Summary Report ACA Small Employer Survey

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1 Summary Report ACA Small Employer Survey Leslie A. Muller, Ph.D. Grand Valley State University 1/20/2015 I would like to thank Priority Health for their funding and collaboration on this survey. I would also like to thank Kathleen Pedres for excellent research assistance.

2 SUMMARY OF RESULTS FOR SMALL FIRMS IN WEST AND SOUTHWEST MICHIGAN OVERALL 1. Only a quarter of small firms that offered health insurance in 2013 and 2014 plan on continuing to offer plans in 2015 and Of those offering plans in 2014, 75% plan on offering insurance in Half of these firms plan on offering plans in Sixteen percent of firms are uncertain as to whether they will offer insurance in 2015; 28% are unsure about Of those companies not offering plans in 2015, 68% plan on sending employees out to the public exchange to buy individual health insurance. CHANGES TO HEALTH PLANS 1. 87% of firms have already or are increasing the cost share of insurance costs borne by the worker % have or are shifting costs by using a high deductible health plan (HDHP) % have or are shifting costs by changing prescription drug coverage. CHANGES TO HIRING 1. 46% have or are limiting or reducing new hiring 2. 28% have or are reducing their overall workforce.

3 Motivation: In 2013, GVSU asked West Michigan firms how the Affordable Care Act (ACA) was affecting their health insurance plans and labor market choices. 1 The results indicated that, for the most part, larger firms with more than 100 full- time workers were planning to continue offering their insurance plans, but planned to decrease costs by using high- deductible health plans and changing prescription coverage. Smaller firms, however, were more likely to stop offering insurance altogether and were more uncertain about whether they would offer insurance plans in the future. The population from which we drew our sample last year was predominantly medium to large firms with 50 or more employees, however, one- quarter of our responses were from firms with fewer than 50 full- time employees. Because many of the changes resulting from the ACA were occurring within firms with less than 100 full- time employees, and because new purchasing options became available in 2014 with the introduction of the Small Business Health Options Program (SHOP), the research this year focuses on firms with 5-49 full- time employees. Survey This year's survey includes many of the same questions as 2013, including firm size, average employee skill level, and industry. Because firms usually do not offer insurance to part- time employees, we added questions on the percentage of part- time employees and percentage of minimum wage workers in the firm. We also inquired about past, current, and future insurance offerings from We added a question this year on if/how employers will compensate employees if they do not offer insurance. Similar to last year, we inquired about cost- containment and labor market changes the firms made directly because of the ACA. Sample The sample was chosen randomly in November 2014 from the database Demographics Now, with a filter to include companies with 5 or more employees. Counties surveyed in West Michigan include Kent, Ottawa, Muskegon and Allegan (KOMA). Berrien, Eaton, and Kalamazoo represent Southwest Michigan. Eighty firms responded to the survey. 70 of them were small firms with fewer than 50 full- time employees. Given the extremely high percentage of small firms in the population, we were not surprised by the percentage of the small business returns. Summary statistics are provided for firm characteristics in the Appendix. Table A2 reports the breakdown of small firms by industry. As compared to last year, manufacturing and construction firms still have the highest percentages, followed by retail. Last year there were very few retail firms, but given that they are typically smaller in size, there are more this year (7% last year vs. 16% this year). Retail also typically has more part- time employees with shorter tenure, so we would expect a lower rate of insurance offerings in general. However, because of the small sample size by industry, no statistical differences on changes within these industries can be assessed. Survey Results Health Insurance Offerings Figure 1 shows health insurance coverage in 2013 and Sixty- one percent of firms offered insurance in 2013, while 55% provided it in Looking to the future, 4 said they will offer employee benefits 1 See Muller, Isely and Levin (2015), Benefits Quarterly, forthcoming. Note that last year's report did not break down some of the results by firm size. Hence, some of the numbers from last year's survey cited here were calculated separately by the author, and cannot be found in the forthcoming article.

4 in 2015, with 16% undecided (Figure 2). The outlook is bleaker in 2016, with only 28% of firms assuring coverage. The percentage of firms who are not offering coverage does not change much between 2015 and 2016, rather firms who will offer insurance in 2015 are uncertain as to whether they will continue to offer it the next year. Firms with fewer than 50 full time employees are not subject to the shared responsibility rules (employer mandate), so they will not be required by law to insure their full- time workforce. Why might small firms drop health coverage? The availability of a public health exchange now gives employers an alternative that allows them to forego offering health insurance to their employees knowing that the employees can still purchase insurance on their own. This seems to be the case among the firms we surveyed, with 68% of those not planning on offering insurance in 2015 encouraging their employees to purchase health insurance on the public exchange (Figure 3). In fact, workers may end up better off on the exchange, since individuals who earn up to 40 of the poverty level are eligible for federal subsidies. Employees are not subsidy- eligible if their employer offers health insurance coverage. Escalating premiums also factor into the decision. Premiums were rising prior to the ACA, and beginning in 2014, new market rules affected small group pricing that drove prices even higher, particularly for groups with a young workforce. In addition, the ACA imposed new taxes on health insurers, which may be passed onto customers in the form of higher premiums. However, the taxes on insurers are small in proportion to the amount of the premium increases many firms have seen. It has also been proposed that the rate increase is due to the ACA minimum coverage requirements for plans. All health plans must now cover ten essential health benefits that include pediatric dental and vision, and habilitative services that many small groups did not previously cover. Finally, small firms may have administrative reasons for dropping plans. Many small businesses do not have Human Resources departments and the paperwork and logistics of providing health coverage can be cumbersome. In fact, in a recent survey of the National Small Business Association (NSBA), small employers reported that the average firm puts in 13 hours and more than $1,200 per month to comply with the ACA. (Clark, 2014) Health Care Cost Containment Measures Last year, we saw firms containing costs predominantly by passing health insurance costs to the worker through higher premiums, changes in pharmaceutical coverage, and the increased use of high- deductible health plans. This year is no different. Figure 4 shows that 87% of small businesses have or are increasing the employee's share of medical services, versus 85% of small firms from last year's survey. Firms are also changing drug coverage to lower costs. Figure 5 shows that while 32% have already made this type of change, are it. Last year not as many firms had implemented changes to prescription drug coverage (19%) but more were changes (47%). The past few years have been a transition period for many firms, and it appears that those who were changes in 2013 made them in The use of High Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs) is becoming more common among all sizes of firms. HDHPs decrease the moral hazard inherent in health insurance by having workers take responsibility for the costs of their medical care before insurance starts paying out. Figure 6 shows the percentage of firms that are using HDHPs as cost- containment measures, or are doing so. Thirty- eight percent are already offering a high- deductible plan, while are doing so. Last year only 29% had offered a plan, with 46% it. Again, many firms that were this option last year appear to have implemented an HDHP for 2014.

5 Changes in Business Practices Last year's survey showed that firms were taking a conservative look at current and future hiring needs by limiting hiring and reducing their current workforce. In the 2013 survey, 39% of small firms were limiting or limiting hiring in the near future. In addition, 31% said they had or were reducing their current workforce. This year's businesses are not acting much differently. Figure 7 shows that 46% of small firms have limited/reduced future hiring, or are doing so. Twenty- eight percent of firms are also reducing or reducing their current workforce. (Figure 8) What Does the Future Hold for Small Businesses? Under the ACA, small businesses now have a market similar to the individual public exchange to shop for insurance. The Michigan Small Business Health Options Program (SHOP) opened at the beginning of 2014 for employers with fewer than 50 employees, and the online portal became active in November 2014 for plans with a January 2015 effective date. Unlike small business insurance before the ACA, SHOP plans are not underwritten, so plan rates will not be determined by individual employee medical conditions. And though difficult to understand and calculate, small business tax credits are available on the exchange for businesses that pay at least 5 of the worker's individual premium, have fewer than 25 employees, and whose workforce has average wages of less than $50,000 annually. Since the SHOP opened, there has been very little take- up by businesses. (Green, 2014) We suspect there are two primary reasons for slow adoption. First, the SHOP is attractive if firms can receive the associated tax credit. Few firms qualify for the credit or are willing to invest the time to understand the complicated tax law to get it. Second, firms are currently only able to choose one insurance carrier on the exchange for their employees. The SHOP will open up multi- choice options in Michigan in 2016, which will make this avenue more flexible and likely more attractive to small firms. Whether small businesses take advantage of these new options depends on whether the administrative duties of the firms are minimal, and more importantly, whether the premiums are affordable. Small business insurance premiums have risen by 123% over the last decade, and in 2014 small businesses paid 18% more than large businesses for health insurance. (Vestal, 2014) Whether premiums continue to rise depends upon many factors, including the ratio of young, healthy workers to older, sicker employees in the risk pool. When a greater proportion of sick individuals buy plans we have adverse selection, which makes the pool of insured at higher risk for large health expenditures. Because of the increased risk insurers take on, they charge higher premiums to everyone. Although some small businesses have seen their rates rise by very little, others have seen up to 50-6 increases. (Bouldin, 2013) These increases could be due to the fact that this is a transitional time for insurers in this new marketplace, and the volatility in the rates may reflect this. Once the exchange has been up and running for a while competition could drive rates down, or the effects of adverse selection could drive rates up. The long run effect of the ACA exchanges is yet to be seen.

6 Figures Figure 1. Percentage of small businesses that offered health insurance to their employees in 2013 and % 55% % 45% Yes 3 No Figure 2. Organization's plans for offering health insurance in 2015 and % % 2 15% 1 5% 44% 43% 4 28% 28% 16% Will have coverage Will not have coverage Not sure/undecided

7 Figure 3. Plans of small firms that will not offer health insurance in % Encourage to purchase on public exchange 12% Compensate employees Use company time to shop health coverage 9% Make advisor available 12% Others 34 Figure 4. Cost Containment Measures: Increase employee's share of medical services % % 1 Already taken Not taken, but Not taken, nor 37

8 Figure 5. Cost Containment Measures: Implement changes to prescription drug coverage 36% 34% 34% 33% 33% 32% 32% 32% 32% 31% Already taken Not taken, but Not taken, nor 37 Figure 6. Cost Containment Measures: Implement use of high deductible health plans 4 38% 3 27% 25% 2 15% 1 5% Already taken Not taken, but Not taken, nor 37

9 Figure 7. Reduce amount of hiring in the next 12 months 6 53% % 22% 1 Yes No, but No, and not 58 Figure 8. Reduce the size of the overall workforce % % 14% 1 Yes No, but No, and not 67

10 References Bouldin, Guy. (December 14, 2013) Obamacare Brings Significant Changes to Small Employers Insurance. Milwaukee Wisconsin Journal Sentinel. Retrieved December 9, 2014 from: brings- significant- changes- to- small- employers- insurance- b z html Clark, Patrick. (February 6, 2014) Small Business Health Premiums Have Nearly Doubled Since Bloomberg BusinessWeek. Retrieved December 9, 2014 from: 06/small- business- health- care- premiums- nearly- double- since Greene, Jay. (September 24, 2014). SHOP Small- biz Insurance Exchange to Open in November. Crain's Detroit. Retrieved December 1, 2014 from: small- biz- insurance- exchange- to- open- in- nov Muller, Leslie A., John Turner, and Adelin Levin. (2015) Employer Reactions to the Affordable Care Act. Benefits Quarterly, forthcoming. Vestal, Christine. (August 28, 2014) Health Law May Benefit More Businesses in the Fall. Kaiser Health News. Retrieved November 25, 2014 from: law- may- benefit- more- small- businesses- in- the- fall/

11 Appendix Figure A1. Number of full- time workers for all sizes of firms % % 3% 3% Less than Figure 2A. Relative Skill of Workforce for Small Businesses % 28% 25% 2 21% 15% 1 7% 7% 5% Low Skill High Skill 67

12 Table A3. Industry Composition for Small Firms Industry Others Construction Manufacturing Retail Health care Professional/ Scientific/ Technical Non profit Accommodation/Food Service Education Real Estate Financial Services Wholesale Trade/Distribution Percentage 27% 17% 16% 16% 9% 7% 3% 1% 1% 1% 1% 70 Table A4. Counties of the Respondent Firms County Allegan Ingham Kent Ottawa Berrien Kalamazoo Muskegon Others Percentage 1 12% 14% 6% 7% 9% 7% 69

13 Figure A5. Percentage of Workforce Considered Part- Time 33% 33% 3 25% 26% 2 15% 1 9% 5% None 1-24% %+ 70 Figure A6. Percentage of Workforce Paid the Minimum Wage 7% 14% None 1-24% 25%+ 79% : 70

14 Table A7. How strongly do respondents agree or disagree that health reform and ACA were an improvement % % 14% 1 4% 4% Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 69

15 Affordable Care Act Employer Survey 2014 Please answer the following questions. NOTE: Please answer the questions to reflect only changes you made or plan to make as a direct result of the Affordable Care Act (ACA). For example, if you were already changing insurance plans, but for other reasons, do not check the corresponding box. A survey similar to this was sent to your company in September To your knowledge, did your company complete and return it? Yes No Not sure 1. How many full time workers (30+ hours per week) does your organization currently employ? Less than Does your organization have enough full- time employees or full time equivalents to be required to comply with the ACA employer mandate? Generally speaking, companies with 100+ employees must comply by 2015; those with employees have until Yes No Not sure 3. On a scale of 1 to 5, with 1 being relatively low skill and 5 being relatively high skill, how would you describe the majority of your workforce? Low skill High skill 4. How would you categorize your organization s industry? Accommodation/Food service Construction Education Financial Services Health care Manufacturing Non profit (specify): Professional, Scientific or Technical services Real estate Retail Wholesale Trade/Distribution Other (specify): 5. Which county is considered the main location of your organization in Michigan? Allegan Ingham County Kent County Ottawa County County Berrien County Kalamazoo County Muskegon County Other 6. Approximately what percentage of your workforce is considered part- time (<30 hours per week)? none 1-24% % + 7. Approximately what percentage of your workforce is paid the minimum wage? none 1-24% 25% +

16 8. Did your organization offer employer- sponsored health insurance (group coverage) to employees in 2013? Yes No 9. Does your organization currently offer employer- sponsored health insurance (group coverage) to employees? Yes No 10. Even if your organization does not currently offer health insurance to employees, compared to 2013, how informed do you feel about the ACA and what is required of your company going forward? I am better informed I am equally informed I am less informed 11. How confident are you that you understand your obligations, if any, as a business under the ACA employer mandate? Not Extremely confident confident 12. What are your future plans with respect to offering employer- sponsored health insurance (group coverage)? Will have coverage Will not have coverage Not sure/undecided In the 2015 plan year In the 2016 plan year 13. If your organization will not offer employer- sponsored health insurance in 2015, check any and all that your organization plans to do: Encourage employees to purchase an individual or family health plan on the public exchange Compensate employees to help them pay for an individual or family health plan Compensation method: Allow employees to use company time to shop for or purchase individual or family health coverage Make an advisor available to employees to help them select an individual or family health plan Other: Not applicable, we will offer health insurance 14. A private health exchange is a marketplace where employers purchase health coverage for their employees, typically up to a predetermined dollar amount (defined contribution), and employees select their health benefits from participating insurers. It is not the same as the public exchange, also known as the federal SHOP or healthcare.gov. Is your organization using a private health exchange as an option for employee health benefits? Yes No Not sure

17 15. The original implementation date of the ACA employer mandate was January 2014, but the government has delayed the mandate. Has this delay affected any changes you are making to your health insurance benefits? Yes, it has delayed our changes No, we already made changes No, we are proceeding with planned changes No, we decided not to make changes 16. Which, if any, of the following cost containment measures has your organization taken or seriously considered in an effort to control health care costs as a result of the ACA? (Check all that apply) Not applicable since my organization does not offer health insurance (Skip to Question 17) Change from a fully- funded to a self- funded plan Change health insurance company or administrator Increase employee s share of medical services (e.g., increased co- pays, coinsurance, share of premium cost, out- of- pocket limits) Switch to a limited (or narrow) network health plan Implement changes to prescription drug coverage (e.g., use of formularies) Implement or expand disease management programs (e.g., diabetes) Implement or expand use of high- deductible health plans (e.g., Health Savings Accounts) Implement or expand wellness programs (weight loss programs, premium discounts) Already taken Not taken, but Not taken, nor Not applicable 17. Has your organization implemented or seriously considered any of the following changes to your staffing or workforce needs as a result of the ACA? Yes No, but No, and not Increase the use of temporary or contingent workers Reduce or limit the amount of hiring in the next 12 months Reduce or limit the amount of hours worked of certain part- time employees Reduce the size of your overall workforce Cancel plans to expand a current location or open up a new location

18 18. If you have implemented or are seriously cost containment measures or staffing changes as noted above, were they in response to what your competitors are doing? Yes No 19. How strongly do you agree or disagree with the following statement: Overall, I think that health reform and the ACA provisions that went into effect in January 2014 were an improvement over the pre- ACA health care system. Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree Thank you for your participation in this survey!

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