Why are Health Insurance Premiums So Much Higher for Public Employers Compared to Private Employers?

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1 Why are Health Insurance Premiums So Much Higher for Public Employers Compared to Private Employers? Alice Zawacki U.S. Census Bureau, Center for Economic Studies Tom Buchmueller University of Michigan, Ross School of Business Jessica Vistnes Agency for Healthcare Research and Quality Academy Health Annual Research Meeting Baltimore, MD June 23, 2013

2 Disclaimer Any opinions and conclusions expressed here are those of the authors and do not necessarily represent the views of the U.S. Census Bureau University of Michigan Agency for Healthcare Research and Quality. All results have been reviewed to ensure that no confidential information is disclosed. 2

3 Motivation Great Recession of State and local governments hit hard Comparing public & private compensation: mixed results Gyourko & Tracy, 1988; Braden and Hyland, 1993; Belman & Heywood, 2004; Keefe, 2010; Bender & Heywood, 2010; Munnell et al., 2011; Gittleman & Pierce, 2011 More consistent finding Public sector compensation: more heavily weighted toward non-wage benefits Health insurance costs as a share of total compensation (BLS) Public: 7.8% in 2000 to 11.6% in 2010 Private: 5.5% in 2000 to 7.5% in

4 Average Total Single Premium per Employee Enrolled ( ) State and Local Governments Private Difference $5,367 $5,627 8% Gap 10% Gap $2,855 $3,182 $2,587 $2,372 $2,194 $2,249 $2,889 $2,655 $2,325 $1,992 $2,051 $2,174 $202 $198 $198 $262 $200 $293 $3,925 $3,575 $3,481 $3,189 $386 $444 $4,595 $4,291 $3,991 $3,705 $586 $604 $4,860 $4,118 $742 $4,386 $4,669 21% Gap $981 $ Source: Medical Expenditure Panel Survey-Insurance Component Internet tables. 4

5 Our Contribution 16.2 million public employees, $148.5 million (2009 MEPS-IC) Findings using MEPS-IC Premiums similar in early years & plans fairly similiar Public plans: supplemental services & lower employee cost sharing Explaining $1433 premium differential seen in 2009 Explain over 1/2 of differential Over 40% of differential: more educated, older, and female 5

6 Data: Medical Expenditure Panel Survey: Insurance Component (MEPS-IC) State and local governments Private sector firms small, public sector firms large Sampling Private: 30,000-35,000 observations Up to 4 health plans Public: state and local governments 3,000 observations: Over 1% nonsampled units State: higher education, corrections, and hospitals Local: counties, municipalities, townships, special districts, school districts All health plans 6

7 Additional Data: Demographic Workforce Characteristics Public/private comparisons sensitive to controls Premiums depend on the risk profile of enrollees 2009 American Community Survey PUMS Public employees: more educated, older, and female 7

8 Premiums and Employee Contributions: Employee Only Coverage Public Private Public- Private Public Private Public- Private Premiums *** *** Contributions (2009$) Percent of premium No employee contribution *** *** *** *** *** *** 8

9 Premiums and Employee Contributions: Employee Only Coverage Public Private Public- Private Public Private Public- Private Premiums *** *** Contributions (2009$) Percent of premium No employee contribution *** *** *** *** *** *** 9

10 Premiums and Employee Contributions: Employee Only Coverage Public Private Public- Private Public Private Public- Private Premiums *** *** Contributions (2009$) Percent of premium No employee contribution *** *** *** *** *** *** 10

11 Premiums and Employee Contributions: Employee Only Coverage Public Private Public- Private Public Private Public- Private Premiums *** *** Contributions (2009$) Percent of premium No employee contribution *** *** *** *** *** *** 11

12 Premiums and Employee Contributions: Employee Only Coverage Public Private Public- Private Public Private Public- Private Premiums *** *** Contributions (2009$) Percent of premium No employee contribution *** *** *** *** *** *** 12

13 Plan Characteristics 2000: Plans fairly similar Public: fee-for service 2009 Similarities Plan type: both sectors moved towards PPO/POS Self-insured Refuses coverage of pre-existing conditions Differences Covered services Cost sharing 13

14 Covered Services Public Private Routine Dental Care Routine Vision Care 2.71% Difference 5.05% Difference 7.74% Difference

15 Deductibles Public Private Mean ($) $101 Difference $284 Difference $0 Deductible (%) Deductible > $1,000 (%) 0.24% Difference 5% Difference 15% Difference 15

16 Hospital Care Public Private Copayments Coinsurance $3 Difference $50 Difference 0.75% Difference 2.08% Difference 16

17 Out-of-Pocket Maximums Public Private $2093 $1450 $1501 $1103 $347 Difference $592 Difference

18 Public-Private Premium Differential Differences in plan characteristics difference in premiums? 2009 data: series of OLS regression models Unit of observation: plan Dependent variable: premium for employee only coverage 18

19 Public-Private Premium Differential Employee demographics: age, gender, education Plan characteristics: type, covered services & cost sharing Establishment characteristics: Size Economies of scale, purchasing power, fewer concerns: adverse selection Size advantages are not reflected in public premiums Unionization Public workers more likely to belong to a union Not an exogenous employee characteristic Value of compensation package: above market clearing level Preferences for health benefits rather than wages 19

20 Explaining the $1433 Premium Differential (2009) Public sector workers more educated, older, more likely to be female Workforce Characteristics Explain $582 or 40.6% Reduce differential to $851 Plan Characteristics Explain $98 or 6.8% Reduce differential to $753 Establishment Characteristics Explain $114 or 8.0% Reduce differential to $639 20

21 Explaining the $1433 Premium Differential (2009) Workforce Characteristics Explain $582 or 40.6% Reduce differential to $851 Cost sharing contributes almost half of the explanation contributed by all plan characteristics Plan Characteristics Explain $98 or 6.8% Reduce differential to $753 Establishment Characteristics Explain $114 or 8.0% Reduce differential to $639 21

22 Explaining the $1433 Premium Differential (2009) Workforce Characteristics Explain $582 or 40.6% Reduce differential to $851 Plan Characteristics Explain $98 or 6.8% Reduce differential to $753 Establishment Characteristics Explain $114 or 8.0% Reduce differential to $639 Firm size explains over $103 or 7.19% of overall differential 22

23 Summary 2000 Public and private plans similar: plan type and mean cost sharing provisions Difference in premiums small: $ Gap in mean premiums increased to $1433 Over 40% of difference explained by differences in employee demographics Cost sharing increased more in private than public sector 23

24 Alternative Interpretations 1. Private: efficient benefit designs Use greater cost sharing to reduce moral hazard Lower utilization of services: benefit low relative to cost Implication: increase in economic welfare 2. If utilization not significantly affected Greater cost sharing: does not necessarily improve efficiency Shift costs from low risk employees higher risk employees 24

25 Impact of ACA Public premiums higher: cadillac tax Private premiums lower: average actuarial value State employees: enroll children in federally subsidized CHIP 25

26 Additional Work: Modifications Oaxaca Decompositions Separate state and local government units State vs. large private plans Local vs. all private plans 2000 and 2009 Some changes to plan, worker, establishment variables 26

27 Additional Work: Findings Generosity: 2000: private plans 2009: public plans Local vs. private premiums Worker and establishment characteristics Explain ~75% in 2000 and <2/3 in 2009 State vs. large private premiums Worker characteristics Explain >75% in each year 27

28 Thank you

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