiums than do covered workers at firms with a smaller share of higher-wage workers. Premiums also vary by the age of the workforce (Exhibit 3). Average premiums are lower for covered workers in firms with a larger share of workers age twenty-six or younger than for covered workers in firms with a smaller share of workers in that age group. In contrast, firms with a larger share of workers age fifty or older have higher average premiums than firms with a smaller share of older workers. Employee Contributions Toward Premiums In 2012 covered workers contributed on average 18 percent of the premium for single coverage and 28 percent of the premium for family coverage the same percentages they contributed in 2011 (Exhibit 2). Compared to workers in large firms, workers in small firms have a slightly lower average percentage contribution for single coverage but a far higher average percentage contribution for family coverage. The average annual contributions in 2012 are $951 for single coverage and $4,316 for family coverage (Exhibit 2). Neither amount is a statistically significant increase over the 2011 value. Workers in firms with a large share of lower-wage workers face higher contributions for family coverage than workers in firms with a small share of lower-wage workers (Exhibit 3). Plan Enrollment Preferred provider organizations remain the most common plan type, enrolling 56 percent of covered workers. Nineteen percent of covered workers are enrolled in high-deductible health plans with a savings Exhibit 2 Average Annual Premiums And Worker Contributions For Single And Family Coverage, 2012 Worker contribution Total premium ($) Dollar amount Percentage Category Single Family Single Family Single Family All plans 5,615 15, , Plan type HMO 5,668 15,729 1,114** 4,563 21** 30 PPO 5,850** 16,356** 1,002 4, POS 5,507 15, ** 4,578 14** 29 HDHP/SO 4,928** 14,129** 765** 3,720** 16** 27 Region Northeast 5,964** 17,099** 1,084** 4, ** Midwest 5,501 15, ,973** South 5,445** 14,988** 945 4, ** West 5,715 16, , Firm size Small (3 199 workers) 5,588 15,253** 848** 5,134** 16** 35** Large (200 or more workers) 5,628 15,980** 1,001** 3,926** 18** 25** SOURCE Kaiser Family Foundation and Health Research and Educational Trust, Survey of Employer Health Benefits. NOTES Data are weighted by covered workers. For plan type, statistical significance denotes difference from all plans. For region and firm size, statistical significance denotes difference from all other firms not in the indicated region or size category. HMO is health maintenance organization. PPO is preferred provider organization. POS is point-of-service plan. HDHP/SO is highdeductible health plan with a savings option. **p < 0: Health Affairs October :10

4 Exhibit 3 Firms Health Coverage Offer Rates, Premiums, And Worker Contributions, By Firm Characteristics, 2012 Average total premium b ($) Average worker contribution b ($) Firm characteristic Percent of firms offering health benefits a Single coverage Family coverage Single coverage Family coverage All firms 61 5,615 15, ,316 Lower-wage workers c <35% low-wage workers 64** 5,673** 15,871** 937 4,237** 35% low-wage workers 28** 5,135** 14,694** 1,069 4,977** Higher-wage workers d <35% high-wage workers 50** 5,448** 15,087** 940 4,652** 35% high-wage workers 77** 5,789** 16,427** 964 3,968** Younger workers e <35% younger workers 60** 5,669** 15,871** 949 4,319 35% younger workers 37** 4,961** 14,217** 979 4,285 Older workers f <35% older workers 53 5,440** 15,281** 953 4,263 35% older workers 62 5,860** 16,392** 949 4,391 Union workers At least some union workers 68 5,734 16, ,362** No union workers 56 5,549 15, ,848** Part-time workers <35% part-time workers 66** 5,597 15, ,317 35% part-time workers 30** 5,751 15,681 1,037 4,310 SOURCE Kaiser Family Foundation and Health Research and Educational Trust, Survey of Employer Health Benefits. NOTES Statistical significance denotes that estimates in each firm characteristic category are statistically different from each other. Percentage of firms that offer health benefits is employer-weighted; premiums and worker contributions are weighted by covered workers. Percentage of firms that offer health benefits among the firm characteristic categories includes only firms that completed the full survey. a Health benefits offered to at least some workers. b For covered workers. c Earning $24,000 or less per year. d Earning $55,000 or more per year. e Age 26 or younger. f Age 50 or older. **p < 0:05 option, 16 percent are enrolled in health maintenance organizations, 9 percent in point-ofservice plans, and fewer than 1 percent in indemnity coverage. Under indemnity or conventional insurance, participants face the same cost sharing regardless of which provider they select. The percentage of covered workers enrolled in each plan type is similar to the percentage in The percentage of workers enrolled in high-deductible plans with a savings option steadily increased each year from 2009, when it was 8 percent, to 2011, when it was 17 percent. However, the 19 percent of covered workers enrolled in these plans in 2012 is statistically unchanged from the 17 percent reported last year. The enrollment distribution varies by employer size, with preferred provider organizations being relatively more popular among large firms, and point-of-service plans and highdeductible plans with a savings option being relatively more popular among small firms (Exhibit 4). Sixty percent of covered workers are in plans that are partially or fully self-funded in 2012 the same percentage as in 2011 (see Appendix 1). 11 However, the percentage of firms in plans that are partially or fully self-funded has steadily increased from 49 percent a decade ago to 60 percent in In a self-funded plan, the plan sponsor pays for most or all of the claims from its own assets rather than purchasing insurance coverage. Of all covered workers in a self-funded plan, 59 percent are in a plan with stop-loss coverage similar to the percentage in Stop-loss coverage is insurance against large claims that limits the amount of medical claims the employer must pay, typically per enrollee or at an aggregate level for the entire covered population. Regardless of whether they work at small or large firms, a similar percentage of workers in self-funded plans are in plans covered by stoploss coverage (71 percent and 58 percent, respectively). Although the difference is large, it is not statistically significant. 12 In most instances, the stop-loss coverage includes a provision that limits claims payments per enrollee. Firms with this kind of coverage were asked in the survey for the dollar amount at which the stop-loss coverage would start to pay for most or all of the claim (this amount is called the attachment point). The average attachment October :10 Health Affairs 2327

5 Web First Exhibit 4 Distribution Of Health Plan Enrollment For Covered Workers, By Plan Type And Firm Size, 2012 SOURCE Kaiser Family Foundation and Health Research and Educational Trust, Survey of Employer Health Benefits, NOTES Less than 1 percent of covered workers in large firms and all firms are enrolled in a conventional, or indemnity, plan. For PPO, POS, and HDHP/SO plans, enrollment in plan type is significantly different between large and small firms (p < 0:05). HMO is health maintenance organization. PPO is preferred provider organization. POS is point-of-service plan. HDHP/SO is high-deductible health plan with a savings option. point in large firms (weighted by covered workers in the plan) is about $223, Cost Sharing GENERAL ANNUAL DEDUCTIBLES: A general annual deductible is the amount an enrollee must pay before all or most services are covered by the health plan. Most covered workers are in a plan with a general annual deductible. For these workers, average deductibles are higher in small firms than in large firms across all plan types (Exhibit 5). The average deductible amounts for single coverage for each plan type were not significantly different from the averages in Looking across all plan types, 49 percent of workers in small firms and 26 percent of workers in large firms are in a plan with a general annual deductible of at least $1,000. These percentages are similar to those in 2011 (50 percent and 22 percent, respectively). In 2012, 27 percent of covered workers in small firms and 7 percent of covered workers in large firms have a general annual deductible for single coverage of at least $2,000 (data not shown). PHYSICIAN OFFICE VISITS: In addition to any general deductible a plan may have, the majority of covered workers must pay a copayment for an office visit. For visits to primary care physicians as well as to specialist physicians, 73 percent of workers have a required copay (Exhibit 5). Smaller percentages of workers pay coinsurance, which is a percentage of the cost of care, for primary care office visits (17 percent of workers) or specialty care visits (19 percent). All of the amounts for copayments and coinsurance for these visits in 2012 are similar to the amounts in Unlike workers in other plan types, workers in high-deductible health plans with a savings option are more likely to be in plans with coinsurance for primary care office visits (53 percent) or no cost sharing (30 percent) than in plans with copayments (17 percent) after the deductible has been met. PRESCRIPTION DRUGS: Most workers (78 percent) with drug coverage are in a plan with three or more tiers of cost sharing for prescription drugs, which means that consumers pay different amounts for prescription drugs depending on where the plan places the drug on its list, or formulary. Among workers in plans with three or more tiers, copayments are far more common than coinsurance in each tier. The average copayments in these plans are $10 for firsttier drugs, $29 for second-tier drugs, $51 for third-tier drugs, and $79 for fourth-tier drugs. These copay amounts are not significantly different from the amounts reported in Covered workers in small firms face higher copays for their first- and second-tier drugs than do workers in large firms. Relatively few covered workers (13 percent) face a separate deductible for prescription drugs in addition to any general annual plan deductible. For those with a separate annual drug deductible, the average deductible is $145. Eleven percent of covered workers have a separate annual out-of-pocket limit that applies only to spending on prescription drugs. The average prescription drug out-of-pocket limit is $1,722. Similar percentages of firms had either a deductible for prescription drugs or a separate annual out-of-pocket limit in 2009, the last time these questions were asked. Availability Of Coverage Sixty-one percent of firms offer health benefits to their workers in 2012, similar to the 60 percent reported in The largest firms are much more likely than the smallest firms to offer health benefits: Virtually all firms with more than 5,000 workers offer benefits to at least some of their employees, whereas only half of firms with 3 9 workers do so. Although the majority of US firms have 3 9 employees, most workers are employed at firms with more than 1,000 employees. Ninety-two percent of workers work in a firm that offers health benefits to at least some of its employees. Firms with a smaller percentage of lower-income workers are more likely to offer coverage than firms with a larger percentage of those workers (Exhibit 3). Many workers at firms that offer health benefits might be ineligible for coverage or choose not to enroll. For example, employees may decide not to enroll in their firm s health plan if they can enroll in coverage through their spouse s employer. In 2012, 62 percent of 2328 Health Affairs October :10

6 Exhibit 5 Cost Sharing In Employer-Sponsored Health Plans, By Type Of Plan, 2012 HMO PPO POS HDHP/SO All plans Deductibles Covered workers with a general annual deductible for single coverage 30% 77% 60% 100% a Average deductible for single coverage b,c Small firms (3 199 workers) $1,114** $1,260** $1,213** $2,386** a Large firms (200 or more workers) $467** $563** $664** $1,881** a All firms $691 $733 $1,014 $2,086 a Physician office visits, primary care d Covered workers with copay 96%** 80%** 92%** 17%** 73% Average copay for primary care physician office visit $21** $23 $25** $23 $23 Covered workers with coinsurance 1%** 14% 3%** 53%** 17% Average coinsurance rate for primary care physician office visit e 18% e 18% 18% Physician office visits, specialist d Covered workers with copay 93%** 80%** 88%** 19%** 73% Average copay for specialist physician office visit $31** $33 $36 $35 $33 Covered workers with coinsurance 3% 16% 4%** 53%** 19% Average coinsurance rate for specialist physician office visit e 19% e 19% 19% SOURCE Kaiser Family Foundation and Health Research and Educational Trust, Survey of Employer Health Benefits, NOTES Since 2010 the survey has asked about the prevalence and cost of physician office visits separately for primary care and specialty care. The average copayments and the average coinsurance forprimaryand specialty office visits include workers who have more than one type of cost sharing. HMO is health maintenance organization. PPO is preferred provider organization. POS is point-of-service plan. HDHP/SO is high-deductible health plan with a savings option. a Composite deductibles are not presented because of the large variation in the percentage of firms with a deductible and the deductible values. b Significance indicators shown are for p values calculated for differences between firm sizes within plan types. c Average deductibles are calculated for covered workers with a general annual deductible for single coverage. d Significance indicators shown are for p values calculated for differences from all plans category. e Not sufficient data. **p < 0:05 workers employed in firms that offered health benefits were covered by a plan from their own employer a figure similar to the percentage reported for the last three years. The average coverage rate is the same for small firms and large firms. Retiree Health Benefits Twenty-five percent of large firms offer retiree health benefits, similar to the 26 percent reported in However, there has been a steady and significant reduction in the share of large firms that offer retiree benefits over a longer period. The share was 66 percent in 1988, 40 percent in 1998, and 32 percent in Among large firms offering retiree benefits in 2012, 88 percent offer coverage to early retirees (those under age sixty-five), and 74 percent offer coverage to retirees old enough to be eligible for Medicare. Employer Health Programs Wellness Employers are taking steps to try to improve the health of their employees. These steps include offering employees the opportunity to assess their health by completing a health risk appraisal or assessment and offering wellness programs to help employees modify unhealthy behaviors or engage in healthy ones. Some employers are beginning to collect biomedical information, such as cholesterol levels and body mass index, from employees and incorporate that information into their wellness and health programs. Eighteen percent of employers that offer health benefits ask employees to complete a health risk assessment or appraisal that is designed to identify a person s health risks and that includes information about medical history, health status, and lifestyle. Large firms are more likely than smaller firms to ask their employees to complete an assessment or appraisal (38 percent versus 18 percent). Of large firms that ask employees to complete an assessment, 63 percent offer workers a financial incentive to do so. 14 Eleven percent of large firms that ask employees to complete an assessment sometimes require an employee with an identified health risk factor to complete a wellness or health management program or activity in order to avoid a financial penalty, such as a higher premium contribution or higher patient cost sharing. Nine percent reward or penalize employees financially based on whether they meet specified biometric targets, such as body mass index or cholesterol level. 15 Sixty-three percent of the employers offering health benefits offer at least one of the following wellness programs in 2012: 16 weight loss programs, gym membership discounts or on-site exercise facilities, smoking cessation programs, personal health coaching, classes in nutrition or healthy living, biometric screening, web-based October :10 Health Affairs 2329

7 Web First resources for healthy living, and a wellness newsletter. This is similar to the 65 percent that did so in Large firms are more likely than small firms to offer at least one wellness program (94 percent versus 63 percent). Eleven percent of firms that offer wellness programs provide financial incentives to encourage employees to participate. 17 On-Site Health Clinics Employers with at least 1,000 employees were asked if they had an on-site health clinic for their employees at any of their major locations. 18 Twenty-two percent of these employers said that they provide at least one on-site health clinic, and 76 percent of the employers who had such a clinic said that employees could receive treatment for nonwork-related illnesses there. Health Reform Although major provisions of the Affordable Care Act do not take effect for several years, some provisions have already been implemented and are affecting employers practices. Grandfathered Health Plans The Affordable Care Act exempts grandfathered health plans from a number of its provisions, such as the requirements to cover preventive benefits without cost sharing and to have an independent appeal process. An employer-sponsored health plan can be grandfathered if it provided coverage to a worker when the act became law and if the plan does not make major changes that reduce benefits or increase employee costs. 19,20 Forty-eight percent of covered workers are in grandfathered health plans in 2012, down from 56 percent in The difference in the percentage of covered workers in grandfathered plans in small firms and large firms is not statistically significant. Coverage Of Children To Age 26 The Affordable Care Act requires firms to extend coverage under group health plans to children of covered workers until the child reaches age twenty-six. Although the child does not need to be a legal dependent, until 2014 plans do not have to enroll children of employees if those children are offered employer-sponsored health coverage at their own job. Twenty-nine percent of small firms and 90 percent of large firms report enrolling at least one adult child under this provision. The number of children who enroll under this provision at each firm is obviously related to the number of covered workers in the firm. Small firms, on average, enroll one or two children under the provision, while the largest firms (those with 5,000 or more workers), on average, enroll 478 children under the provision. In total, 2.9 million adult children who would not have been enrolled in employer-sponsored health plans without the Affordable Care Act provision are currently enrolled. This is a significant increase from 2.3 million, the number reported in Conclusion Overall, premiums rose moderately for single and family coverage during the last year, while cost-sharing levels, offer rates, and coverage rates remained stable. The continued slow economy, slow growth in health care costs, and uncertainty about the implementation of the Affordable Care Act may have worked together to discourage employers from making big changes in their health plans. In fact, almost half of covered workers are covered by grandfathered health plans that are not subject to many of the provisions of the new law. However, the percentage of covered workers in grandfathered plans has fallen somewhat since There are important differences between the health plans being offered at small firms and those offered at large firms. Although the average family premium is lower at small firms than at large firms, workers at small firms are often responsible for paying a larger share of the premium than workers in large firms. Also, workers at small firms typically face higher cost sharing and out-of-pocket maximums which means that in addition to higher premium contributions, they are also left with a higher financial burden when using services. Employers, particularly large employers, continue to offer wellness benefits and other programs to improve employees health and try to contain health care costs. Wellness programs vary greatly in their level of employee engagement and their scope, ranging from newsletters and online information to personal health coaching and classes. In addition to providing financial incentives to employees who participate in these programs, a few employers are tying financial rewards to completing wellness programs or meeting specified biometric targets or penalizing employees for failing to do so. In addition, more than one in five very large employers (those with at least 1,000 employees) have at least one on-site health clinic for their employees. Most of the clinics can be used for non-work-related as well as work-related health conditions. These programs show that large employers in particular continue to make major investments in the health of their employees, beyond the contributions they make to their workers health plans Health Affairs October :10

8 The authors thank Bianca DiJulio and Janet Lundy at the Kaiser Family Foundation and Andy Bostick at the Health Research and Educational Trust for their comments on the manuscript. They also thank Michael Yang and Jeremy Pickreign at NORC at the University of Chicago for their advice on issues related to the survey design. [Published online September 11, 2012.] NOTES 1 Kaiser Commission on Medicaid and the Uninsured. The uninsured: a primer key facts about Americans without health insurance [Internet]. Washington (DC): The Commission; 2011 Oct [cited 2012 Aug 16]. (Issue Brief). Available from: 2 Kaiser Family Foundation, Health Research and Educational Trust. Employer health benefits: 2012 annual survey [Internet]. Menlo Park (CA): KFF; 2012 Sep [cited 2012 Sep 11]. Available from: 3 Weights greater than six times the interquartile range were reduced to that threshold. Although still accounting for the different probability selections between large and small firms, this method ensures that individual respondents do not overly influence statistics calculated among subpopulations. 4 Analysis of the 2011 survey data using both R and SUDAAN (the statistical package used prior to 2012) produced the same estimates and standard errors. 5 For a more detailed description of the survey methodology, see Kaiser Family Foundation. Survey design and methods. Chapter in: Employer health benefits: 2012 annual survey [Internet]. Menlo Park (CA): KFF; 2012 Sep [cited 2012 Sep 11]. Available from: 6 Kaiser Family Foundation. Technical supplement: standard error tables for selected estimates [Internet]. Menlo Park (CA): KFF; 2012 Sep [cited 2012 Sep 11]. Available from: Standard%20Error.pdf 7 The survey defines a health maintenance organization as a plan that does not cover nonemergency out-of-network services. Preferred provider organizations and point-of-service plans have lower cost sharing for innetwork services than health maintenance organizations do. Point-ofservice plans use a primary care gatekeeper to screen for specialist and hospital visits. 8 Federal law requires a deductible of at least $1,200 for single coverage and $2,400 for family coverage for high-deductible health plans qualified to offer health savings accounts in See Internal Revenue Service. Health savings accounts and other tax-favored health plans [Internet]. Washington (DC): IRS; 2012 Jan 11 [cited 2012 Aug 28]. (Publication No. 969). Available from: 9 Kaiser/HRET surveys use the Aprilto-April time period, as do the sources in this and the following note. The inflation numbers are not seasonally adjusted. Bureau of Labor Statistics. Consumer Price Index all urban consumers [Internet]. Washington (DC): Department of Labor; 2012 [cited 2012 Aug 27]. Available from: timeseries/cuur0000sa0?include_ graphs=false&output_type=column &years_option=all_years 10 Wage data are based on the change in total average hourly earnings of production and nonsupervisory employees. Bureau of Labor Statistics. Employment, hours, and earnings from the Current Employment Statistics survey (national) [Internet]. Washington (DC): Department of Labor; 2012 [cited 2012 Aug 28]. Available from: timeseries/ces To access the Appendix, click on the Appendix link in the box to the right of the article online. 12 The standard errors are 6.8 percent for small firms and 3.3 percent for large firms. 13 The average attachment point in small firms is about $140,000, which is almost twice the amount reported in 2011 for small firms. This value has a very high relative standard error (40 percent) because there are very few small, self-funded employers represented in the survey, and one of them reported a very high value ($2,000,000). Including this firm increases the average by almost 100 percent. 14 The estimate for small firms is not reported in the text because of the high standard error associated with this estimate. Although 19 percent of small firms that ask their employees to complete a health risk assessment reported that they offer a financial incentive, the relative standard error is 0.36, which indicates considerable uncertainty. The difference between large and small firms is statistically significant at the 0.05 confidence level. 15 The percentages of small and large firms offering financial rewards or levying penalties for completing wellness programs or meeting biometric outcomes are not significantly different. The small firm estimates are not reported because of the high relative standard errors for the percentage of firms that levy financial penalties for not completing wellness programs and not meeting biometric outcomes (0.56 and 0.68, respectively). Smoking cessation is not included as a biometric outcome within this question. 16 If those firms that reported offering other types of wellness programs are included, the percentage offering at least one wellness benefit is 64 percent. Of the firms that said they offered other programs, 2 percent offer flu shots and 7 percent offer employee assistance programs. 17 Firms that offer only web-based resources for healthy living or a wellness newsletter as opposed to one of the other specified wellness programs were not asked about their use of financial incentives. The most common financial incentives were gift cards (8 percent of firms), followed by lower premiums (3 percent) and higher contributions to health reimbursement arrangement or a health savings account and lower cost sharing (both 1 percent). 18 We defined an on-site health clinic as a clinic at a workplace staffed by health professionals such as nurses or doctors where employees can receive health care for either workrelated or non-work-related conditions. 19 Departments of the Treasury, Labor, and Health and Human Services. Group health plans and health insurance coverage relating to status as a grandfathered health plan under the Patient Protection and Affordable Care Act: interim final rule and proposed rule. Fed Regist. 2010;75(116): Departments of the Treasury, Labor, and Health and Human Services. Amendment to the interim final rules for group health plans and health insurance coverage relating to status as a grandfathered health plan under the Patient Protection and Affordable Care Act. Fed Regist. 2010;75(221): October :10 Health Affairs 2331

9 Web First ABOUT THE AUTHORS: GARY CLAXTON, MATTHEW RAE, NIRMITA PANCHAL, ANTHONY DAMICO, HEIDI WHITMORE, KEVIN KENWARD & AWO OSEI-ANTO Gary Claxton is director of the Health Care Marketplace Project, Kaiser Family Foundation. In this month s Health Affairs, Gary Claxton and coauthors report on findings of the 2012 annual Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefit Survey. Health care premiums rose moderately for single and family coverage in 2012 compared to the previous year, and cost-sharing levels remained relatively stable. Of note, 2.9 million young adults who would not otherwise have been covered by a parent s employersponsored health insurance were covered because of a provision of the Affordable Care Act. Claxton is a vice president and director of the Health Care Marketplace Project at the Kaiser Family Foundation. The project provides information, research, and analysis about trends in the health care market and about policy proposals that relate to health insurance reform and the changing health care system. Before he joined the foundation, Claxton worked as a senior researcher at the Institute for Health Care Research and Policy at Georgetown University, where his research focused on health insurance and health care financing. From March 1997 to January2001heservedasthe deputy assistant secretary for health policy at the Department of Health and Human Services, where he advised the secretary on health policy issues, including improved access to health insurance, Medicare reform, administration of Medicaid, financing of prescription drugs, expansion of patient rights, and health care privacy. Claxton earned a bachelor s degreein political science from the University of Michigan. Matthew Rae is a senior policy analyst at the Kaiser Family Foundation. Matthew Rae is a senior policy analyst at the Kaiser Family Foundation. Previously, in addition to interning at the Government Accountability Office and the New York City Department of Small Business Services, he worked at the Service Employees International Union and the Oregon Federation of Nurses and Health Professionals. He earned master s degreesin public administration and public health from Columbia University. He is currently completing a graduate certificate program in survey design and data analysis at the George Washington University. Nirmita Panchal is a policy analyst at the Kaiser Family Foundation. Nirmita Panchal is a policy analyst at the Kaiser Family Foundation. Her work focuses on researching and analyzing trends in the private health insurance market. She recently contributed to the project s Health Care Costs: A Primer, and the annual employer health benefit survey. Panchal holds a master s degreeinpublic health, with a concentration in epidemiology and health policy, from the George Washington University. While working toward this degree, she was an intern at the District of Columbia s Department of Health and a program associate for the Washington AIDS Partnership. Anthony Damico is a statistical analyst at the Kaiser Family Foundation. Anthony Damico is a statistical analyst at the Kaiser Family Foundation, where he conducts data analysis for various policy reports. He has published in peerreviewed policy and methods journals using the R, SAS, Stata, and SUDAAN statistical programming languages. Previously, he was a survey researcher at the Center for the Study of Services, in Washington, D.C. He earned a master s degree in health policy from the Johns Hopkins University Health Affairs October :10

10 Heidi Whitmore is a senior research scientist at NORC at the University of Chicago. Heidi Whitmore is a senior research scientist at NORC at the University of Chicago, a position she has held since January Whitmore has more than seventeen years experience in the fields of survey design and administration and of health policy research. She specializes in surveys and studies that track changes in health insurance, including employerbased health benefits, the individual market, the military health system, and other forms of coverage. Her previous positions include researcher at the Center for Studying Health System Change, deputy director of research at the Health Research and Educational Trust, senior consultant at KPMG Consulting, and research analyst at theamericanassociationofhealth Plans. Whitmore holds a master s degree in public policy from Georgetown University. Kevin Kenward is director of research at the Health Research and Educational Trust. Kevin Kenward is director of research at the Health Research and Educational Trust, an affiliate of the American Hospital Association. His previous positions include director of research for the National Council of State Boards of Nursing, director of the American Medical Association s Division of Survey and Data Resources, assistant survey director at NORC at the University of Chicago, and evaluation specialist for the City of Chicago.Hehasservedasan editorial referee for the Journal of the American Medical Association, the Journal of Healthcare Quality, andthejournal of Social Service Research, and he has worked as a book editor for the Journal of Nursing Research. Kenward earned a doctorate in social work from Washington University in St. Louis. Awo Osei-Anto is a PhD candidate in health policy at Brandeis University. Awo Osei-Anto is a PhD candidate in health policy at Brandeis University. She was a senior researcher and project manager at the Health Research and Educational Trust. Most recently, she conducted research on various projects to assess the impact of Medicare s payment policy on hospitals, determine hospitals capacity to implement novel technology to screen for colorectal cancer, and assess trends in employer-sponsored health benefits. Previously, Osei-Anto was aconsultanttopharmaceutical companies and patient advocacy groups. She also worked as a health and welfare benefits analyst, negotiating benefit plans for clients employees. Osei-Anto earned a master s degree in public policy and a certificate in health administration and policy from the University of Chicago. October :10 Health Affairs 2333