Employer-sponsored Health Insurance among Small Businesses: The 2000 California HealthCare Foundation/Mercer Survey

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1 Employer-sponsored Health Insurance among Small Businesses: The 2000 California HealthCare Foundation/Mercer Survey March 2002 Prepared for the California HealthCare Foundation by William M. Mercer, Inc.

2 Acknowledgments William M. Mercer is a global consulting firm headquartered in New York, specializing in employee benefits, compensation, communication, and actuarial services. Mercer has conducted the Mercer/Foster Higgins National Survey of Employer-sponsored Health Plans since 1996, when it acquired Foster Higgins, the consulting firm that established the study in The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. CHCF s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems. For more information, visit us online ( Additional copies of this publication can be found online ( Two related reports from the same survey can be found online also: Why Don t More Small Businesses Offer Health Insurance? Summary Report on the 2000 California HealthCare Foundation/Mercer Survey and Why Don t More Small Businesses Offer Health Insurance? Detailed Findings from the 2000 California HealthCare Foundation/Mercer Survey. ISBN Copyright 2002 California HealthCare Foundation 476 Ninth Street Oakland, CA Tel: Fax:

3 Contents Key Findings...1 I. Introduction...3 Purpose...3 About the Report...4 Further Survey Data...4 II. California Sponsors with 2 to 50 Employees...5 Prevalence of Health Coverage among Small Employers in California...5 Characteristics of Sponsors and Their Workforces...6 Benefit Eligibility and Program Management...8 Description of Health Coverage Offered...10 III. Health Plan Sponsors with 10 to 50 Employees in California and Nationwide: Trends and Comparisons...15 Type of Plan Offered...16 Employee Enrollment...17 Plan Cost...18 Employee Contributions...19 Appendix A: Data Tables...20 Appendix B: Methodology...27

4 Key Findings Over two-thirds of small California employers (69 percent) offer health coverage to at least some of their employees. This ranges from 64 percent of employers with 2 to 9 employees to 89 percent of those with 25 to 50 employees. When coverage is offered, most employees 82 percent on average are eligible, and most of those who are eligible (83 percent) elect to enroll in the plan. About half of those who enroll elect dependent coverage. The type of health plan most commonly offered by small California employers is the Health Maintenance Organization (HMO) (60 percent of plan sponsors), followed by the Preferred Provider Plan (PPO) (44 percent). Only 11 percent offer a point-of-service (POS) plan, and just 4 percent offer a traditional indemnity plan (TIP). Typically, only one type of plan is offered to employees; only 16 percent of sponsors provide a choice of plan types at their largest worksite. In 2000, total health benefit cost averaged $2,918 per employee among small California health plan sponsors. (This includes employer and employee contributions to the cost of medical plans and, when offered, dental and vision plans, for all active enrolled employees and their covered dependents.) These employers experienced a cost increase of 5.8 percent from 1999 to In 2000, 60 percent of sponsors expected that their health benefit cost would rise in 2001, by an average of 10.8 percent, while 35 percent thought cost would stay about the same. Still, only 13 percent of sponsors said they were somewhat or very likely to reduce benefits over the coming two years, and only 21 percent said they were somewhat or very likely to increase employee contributions. HMO coverage is significantly less expensive than PPO coverage. The average annual cost of HMO coverage in 2000 was $2,618 per employee (including covered dependents), compared to $2,906 per employee for PPO coverage. The 2000 California HealthCare Foundation/Mercer Survey 1

5 Two-thirds of health plan sponsors (67 percent) pay the full cost of coverage for their employees; 25 percent pay the full cost of dependent coverage. When employees are required to contribute to the cost, they pay, on average, 41 percent of the cost of employee-only coverage and 79 percent of the cost of dependent coverage. This includes plans in which the employee pays the full cost of coverage. Health benefit cost is far lower among small employers in California than in the country as a whole. For a comparison group of sponsors with 10 to 50 employees, per-employee cost averaged $3,021 in California but $3,931 in the country as a whole. Among sponsors with 10 to 50 employees, 61 percent of covered employees in California are in HMOs, compared to 37 percent of employees nationally. This difference, along with the lower cost for HMO, PPO, and POS plans in California compared to the nation, explain why total health benefit cost is so much lower in California. Although HMOs offer the least expensive type of coverage available in California, there has been no growth in HMO enrollment over the past two years. In 1998, among sponsors with 10 to 50 employees, HMO enrollment was 61 percent; it was 61 percent in 2000 as well. Between 1998 and 2000, PPO enrollment grew from 24 percent to 29 percent while POS enrollment declined from 13 percent to 8 percent. Traditional indemnity plan enrollment was unchanged, at 2 percent in both years. The 2000 California HealthCare Foundation/Mercer Survey 2

6 I. Introduction Purpose The broad aim of this research was to better understand why some small California employers (defined as having 2 to 50 employees) choose to sponsor employee health plans and others do not. More specifically, the primary informational objectives were to: Create demographic profiles of sponsors and non-sponsors. Explore the attitudes of sponsors and non-sponsors toward purchasing coverage. Learn about any barriers small employers might face in purchasing coverage. Test understanding of the small employer health plan market and the cost of coverage. Describe health plans offered by small employers in terms of cost, plan type, employee contributions. Compare health plan information to similar information collected in 1998, and to national norms. To meet these objectives, the California HealthCare Foundation hired William M. Mercer, Inc., an employee benefits consulting firm, to assist in conducting a survey. A sample of small California firms was drawn from the Dun & Bradstreet database of private employers and screened for benefits status. Telephone interviews were conducted in English and Spanish between October and December Interviews were completed with 924 small (2 to 50 employees) California firms currently offering health insurance to their workers and 904 small firms not offering benefits. Appendix B provides further details on the survey methodology. The 2000 California HealthCare Foundation/Mercer Survey 3

7 About the Report The next section of this report looks at results for all surveyed sponsors, including information on firm and workforce characteristics, health plan offerings and enrollment, and cost and contributions data. Section 3 looks at aggregated data on plan sponsors with 10 to 50 employees in order to compare results with the 1998 CHCF study of small California employers and the 2000 Mercer/Foster Higgins National Survey of Employer-sponsored Health Plans, both of which collected data on employers with 10 to 49 employees. Appendix A provides a set of tables presenting the results of the survey questions overall and by geography (Los Angeles compared to the rest of the state); Appendix B gives a detailed explanation of the survey methodology. Further Survey Data While this report primarily examines the survey data in order to document the characteristics of small firms that offer health insurance to employees, two other reports draw on the survey data with different objectives. The first, titled Why Don't More Small Businesses Offer Health Insurance? Summary Report on the 2000 California HealthCare Foundation/Mercer Survey, provides a brief overview addressing the title question. The second, titled Why Don't More Small Businesses Offer Health Insurance? Detailed Findings from the 2000 California HealthCare Foundation/Mercer Survey, provides much more information about the data while examining this question. Both of these reports are available on the California HealthCare Foundation s Web site at The survey data are publicly available through the Inter-university Consortium for Political and Social Research (ICPSR). To access the data, expected to be available after May 1, 2002, visit and then search for study number The 2000 California HealthCare Foundation/Mercer Survey 4

8 II. California Health Plan Sponsors with 2 to 50 Employees Prevalence of Health Coverage among Small Employers in California Employers were asked if they made health coverage available to at least some full-time employees. Overall, 69 percent of California employers with 2 to 50 employees provide some form of health coverage. Incidence of health coverage increases with employer size, from 64 percent of employers with 2 to 9 employees, to 82 percent of those with 10 to 24 employees, to 89 percent of those with 25 to 50 employees. Figure 1. Offer Health Benefits in 2000, by Employer Size Percent of employers 89% 82% 69% 64% Number of employees Incidence rates are very sensitive to sample design, survey methodology and question wording. However, a 2001 study conducted by the Kaiser Family Foundation and Health Research and Educational Trust produced fairly similar incidence rates for the nation as a whole: 58 percent The 2000 California HealthCare Foundation/Mercer Survey 5

9 for employers with 3 to 9 workers, 76 percent for employers with 10 to 24 workers, and 90 percent for employers with 25 to 50 workers. Characteristics of Sponsors and Their Workforces Industry Group One-third of small California health plan sponsors are in service industries, with an additional 10 percent in health care and 8 percent in financial services. Wholesale/retail trade and manufacturing employers are nearly equally represented, at 18 and 17 percent respectively. Note that these data do not show the prevalence of health coverage within an industry. Figure 2. Industry Breakdown of Sponsors Health care 10% Financial services 8% Transp/ communic/ utility 4% Other 10% Wholesale/ retail trade 18% Services 33% Manufacturing 17% The 2000 California HealthCare Foundation/Mercer Survey 6

10 Staff Size Among California employers with 2 to 50 employees, plan sponsors employ, on average, 11.3 employees 9.4 full-time employees and 2.0 part-time employees. Part-timers account for 17 percent of sponsors total employees. About two-fifths also employ temporary or seasonal workers. On average, 6 percent of total wage costs go to temporary/seasonal workers. Employee Demographics On average, 62 percent of sponsors employees are white; 56 percent are male. Sixteen percent of sponsor firms are minority-owned. Sponsors report that 16 percent of their employees are under age 25, 75 percent are 25 to 54, and 9 percent are 55 or older. Sponsors report that 22 percent of their employees, on average, earn annual salaries of $50,000 or more, while only 13 percent earn $20,000 or less. Table 1. Employee Demographics Average % of Employees Age Employees under age 25 16% Employees age % Employees age 55 and older 9% Ethnicity White 62% Hispanic 23% Gender Female 44% Male 56% Salary $20,000 or less 13% $20,001 $49,999 60% $50,000 or more 22% Don t know 5% The 2000 California HealthCare Foundation/Mercer Survey 7

11 Benefit Eligibility and Program Management Employee Eligibility and Take-up of Health Coverage Among health plan sponsors, on average 82 percent of all employees are eligible for coverage in their employer s plan. Of those, 83 percent are enrolled in the plan. About half of the enrolled employees (52 percent) elect dependent coverage. Figure 3 shows the average percentages of an employer s total workforce that is eligible for coverage, enrolled, and elects dependent coverage. Figure 3. Employee Take-up of Health Plan Coverage Eligible, not enrolled 15% Not eligible 18% Enrolled without dependent coverage 40% Enrolled, with dependent coverage 27% Although half of plan sponsors currently have one or more part-time employees, only 16 percent say part-timers are eligible for coverage (most often, if they work a specified number of hours per week). Same-sex domestic partners are eligible for coverage in 15 percent of sponsors' plans. Only 4 percent of small California health plan sponsors extend coverage to any retirees. Method of Obtaining Coverage Over two-thirds of sponsors (68 percent) seek help from an insurance agent or outside consultant when they evaluate health plans for their employees. Nearly a fourth (23 percent) say they used the Internet to gather information about health insurance for their workers in the past two years (11 percent don t have access to the Internet). Most often, these employers visit a health plan or insurance company Internet site. The 2000 California HealthCare Foundation/Mercer Survey 8

12 Another way small employers can access the health plan market is through a purchasing alliance, an organization that negotiates contracts with many different health plans on behalf of small employers. Employers who use a purchasing alliance can offer employees a choice of plans. Eight percent of sponsors use a purchasing alliance, most often PacAdvantage or California Choice, and another 5 percent are considering one. Over half of sponsors (55 percent) say they have never heard of purchasing alliances. Only a handful of sponsors 2 percent say they ever applied for coverage and were turned down. Length of Time Coverage Has Been Offered Among all small California health plan sponsors, the average length of time that coverage has been offered is about nine years; however, a third have offered a health plan for three years or less. When we examine this group of sponsors, we see that only a third of these have been in business for three years or less in other words, began offering coverage at the time they started the new business. In fact, half have been in business for seven years or more which means they waited four years or more before offering health coverage. Figure 4. Number of Years Offering a Health Plan Percent of sponsors with 2-50 employees 33% 16% 8% 10% 8% 11% 15% 3 years or fewer 4-6 years 7-9 years years years 20 or more years Don't know The 2000 California HealthCare Foundation/Mercer Survey 9

13 Description of Health Coverage Offered Type of Plan Offered HMOs are the most common type of plan offered by small California health plan sponsors (60 percent). PPOs are offered by 44 percent. Only 11 percent offer a POS plan, and traditional indemnity plans, offered by just 4 percent, are all but extinct. Figure 5. Type of Plan Offered yp p Percent of sponsors with 2-50 employees 60% 44% 11% 4% HMO PPO Point-ofservice Indemnity Only 16 percent of employers provide employees at their largest single worksite with a choice of plan types: 43 percent offer only an HMO, 27 percent offer only a PPO, 8 percent offer only a POS plan, and 3 percent offer only a traditional indemnity plan. Figure 6. Plan Types Offered at Largest Worksite 43% 27% 8% 3% 13% 3% 3% HMO only PPO only Point-ofservice plan only Traditional indem nity plan only HMO and PPO Other mix of plan types Don't know The 2000 California HealthCare Foundation/Mercer Survey 10

14 Enrollment The majority of employees working for small California employers (54 percent) are enrolled in HMOs. PPOs enroll 35 percent, followed by POS plans (9 percent). Only 2 percent of employees remain in traditional indemnity plans. HMO enrollment is significantly higher among Los Angeles employees than among those in the rest of the state 62 percent compared to 48 percent. Conversely, PPO enrollment is lower in Los Angeles (28 percent) than elsewhere in the state (41 percent). Figure 7. Employee Enrollment p y Percent of covered employees enrolled Point-ofservice 9% Indemnity 2% PPO 35% HMO 54% Medical Plan Cost by Type of Plan In examining the medical plan component of total health plan cost, dental cost is not included, even if dental coverage was provided through a medical plan. Cost for any freestanding vision benefit is also excluded. Cost is calculated on a per-employee basis and includes cost for enrolled employees and any covered dependents (divided by the number of enrolled employees). Any employee premium contributions are included in the cost. Employee out-of-pocket costs, such as deductibles and copays, are not included. Although the majority of survey respondents provided costs for both 1999 and 2000, some provided costs for only one year. Average costs for 2000 include all respondents providing costs for However, to calculate an average cost increase from 1999 to 2000, only respondents providing costs for both years were included. The 2000 California HealthCare Foundation/Mercer Survey 11

15 HMO coverage was the least costly in 2000, averaging $2,618 per employee. Among those respondents who provided costs for both 1999 and 2000, cost rose an average of 4.5 percent. PPO plan cost averaged $2,906, rising 10.0 percent among respondents providing cost for both years. POS plan coverage was the most expensive of the three plan types, at $3,143 per employee, up 4.4 percent. Too few employers offer traditional indemnity plans to provide reliable cost data. Figure 8. Medical, Dental, and Total Health Benefit Cost per Employee, 2000 $2,618 $2,906 $3,143 $3,494 $2,918 $531 HMO PPO Point-ofsevice Medical plan cost Traditional Indemnity Dental cost Total health benefit cost Total Health Benefit Cost Total health benefit cost includes the cost of all medical plans and, when offered, dental and vision plans, for employees and covered dependents. In 2000, 35 percent of sponsors offered comprehensive dental coverage to employees and an additional 11 percent covered preventive dental care only. Vision benefits were offered by 23 percent. (While cost for vision benefits is included in the total health benefit cost, respondents were not asked to break out cost for these benefits on a per-employee basis.) In 2000, total health benefit cost averaged $2,918 per employee. Among the 429 respondents who provided costs for both years, cost increased an average of 5.8 percent from 1999 to There was a difference of more than $200 in the average total cost per employee between Los Angeles employers ($2,803) and those in the rest of the state ($3,029). Los Angeles employers report slightly lower average costs for both HMOs and PPOs than do employers in the rest of the state. In addition, enrollment in HMOs is higher in Los Angeles than the rest of the state, contributing to lower total health benefit cost. The 2000 California HealthCare Foundation/Mercer Survey 12

16 Figure 9. Average Total Health Benefit Cost per Employee + 5.8% $2, % $2, % $3,029 All small California employers Los Angeles Rest of state When asked to predict their total health benefit cost for 2001, 60 percent of sponsors thought cost would increase, by an average of 10.8 percent. Only 2 percent predicted a decrease, and 35 percent thought cost would stay about the same; 3 percent couldn t say. Despite this, few sponsors say they will reduce benefits over the next two years ( ). Only 3 percent say they are very likely to do so, and an additional 10 percent say they are somewhat likely to do so. Nor are many sponsors planning to raise employee contributions only 6 percent say it is very likely they will raise contributions over the next two years, and another 15 percent say it is somewhat likely. Employee Contributions Health plans often require a minimum level of employee participation (generally 75 percent of eligible employees) from plan sponsors with fewer than 50 employees before they will write coverage. Because of this, small employers are more likely than larger employers (those with more than 50 employees) to provide coverage without requiring an employee contribution. Twothirds of sponsors (67 percent) pay the full cost of employee-only coverage. A handful (1 percent) requires the employee to pay the full cost. The rest share the cost with employees, most often by establishing fixed percentages for employer and employee to pay (27 percent), although some (4 percent) set a defined dollar amount for either the employee or employer. Only 25 percent of sponsors require no employee contribution for dependent coverage, while 35 percent require the employee to pay the full cost. About one-fifth (22 percent) of employers share cost with employees using fixed percentages; 6 percent set a defined dollar contribution for either the employer or employee. The 2000 California HealthCare Foundation/Mercer Survey 13

17 Table 2. Employee Contribution Strategies among Sponsors with 2 to 50 Employees Employee-only Family Strategy Coverage Coverage No employee contribution required 67% 25% Employer and employee each pays a fixed percentage Employer/employee pays defined dollar amount 27% 22% 4% 6% Employee pays full cost of coverage 1% 35% Other 1% 3% Don t know 1% 8% How does this translate into cost for the employee? Looking at each employer s primary medical plan, among just those plans that require an employee contribution (including those in which the employee pays the full cost of coverage), the average monthly contribution is $77 for employeeonly coverage and $205 for family coverage (the cost for the employee, spouse, and two children). Table 3. Employee Contributions in Primary Plan Employee only Among those requiring a contribution, average amount: As a percent of premium 41% Per month, in dollars $77 Dependent coverage Among those requiring a contribution, average amount: As a percent of premium 79% Per month, in dollars $205 Making premium contributions with pre-tax dollars Section 125 plans (also known as premium-only, premium conversion, or cafeteria plans) allow employees to pay their health insurance premiums with pre-tax dollars. Given that the only real downside to offering a Section 125 plan is an annual filing of IRS form 5500, it is surprising that only 15 percent of sponsors currently have that arrangement in place. In fact, only 57 percent of sponsors say they have even heard of Section 125 plans. The 2000 California HealthCare Foundation/Mercer Survey 14

18 III. Health Plan Sponsors with 10 to 50 Employees in California and Nationwide: Trends and Comparisons This section compares results from the 2000 survey with results from a 1998 survey of small California health plan sponsors to see how health plan offerings, enrollment, cost, and employee contributions have changed over the two-year time period. In addition, the 2000 results for California are compared with national results from Mercer s National Survey of Employersponsored Health Plans for Neither Mercer s national survey nor the 1998 California survey (which was conducted as part of the Mercer survey that year) includes sponsors with fewer than 10 employees. Accordingly, in this section, for comparative purposes, we will use a subset of sponsors with 10 to 50 employees from the 2000 California survey. The 2000 California HealthCare Foundation/Mercer Survey 15

19 Type of Plan Offered California In 2000, HMO coverage was provided by 70 percent of California health plan sponsors with 10 to 50 employees, up from 65 percent in The percentage of sponsors offering PPO coverage rose from 39 percent to 44 percent, while those offering POS plans dropped from 20 to 12 percent. The use of traditional indemnity plans was unchanged, with 4 percent of sponsors offering one in National Nationally, only 38 percent of small employers offering health insurance offered an HMO in 2000 not much more than half the percentage that did so in California. However, there was little difference in the prevalence of the other two managed care plan types. Nationally, PPOs are offered by 43 percent of sponsors and POS plans by 19 percent. However, traditional indemnity plans, nearly extinct in California, are still offered by 13 percent of small employers that offer health insurance nationwide. Employers in California are considerably more likely to offer employees at their largest worksite a choice of plan types (26 percent) than are employers nationwide (16 percent). Table 4. Type of Plan Offered Percent of Sponsors with 10 to 50 Employees California National Plan HMO 65% 70% 30% 38% PPO 39% 44% 45% 43% Point-of-service plan 20% 12% 22% 19% Traditional indemnity plan 4% 4% 18% 13% Offer choice of plan types at largest work site 26% 26% 16% 16% The 2000 California HealthCare Foundation/Mercer Survey 16

20 Employee Enrollment California From 1998 to 2000, employee enrollment in California remained relatively stable. HMO enrollment was unchanged, at 61 percent in both years. PPO enrollment rose from 24 to 29 percent, while POS plan enrollment fell from 13 to 8 percent. Traditional indemnity plan enrollment remained at a low 2 percent in National Enrollment patterns in California are very different from the country as a whole. The major difference is the greater use of HMOs in California. Nationally, PPOs lead the small employer health plan market, enrolling 42 percent of all covered employees, followed by HMOs, with 37 percent, and POS plans, with 14 percent. Traditional indemnity plans still enroll 8 percent of all covered employees in this employer size group. Table 5. Employee Enrollment: Percent of Covered Employees among Employers with 10 to 50 Employees California National Plan HMO 61% 61% 26% 37% PPO 24% 29% 41% 42% Point-of-service plan 13% 8% 18% 14% Traditional indemnity plan 2% 2% 14% 8% Figure 11. Employee Enrollment p y Percent of covered employees, among sponsors with employees POS 8% Indemnity 2% POS 14% Indemnity 8% PPO 29% HMO 37% HMO 61% PPO 41% California National The 2000 California HealthCare Foundation/Mercer Survey 17

21 Plan Cost While average cost is lower in California for each type of medical plan, the biggest difference is in HMO cost. In California, average HMO cost is $2,648; for employers of this size in the country as a whole, it is $3,378, a difference of about $700. Table 6. Average Medical Plan Cost per Employee for 2000 Cost per Employee among Employers with 10 to 50 Employees Plan California National HMO $2,648 $3,378 PPO $3,230 $3,817 POS $3,362 $3,672 PPO coverage is also far less expensive in California than in the country as a whole $3,230 compared to $3,817. POS plan cost averages $3,672 nationally and $3,362 in California. Comprehensive dental coverage is provided by 47 percent of California sponsors, at an average cost of $524 per employee. Nationwide, 45 percent of small sponsors offer dental coverage. Total health benefit cost includes cost for all medical plans and any dental or vision benefits that are offered. Among employers with 10 to 49 employees, total health benefit cost was far lower in California in 2000 than in the country as a whole $3,021 per employee compared to $3,931. This is largely due to the greater use of HMOs by California employers and the lower cost of California HMOs. Figure 12. Total Health Plan Cost per Employee for 2000 Sponsors with employees $3,931 $3,021 California National The 2000 California HealthCare Foundation/Mercer Survey 18

22 Employee Contributions To compare employee contributions nationwide and in California, we will look at the two dominant plan types, HMOs and PPOs. National Nationwide, HMO sponsors are more likely to require a contribution for employee-only HMO coverage (47 percent) than sponsors in California (34 percent). The average contribution amounts are also higher in the country as a whole than in California, at $73 per month for employee-only coverage and $246 per month for family coverage. Employees enrolled in PPOs in California also enjoy lighter contribution requirements than employees elsewhere in the country. Nationwide, 40 percent of PPO sponsors with 10 to 49 employees require a contribution for employee-only coverage, while only 29 percent of those in California do so. Average contribution amounts are $78 per month for employee-only coverage and $253 for family coverage, compared to $74 and $223, respectively, in California. Table 7. Contribution Requirements: Sponsors with 10 to 50 Employees California National Employee-only coverage Require contribution: HMO (% of employers) 34% 47% PPO (% of employers) 29% 40% POS (% of employers) 38% 53% Average contribution: HMO ($/month) $63 $73 PPO ($/month) $74 $78 POS ($/month) $68 $71 Family coverage Require contribution: HMO (% of employers) 64% 76% PPO (% of employers) 67% 79% POS (% of employers) 68% 82% Average contribution: HMO ($/month) $226 $246 PPO ($/month) $223 $253 POS ($/month) $274 $249 The 2000 California HealthCare Foundation/Mercer Survey 19

23 Appendix A: Data Tables Table A1. Characteristics of Sponsors and Their Employees By Region 2 50 Employees (n=924) Los Angeles CMSA (n=378) Rest of California (n=546) Primary type of business Manufacturing 17% 17% 17% Wholesale/Retail trade 18% 18% 19% Services 33% 33% 32% Transportation/Communication/Utilities 4% 5% 2% Health Care 10% 11% 10% Financial Services 8% 8% 7% Other 10% 9% 12% Average number of employees Full-time Part-time Total Percentage of employees who are part-time None 49% 52% 46% Average (including 0) 17% 16% 18% Average (excluding 0) 34% 33% 34% Age: percentage of total employees who are: Under age 25 16% 16% 16% % 76% 74% 55 or over 9% 8% 9% Gender: percentage of total employees who are female Mean 44% 44% 45% Race: percentage of total employees who are white Don t know 3% 3% 4% Mean 62% 56% 69%* * Statistically significant at.05 level. The 2000 California HealthCare Foundation/Mercer Survey 20

24 Table A2. Benefit Eligibility and Program Management By Region 2 50 Employees (n=924) Los Angeles CMSA (n=378) Rest of California (n=546) Do you make health coverage available to some or all part-time employees? Yes, work a certain number of hours per week 11% 9% 13% Yes, meet some criteria 5% 4% 7% No 35% 35% 34% No part-time employees 49% 52% 46% Do eligible dependents include domestic partners? Yes, same sex partners (Net) 15% 11% 19%* -Yes, same-sex partners only 2% 2% 2% -Yes, both same-sex and opposite-sex partners 13% 9% 17%* Yes, opposite-sex partners only 18% 23%* 14% No, but considering including domestic partners 2% 2% 3% No 46% 46% 47% Don t know 18% 18% 18% Do you offer health coverage to any retirees (aside from COBRA requirements)? Yes 4% 2% 5% No 93% 95% 92% Don t know 3% 4% 3% How long ago did your organization begin offering health insurance? 1 year or less 17% 19% 15% 2 3 years 16% 14% 18% 4 6 years 16% 17% 16% 7 9 years 8% 8% 7% years 17% 16% 19% years 8% 7% 9% 30 or more years 3% 3% 4% Don t know 15% 16% 13% Average number of years Does your firm have access to the Internet? Yes, have access 89% 88% 89% -Used it to get information 23% 21% 24% -Haven t used it to get info. 65% 67% 64% -Don t know if used 1% 0% 1% No, don t have access 11% 12% 11% * Statistically significant at.05 level. The 2000 California HealthCare Foundation/Mercer Survey 21

25 Table A2. Benefit Eligibility and Program Management (continued) 2 50 Employees (n=924) Los Angeles CMSA (n=378) By Region Rest of California (n=546) In evaluating health plans for your employees, do you do that internally or do you seek help from an insurance agent or outside consultant? Internal only 30% 30% 30% External only 60% 59% 61% Both 8% 9% 7% Internally/Both 37% 39% 36% Externally/Both 68% 68% 67% Don t know 3% 3% 3% Have you ever seen, heard, or read anything about purchasing alliances? Yes, have heard of purchasing alliances (Net) 44% 42% 46% -Currently use purchasing alliance 8% 7% 10% -Considering using 5% 3% 7% -Not using and not considering 30% 32% 29% No, have not heard of purchasing alliances 55% 58% 53% Don t know 1% 1% 1% The 2000 California HealthCare Foundation/Mercer Survey 22

26 Table A3. Description of Health Coverage Offered By Region 2 50 Employees (n=924) Los Angeles CMSA (n=378) Rest of California (n=546) Which of the following types of health plans do you offer? Health Maintenance Organization 60% 64% 55% Preferred Provider Plan 44% 40% 49% Point-of-Service Plan 11% 12% 10% Traditional Indemnity Plan 4% 4% 5% Percentage of active employees enrolled in each plan type: Health Maintenance Organization 54% 62% 48% Preferred Provider Plan 35% 28% 41% Point-of-Service Plan 9% 10% 9% Traditional Indemnity Plan 2% 1% 3% Choice of plans offered at single largest worksite: HMO only 43% 47% 40% PPO only 27% 23% 32% POS only 8% 9% 6% TIP only 3% 2% 3% More than one Managed Care Plan (No TIP) 15% 15% 14% TIP and Managed Care Plan 2% 2% 1% Don t know 3% 3% 3% 2000 average costs per employee: Health Maintenance Organization $2,618 $2,529 $2,724 Preferred Provider Plan $2,906 $2,835 $2,949 Point-of-Service Plan $3,143 $3,298 $2,946 Traditional Indemnity Plan $3,494 ID ID Freestanding dental $531 $438 $ total health benefit cost $2,918 $2,803 $3,029 How do you set employee contributions to your plan(s) for employee-only coverage? The employer pays the full cost of coverage 67% 67% 66% The employee pays the full cost 1% 2% 1% The employer and employee each pay a fixed percentage of the cost 27% 26% 27% The employer/employee pays a defined dollar amount 4% 4% 5% Some other way 1% 0% 1% Don t know 1% 0% 1% How do you set employee contributions to your plans for family coverage? The employer pays the full cost of coverage 25% 27% 24% The employee pays the full cost 35% 38% 32% The employer and employee each pay a fixed percentage of the cost 22% 19% 25% The employer/employee pays a defined dollar amount 6% 7% 7% Some other way 3% 1% 5% Don t know 7% 7% 7% Refused 1% 1% 1% ID = Insufficient data. The 2000 California HealthCare Foundation/Mercer Survey 23

27 Table A3. Description of Health Coverage Offered (continued) By Region 2 50 Employees (n=924) Los Angeles CMSA (n=378) Rest of California (n=546) Employee Contributions for Employee-only Coverage: -Health Maintenance Organization (HMO) Percentage of employers requiring a contribution 29% 29% 29% Average contribution as a percent of premium 45% 45% 44% Average monthly contribution amount $79 $69 $89 Number of respondents (this question only) Point-of-Service (POS) Percentage of employers requiring a contribution 21% 16% 27% Average contribution as a percent of premium 36% 46% 28% Average monthly contribution amount $60 $82 $47 Number of respondents (this question only) Preferred Provider Plan (PPO) Percentage of employers requiring a contribution 24% 25% 23% Average contribution as a percent of premium 37% 38% 36% Average monthly contribution amount $89 $94 $83 Number of respondents (this question only) Employee Contributions for Family Coverage: -Health Maintenance Organization (HMO) Percentage of employers requiring a contribution 53% 53% 53% Average contribution as a percent of premium 80% 83% 77% Average monthly contribution amount $213 $246* $168 Number of respondents (this question only) Point-of-Service (POS) Percentage of employers requiring a contribution 62% 64% 59% Average contribution as a percent of premium 70% 70% 69% Average monthly contribution amount $225 $253 $182 Number of respondents (this question only) Preferred Provider Plan (PPO) Percentage of employers requiring a contribution 54% 52% 56% Average contribution as a percent of premium 76% 78% 75% Average monthly contribution amount $227 $280 $183 Number of respondents (this question only) Do you offer dental coverage to any employees? Yes 47% 44% 49% No 50% 52% 48% Don t know 3% 3% 3% Do you offer vision coverage (beyond annual exams)? Yes 23% 21% 26% No 75% 77% 74% Don t know 1% 3% 0% * Statistically significant at.05 level. The 2000 California HealthCare Foundation/Mercer Survey 24

28 Table A4. Health Benefits among Sponsors with 10 to 50 Employees 2000 National 2000 California 1998 California Type of plan offered HMO 38% 70% 65% PPO 43% 44% 39% POS 19% 12% 20% TIP 13% 4% 3% Number of respondents Employee enrollment HMO 37% 61% 61% PPO 41% 29% 24% POS 14% 8% 13% TIP 8% 2% 2% Number of respondents Average total health plan cost per employee, for active employees (includes dental) Total health plan cost $3,931 $3,021 $2,865 Number of respondents Average medical plan cost per employee, for active employees HMO $3,378 $2,648 $2,283 Number of respondents POS plan $3,672 $3,362 $2,663 Number of respondents PPO plan $3,817 $3,230 $3,225 Number of respondents Average 2000 dental cost per employee Dental $454 $524 $509 Number of respondents Employee contributions for employee-only coverage -Health Maintenance Organization (HMO) Percentage of employers requiring a contribution 47% 34% 41% Average contribution as a percent of premium 34% 40% 36% Average monthly contribution amount $73 $63 $52 Number of respondents Point-of-Service (POS) Percentage of employers requiring a contribution 53% 38% 35% Average contribution as a percent of premium 37% 33% 39% Average monthly contribution amount $71 $68 $51 Number of respondents The 2000 California HealthCare Foundation/Mercer Survey 25

29 Table A4. Health Benefits among Sponsors with 10 to 50 Employees (continued) -Preferred Provider Plan (PPO) Percentage of employers requiring a contribution Average contribution as a percent of 2000 National 2000 California 1998 California 40% 29% 31% 37% 34% 26% premium Average monthly contribution amount $78 $74 $47 Number of respondents Employee contributions for family coverage -Health Maintenance Organization (HMO) Percentage of employers requiring a contribution 76% 64% 78% Average contribution as a percent of premium 58% 81% 70% Average monthly contribution amount $246 $226 $175 Number of respondents Point-of-Service (POS) Percentage of employers requiring a contribution 82% 68% 70% Average contribution as a percent of premium 63% 78% 68% Average monthly contribution amount $249 $274 $153 Number of respondents Preferred Provider Plan (PPO) Percentage of employers requiring a contribution 79% 67% 64% Average contribution as a percent of premium 64% 78% 64% Average monthly contribution amount $253 $223 $161 Number of respondents The 2000 California HealthCare Foundation/Mercer Survey 26

30 Appendix B: Methodology Overview of the Research Design The study design called for equal numbers of sponsors and non-sponsors to be interviewed in size groups of 3 to 9 employees, 10 to 24 employees, and 25 to 49 employees. The study was conducted by phone, using computer-assisted telephone interviewing (CATI), with provisions for interviewing in English and Spanish. A sample of California employers in three size strata was drawn from the Dun & Bradstreet (D&B) database of private employers. Contacts were screened for benefits status, and a total of 11,792 employers provided this information. Based on the screening question, either the sponsor or the non-sponsor survey instrument was administered until the quotas were reached. The two questionnaires were kept as much the same as possible to permit direct comparisons of sponsors and non-sponsors. Overall, 1,828 interviews were completed (924 sponsors and 904 nonsponsors). The biggest difference between the two questionnaires was a set of questions for plan sponsors on the specifics of their health plan offerings. These questions mirrored questions asked in a California HealthCare Foundation study conducted in 1998, again with the help of William. M. Mercer, Incorporated. Mercer has conducted a major annual study of employer health plan sponsors since In 1998, at the request of the California HealthCare Foundation, Mercer oversampled California employers with 10 to 49 employees. In that year, California sponsors were interviewed with the same survey instrument used in the larger study and asked a few supplemental questions. Questionnaire Development Questions for plan sponsors regarding their current health plan offerings were taken from the Mercer/Foster Higgins National Survey of Employer-sponsored Health Plans to permit comparisons with results from CHCF s 1998 employer study and with national results from the 2000 Mercer study. Most of the questions asked of both sponsors and non-sponsors were developed in consultation with a broad panel of experts on health insurance and health policy research in California. The questionnaire was pre-tested among a small sample of employers and revised accordingly. The questionnaire was then translated into Spanish. Sampling Method To judge how large a sample would be needed to meet the study s quotas of 300 sponsor interviews and 300 non-sponsor interviews in each of three size categories (a total of 1800 interviews), Mercer s data vendor, ICR Survey Research, conducted telephone screening of a sample of California employers to determine approximate health plan offer rates by employer size. The pre-test confirmed that offer rates increase significantly with number of employees. A sample was drawn from the D&B database of private employers, stratified by size. To further The 2000 California HealthCare Foundation/Mercer Survey 27

31 ensure that the surveyed group would be representative of all small California employers, the sample was also stratified by single-site or multiple-site employers, and by employer location (Los Angeles versus the rest of California). As this was an enterprise rather than establishment study, in all cases only the ultimate parent company was included. Interviewing Procedures In drawing the sample from the D&B database, we requested the contact name associated with a number of specific human resources job titles. If no such contact was listed in the D&B database, we requested the name of the owner or CEO. At the time of the phone call, interviewers asked first to speak with the contact person listed in the sample. If that person was unavailable, or if no contact name had been provided at all, interviewers asked to speak (in the following order) with the Human Resources Director, Owner, General Manager, or the person responsible for making the decision about offering or not offering benefits in the office. If one of these persons was available, the interviewer would proceed with the screener question (to determine benefits status). If not, the call would be terminated before asking the screener question and the same process would be followed during the next attempt. Once the screener question was asked of the most appropriate person, the interviewer would request a full interview. If the interview could not be completed at the time, the correct contact name would be recorded and upon call-back this person would be asked for by name. A maximum of 8 attempts were made to reach the appropriate person and complete an interview. In contacting businesses, whenever a Spanish language problem was detected, the interviewer attempted to determine if the respondent preferred to be interviewed in English or Spanish. If Spanish was preferred, interviewers fluent in Spanish called back to interview the person in Spanish. Of the 1,828 interviews conducted, only 8 were conducted in Spanish. Although the sample was drawn for employers with 3 to 49 employees, employers with either 2 or 50 employees in other words, one less or one more employee than the targeted size were deemed eligible. The following table shows the disposition of the sample for the fully worked replicates of the sample (meaning 8 attempts at contact were made). To achieve the last 85 interviews required for our quotas, an additional replicate was used during the last week of interviews and was only partially worked. The 2000 California HealthCare Foundation/Mercer Survey 28

32 Table B1. Sample Disposition (through 12/14/00) Total Total listings dialed one or more times Ineligible listings Non-working numbers Not a business Wrong business Out of business Data/Fax line No employees Does not meet employee size definition Benefits through state/union Benefits through parent Duplicate #/Already completed Other Ineligible Eligible No contact made No answer/answering machine/busy Answering service Language Barrier (non-spanish) Other (unspecified) Contact Made Refused (unable to ask/answer screener) Unable to talk to appropriate person Appropriate person not available for duration of study Contact person no longer with company Call Limit Reached Reached and Screened Offer Benefits Refused interview Unable to complete interview after repeated attempts Call limit reached (8 attempts with no answer) Terminated immediately after start Terminated quota filled Completed interview Break offs (partial complete) Do Not Offer Benefits Refused interview Unable to complete interview after repeated attempts Call limit reached (8 attempts with no answer) Terminated immediately after start Terminated quota filled Completed interview Break offs (partial complete) The 2000 California HealthCare Foundation/Mercer Survey 29

33 Interviewing Period Interviewing was conducted over a 9-week period starting on October 18, 2000 and ending on December 22, All interviewing (except for scheduled call-backs) was conducted between the hours of 8:30 a.m. and 5:00 p.m. P.S.T. weekdays. Sample Weighting Unbiased survey estimates require the use of sampling weights that are based on the original selection probabilities of the units in the sample. The base sampling weight is the inverse of the selection probability. In this survey, the selection probability of a unit is the ratio of the number of units selected in a sampling stratum (the sampling nominal sample size) to the number of units in the full sampling stratum. That is, if in a specific sampling stratum, 1,000 D&B records are selected randomly and with equal probability from a sampling frame of 1,000,000 D&B records of that sampling stratum, then the selection probability is 1/1,000 and the base sampling weight is 1,000. This base sampling weight is the same for all employers in the sample for that sampling stratum, including eligible responding employers (both sponsors and non-sponsors), ineligible employers (such as employers that obtain benefits from other sources or out-of-business employers), and employers that refuse to respond. Because sponsors and non-sponsors did not have equal probability of selection, additional weights were required. The table below shows the weights applied to each stratum. Note that the majority of employers in each stratum offer benefits. Because the survey design called for equal numbers of interviews with sponsors and non-sponsors, the sample in most strata had to be several times larger than it would have been if there had been an equal probability of selecting a non-sponsor as a sponsor. The weight for the sponsors is higher than for non-sponsors because the sponsors were sub-sampled. Statistical Testing The 2000 data were tested for statistically significant differences using the Neuman-Kuels t-test. This is a more conservative version of the standard t-test; in other words, it is less likely to mark cells as significantly different from the standard t-test when they are not different. The data were tested using a 95 percent confidence level. Results were tested for employer size categories, benefit status (sponsors and non-sponsors), geographic region (Los Angeles and the rest of California), and likelihood of offering benefits (likely and not likely). The 2000 California HealthCare Foundation/Mercer Survey 30

34 Table B2. Prevalence (Offering Benefits) and Weights % Offering Benefits Weight Benefits Weight No Benefits Los Angeles CMSA Universe Single sites 3 9 employees % % % Ultimates (parent company when enterprise had multiple establishments) Single sites % * 3 9 employees % % *No respondents in 3 9 category category weighted to represent both groups. % Offering Benefits Weight Benefits Weight No Benefits Rest of California Universe Single sites 3 9 employees % % % Ultimates (parent company when enterprise had multiple establishments) Single sites % employees % % Notes While other research suggests that the prevalence of California employers offering health coverage has risen in recent years, because of changes in survey methodology and question wording we cannot compare the incidence results from our 1998 and 2000 surveys. In Mercer s national survey, and in the California supplement to the national survey in 1998, the smallest employer size group was 10 to 49 employees (employers with 50 employees were placed in the next size group). However, the California survey for 2000 was conducted on a stand-alone basis, and included smaller employers. While the sample was drawn for employers with 3 to 49 employees, employers with 2 or 50 employees were accepted. For convenience, when comparing the results across the three studies, we will refer to the size stratum as 10 to 50 employees. In addition, for comparative purposes, in computing 2000 results for employers with 10 to 50 employees, all respondents who were sampled in the 10 to 49 size stratum were included, even if they reported a lower number of employees during the interview. Likewise, respondents who were sampled in the 3 to 9 size stratum but reported a greater number of employees were excluded. The 2000 California HealthCare Foundation/Mercer Survey 31

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