1 Small Employers and Health Insurance Results of a survey of small employers in six rural California counties
2 The Small Business Health Insurance Survey Project Why study small employers? Small businesses are a major driver of the economy They employ more than half of private sector employees They produce roughly half of the private GDP Ninety percent of small businesses employ fewer than 20 people. Healthcare expenses have the potential to undermine the viability of small businesses And this can affect the stability of the rural healthcare delivery system and local economies Self-employed and small businesses purchase insurance disproportionately in the non-group and small group market Products in these markets are generally more expensive, provide less coverage, and have the fewest consumer protections Many current national health care reform proposals are based on the idea that this market will remain an important source of insurance coverage.
3 About the Project Community Health Services partnered with The Access Project (TAP) TAP is a national research and advocacy organization affiliated with Brandeis University that supports local access improvement efforts It provides technical assistance to local efforts through research, policy analysis, community engagement, and communication services TAP has studied the adequacy of health insurance and medical debt since The California Endowment funded TAP to conduct a survey of small employers in six rural California counties Learn more about the experiences of small employers in trying to obtain health insurance for their employees Learn more about small employers attitudes toward health system reform Engage small employers in the county in local, state, and national efforts to improve and reform the health care system
4 Background on Health Care Costs More and more families in the U.S. are having trouble affording medical care In 2007, more than two in five (41%) adults under the age of 65 reported difficulty paying medical bills, up from 34% in Over a quarter had medical debt (28%) Underinsurance a growing concern. In 2007: 1/3 of the continuously insured had medical bill problems 1/4 (24%) had medical debt 1/3 of insured with medical debt used up all of their savings to pay off medical bills Underinsurance will increase as health care costs rise and more costs are shifted to consumers In 2009, nearly 2/3 of insured adults were worried about being able to afford medical care and prescription medications
5 Average Health Insurance Premiums and Worker Contributions for Family Coverage, % Increase $12,680 $5,791 $4,247 $1, % Increase $9,325 $3, Employer Contribution Note: The average worker contribution and the average employer contribution do not add to the average total premium due to rounding. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Worker Contribution
6 Cumulative Changes in Health Insurance Premiums, Inflation, and Workers Earnings, % 120% 119% 100% 80% 60% 40% 20% 0% 34% 29% Note: Due to a change in methods, the cumulative changes in the average family premium are somewhat different from those reported in previous versions of the Kaiser/HRET Survey of Employer-Sponsored Health Benefits. See the Survey Design and Methods Section for more information, available at Health Insurance Premiums Workers' Earnings Overall Inflation Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).
7 Changes in cost sharing Between 2007 and 2008, the annual deductible for workers in PPOs with a deductible increased from $461 to $560 for single coverage, from $1,040 to $1,344 for family coverage Between 2006 and 2008, the percentage of covered workers in a plan with a deductible of at least $1,000 for single coverage grew from 10% to 18% Among small firms (3-199 workers) the percentage increased from16% to 35%
8 Percentage of All Firms Offering Health Benefits, * 100% 90% 99% 99% 99% 98% 98% 99% 98% 98% 99% 99% 80% 70% 60% 50% 40% 30% 20% 10% 68% 68% 65% 66% 65% 63% 59% 60% 59% 56% 57% 58% 58% 55% 52% 47% 48% 45% 62% 49% 0% *Tests found no statistical differences from estimate for the previous year shown (p<.05). Note: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, All Small Firms (3-199 Workers) All Large Firms (200 or More Workers) 3-9 Workers
9 TAP s First California Small Employer/ Rural Business Survey 2008 Health Insurance Survey of California Farm and Ranch Operators TAP was funded by The California Endowment Family farmers and ranchers experiences typical of other small business people Random survey of 1,787 non-corporate farm and ranch operators TAP contracted with the USDA to conduct the survey
10 CA Farm/Ranch Survey Almost all respondents (90%) were continuously insured 30% purchased in non-group market vs. national average of 8% 31% spent >10% of income on health care Key factor was purchasing insurance in non-group market 20% said healthcare costs contributed to financial problems: among this group They spent on average 37% of income on health care 28% said caused them to delay needed business investments 28% had to take off farm/ranch work or work more 11% had difficulties paying off farm/ranch loans
11 The California Rural Small Employer Survey Conducted in 6 counties between Nov and Jan Del Norte, Glenn, Mendocino, Shasta Low response rates in Yolo and Imperial Partnered with county health departments Outreach through local business organizations Completed online 254 respondents 57 respondents in Mendocino County
12 Who Responded? Respondents were really small employers 65% had 5 or fewer full time employees (66% in MC) 80% had 10 or fewer employees (81% in MC) More than half (54%) had gross revenues under $500,000 (67% in MC) Businesses ranged across industry categories Half did and half didn t offer insurance 49% offered to full time, or full and part time employees (47% in MC) 51% did not offer insurance (53% in MC)
13 Among Those Who Offer Insurance Experiences with Their Health Plans
14 Why Do Small Businesses Offer Health Insurance? Owners need it for themselves and families 61% rated very important (59% in MC) Important for employee well being It s the right thing to do -- 58% (67% in MC) Increases employee satisfaction -- 55% (70% in MC) Easier to hire and keep good employees -- 58% (58% in MC) Least important reason for offering Most of competitors offer insurance Employers are committed to continuing to offer insurance Only 5% considering dropping insurance in next year
15 Reasons for Choosing A Health Plan Keeping premiums down is important -- 66% (63% in MC) But employers had other concerns as well. They rated the following as Very Important; Providing comprehensive benefits -- 49% (60% in MC) Limiting cost sharing -- 38% (44% in MC) Access to wide network of providers -- 46% (46% in MC) Good customer service -- 52% (54% in MC) Least important reasons Excluding benefits -- 8% (0% in MC) Having high cost sharing -- 11% (8% in MC) Limiting the provider network -- 6% (4% in MC)
16 Nonetheless... Most saw their premiums increase 83% renewed with the same insurer (100% in MC). Of these, 87% had a premium increase 4% said premiums stayed the same Only 1% said premiums decreased Many were forced to increase costs for employees In the last 2 years 27% raised deductibles (19% in MC%) 30% raised other cost sharing (22% in MC) 28% increased employee portion of premium (22% in MC) But Only 4% eliminated benefits (11% in MC) Only 6% limited networks (7% in MC)
17 How Employers Rate Their Health Plan Employers generally satisfied with their health plans Majorities rated them positively on most items On various positive measures of their health plan, between 68% and 85% strongly or somewhat agreed But a significant minority reported problems Percent that strongly or somewhat disagreed with the following statements Requires level of out-of-pocket spending I expected 22% (20% in MC) Allows employees to get health care they need 15% (26% in MC) Provides good value for premium dollar 30% (42% in MC)
18 Among Those Who Do Not Offer Insurance Why They Don t Offer Insurance
19 Why Don t Employers Offer Insurance Differences between those who did and did not offer insurance Main difference: those who didn t offer insurance generally had lower revenues Main reasons for not offering insurance were related to cost Premiums cost too much 85% (77% in MC) Revenue too uncertain to commit to a plan 66% (61% in MC) Doesn t offer value given premiums and cost-sharing 49% (39% in MC) Insufficient numbers of workers to buy group coverage also a factor 57% (52% in MC)
20 Among All Employers Attitudes Toward Health System Change
21 Survey Questions Why are health care costs rising? What policy options would you support to make health insurance more affordable? Which reform principles would you support?
22 Why are Health Care Costs Rising? Respondents agreed most strongly with the following statements about why health care costs are rising: We spend too much on insurance bureaucracies and administration 65% (83% in MC) Pharmaceutical companies make too much money 64% (75% in MC) Insurance companies make too much money 51% (76% in MC) The population is aging 42% (40% in MC) There is no oversight of insurance company practices 39% (63% in MC) The fewest strongly agreed with these statements about why costs are rising: New health care technology 17% (25% in MC) People use services they don t really need 21% (15% in MC) Insurance companies have to comply with too many government rules and regulations 18% (6% in MC)
23 What Would Make Insurance More Affordable? Respondents agreed most strongly with the following ideas for making insurance more affordable: Require insurers to spend a certain percentage of each premium dollar on health care rather than on marketing, administration and other costs 50% (70% in MC) Create standard benefit packages so it is easier for people to compare health plan prices 48% (42% in MC) Charge people who engage in unhealthy behaviors more so that others can pay less 38% (40% in MC) The fewest strongly agreed with these ideas: Increase deductibles and other out-of-pocket costs to keep people from seeking unnecessary health care 11% (10% in MC) Use public funds to subsidize employer and employee premiums 16% (19% in MC) Sell plans that don t cover certain services, such as pharmacy or maternity, to keep the cost of insurance premiums affordable 20% (15% in MC)
24 Principles for Reforming the Health System Respondents most strongly agreed with these principles The healthcare system needs to guarantee coverage for everyone 43% (72% in MC) Health insurance premiums should not vary depending on the type or size of business 38% (31% in MC) The fewest respondents strongly agreed with these principles Individuals who don t have insurance should be required to purchase it 9% (17% in MC) All employers should be required to offer health insurance to their workers or pay into a pool to help cover the uninsured 15% (21% in MC) Most other options fell into a middle range, with more than half of respondents either strongly or somewhat agreeing. These included: The costs of health care should be shared by the government, employers, health insurers, providers, and individuals Health insurance premiums should not vary depending on people s health conditions
25 In Summary Small employers who offered insurance did so because they thought it was the right thing to do It was also a matter of personal significance, as they needed health insurance for themselves and their families. Small employers don t offer insurance primarily because of the cost, not because they don t think it is necessary to hire good people The costs of health care are placing a significant burden on our small employers As key economic drivers, this can affect our local economy Small employers attitudes toward health system reform vary greatly. Many are open to changes not usually associated with small business people, such as better oversight of the insurance industry or buying into public programs. And many do not support some commonly suggested ideas such as allowing the sale of high deductible policies or policies with slimmed down benefits.
26 Final Thoughts National Health Care Reform Health care reform is now a major topic of discussion at the national level. Most current proposals would require people who don t have insurance to purchase it on the non-group market. Many also require employers to offer insurance or pay into a pool Research shows that non-group and small-group insurance costs more and covers less, and charges those with pre-existing conditions unaffordable rates. National organizations that speak for small business do not represent the opinions of all small business people small business opinion is not monolithic. It is important for these voices to be heard in the national debate.
27 Final Thoughts State Level Health Care Reform California is currently considering legislation that would respond to some of the preferences expressed in this survey AB 786 Insurance Market Standards Would organize health insurance policies into coverage categories that would enable consumers to better track premiums, benefits, and cost sharing. Would develop minimum benefit standards SB 316 Capping Administration and Profit Would require every insurer to spend at least 85 percent of premiums on patient care AB 1218 Health Insurance Rate Approval Requires health insurers to get approval for increases in premiums and cost-sharing
28 Resources Center for Rural Affairs - Works to establish strong rural communities, social and economic justice, environmental stewardship, and genuine opportunity for all while engaging people in decisions that affect the quality of their lives and the future of their communities. Small Business Majority - A national nonprofit advocacy organization focused on solving the single biggest problem facing America s 27 million small businesses: the skyrocketing cost of providing healthcare to employees. Run by small business owners who know the challenges entrepreneurs face and how critical affordable and accessible healthcare is to a small business owner s success.
29 In Conclusion Health care reform will affect you What can you do? Find out what is happening Look for organizations that represent your point of view Call your legislators Look for ways to get involved
30 For More Information on the California Small Employers Survey Contact Carol Pryor The Access Project x227 or Bill Lottero x237
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