Opinion: Proposals for Health Policy. A Shared Responsibility: U.S. Employers and the Provision of Health Insurance to Employees

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1 Opinion: Proposals for Health Policy Sara R. Collins Karen Davis Alice Ho A Shared Responsibility: U.S. Employers and the Provision of Health Insurance to Employees Employer-based health insurance is the backbone of the U.S. system of health insurance coverage. Yet it has been slowly eroding, and if these trends continue greater numbers of Americans are likely to be uninsured or without affordable coverage. Employer coverage has marked advantages, including benefits to employers and a natural risk pool that offers better benefits at lower cost than individual coverage, and is highly valued by employees. The shift of health care costs from employers who do not cover their workers to other parts of the economy is substantial. Very little attention has been given to policies that might strengthen and expand employer coverage. It will be important to shore up employer coverage both to curb its recent erosion and to build toward a more comprehensive system of health insurance. Employer-provided health insurance forms the backbone of the U.S. system of health insurance coverage. More than 160 million people, or 64% of the population under age 65, are covered under employer plans (DeNavas-Walt, Proctor, and Mills 2004). Employers contribute more than $400 billion toward coverage of workers and dependents (Davis 2004). Yet, as extensive and important as this coverage is, it is the subject of criticism from both the political left and the right. Those favoring a single-payer insurance system would like to see the employer-based system replaced by a government program. Those who prefer individual choice would like to see it replaced by individual insurance or by individual choice within a group not tied to place of employment. There are important reasons, however, to retain the system of employer-sponsored health insurance, and to develop policies that would strengthen and expand such coverage. Employers benefit from having insured employees by enhancing their ability to recruit and retain employees, by increasing employee health, productivity, and morale, and by reducing costs of absenteeism, sick employees on the job (presenteeism), and early departure from the labor force (Collins et al. 2004a; Collins et al. 2004b; Fronstin and Helman 2003; Goetzel et al. 2004; O Brien 2003). Indeed, despite the position of some business organizations, a recent survey found that a majority of employers support provision of employer-sponsored coverage, and prefer it as an alternative to expansion of public Sara R. Collins, Ph.D., is a senior program officer; Karen Davis, Ph.D., is the president; and Alice Ho is a research associate, all at the Commonwealth Fund. Address correspondence to Dr. Collins at the Commonwealth Fund, 1 East 75 th St., New York, NY src@cmwf.org 6 Inquiry 42: 6 15 (Spring 2005). Ó 2005 Excellus Health Plan, Inc /05/

2 Table 1. Employees with own employer, other employer, or no employer coverage, by size of establishment Not covered by employersponsored plan Covered Covered by own by other Total employer employer Total Uninsured Number of workers (in millions) By size (number of workers) of establishment, (%) , one location , multiple locations , one location , multiple locations , one location , multiple locations , one location , multiple locations Source: Analysis of 2001 Medical Expenditure Panel Survey. Note: Percentages may not sum to 100 due to rounding. Shared Responsibility programs to cover the uninsured (Collins et al. 2004a). In addition, employer groups are natural risk pools. Individuals are covered by virtue of taking a job, not because they incur, or expect to incur, a health problem. Individual insurance by contrast attracts those who are sick, or who are at risk of becoming sick. In part because adverse risk selection is not as great a danger in employer coverage, employer group premiums are closer to actual medical outlays, and administrative costs and insurance reserves are less (U.S. House of Representatives 1993). Finally, employer-sponsored insurance is strongly preferred by the majority of Americans; not surprisingly, it is the coverage of choice for those who currently have it (Collins et al. 2004c; Duchon et al. 2000). Even low-wage uninsured workers, when asked about the type of coverage they might like, often prefer the kind of coverage that better paid workers enjoy through employer-group policies. There are a number of policy strategies that could expand and strengthen employer-sponsored coverage, either as part of a broader expansion plan to achieve near universal coverage or implemented on their own. They include: 1) financial assistance to low-wage workers to take up offers of employer coverage; 2) provision of reinsurance or stop-loss coverage to reduce and stabilize insurance premiums, especially for smaller firms; 3) creation of larger purchasing pools for smaller businesses to obtain better premiums, better benefits, and wider choices; and 4) incremental policies, such as provisions to cover young adults under parents insurance policies, maximum waiting periods for coverage upon new employment, and extension of coverage for short periods of time following termination of employment. As a foundation for considering policy options for strengthening employer coverage, we explore the characteristics of workers who fail to receive coverage from their own firms. We also examine the initial incidence of health care costs for workers and how those costs are distributed across workers, employers, and government. Background According to the 2001 Medical Expenditure Panel Survey (MEPS), about 76.9 million workers, or 68% of people who have full-time and part-time jobs, receive health insurance coverage from their own employers at some time during the year (Table 1). 1 Some of these workers have coverage for the full year, while others have coverage for just part of the year. The remaining 35.9 million workers do not have coverage from their employers at any time during the year. This group of workers either gains insurance coverage from other employers (16 million) or is without employer-sponsored coverage of any kind (19.8 million). Nearly 13 million workers are uninsured for the full year, 3.7 million are covered 7

3 Inquiry/Volume 42, Spring 2005 Table 2. Characteristics of employees with own employer, other employer, and no employer health insurance coverage, by wage rate, poverty, age, and family status Not covered by Covered Covered employer-sponsored plan by own by other Total employer employer Total Uninsured Number of workers (in millions) By wage rate (%) ,$10/hr $10 15/hr $15/hr By poverty (%) ,100% % % % By age (%) By family status (%) Single, no children Single, w/children Married, no children Married, w/children Source: Analysis of 2001 Medical Expenditure Panel Survey. Note: Percentages may not sum to 100 due to rounding. by public programs, and 3.2 million purchase private coverage (data not shown). The questions for policymakers seeking to strengthen the employer-based system include: 1) Who are the 35.9 million workers who do not have coverage through their employers, 2) where do they ultimately receive coverage and how many are uninsured, and 3) what are the costs to workers, other employers, and public institutions when workers do not receive coverage through their own employers? Who are the Workers Who Lack Job-Based Coverage? Workers in small firms. The MEPS data underscore a well-known observation: firm size is strongly associated with whether employees have health insurance coverage through their jobs (Table 1). Just 44% of workers in establishments that have fewer than 25 employees and are not part of larger entities have coverage through their own employers. About 22%, or three million of these workers, obtain coverage through someone else s employer plan; 3.6 million, or 25%, are uninsured. Workers in multi-small establishment firms are somewhat more likely to have coverage through their jobs than employees in singleestablishment small firms. While workers in small firms are at greatest risk of lacking job-based coverage, millions of workers in large companies are also without coverage. More than one-quarter of employees in companies with 500 or more workers do not receive health insurance through their jobs (data not shown). The rate is higher for employees in firms of 500 or more with only one location 39% do not have own-employer coverage (Table 1). About 3.7 million workers employed in the largest firms receive coverage through another employer, while more than three million are uninsured. Workers who earn low wages. Earning low wages is a known risk factor for lacking insurance coverage from one s employer in both small and large firms. According to the

4 Shared Responsibility Table 3. Sources of insurance coverage for employees not covered by own employer Total workers not covered by own Offered, don t Not employer a take up offered Number of workers (in millions) Insurance coverage (%) Other employer Other private Public programs Uninsured Source: Analysis of 2001 Medical Expenditure Panel Survey. Note: Percentages may not sum to 100 due to rounding. a Whether an employee has received an offer of insurance is unknown for 2.6 million workers not covered by their own employers. MEPS, just 47% of workers who earn less than $10 an hour have coverage from the companies they work for, compared to 80% of those who earn more than $15 an hour (Table 2). About 5.4 million workers earning less than $10 an hour are insured through another family member s employer plan and 6.6 million are uninsured. Workers in low-income households. Similarly, workers in low-income households tend to have jobs in which they do not have employersponsored coverage. About a quarter (26%) of workers living in households with incomes under the poverty level have insurance through the company they work for, compared to threequarters of workers with incomes in excess of 400% of the poverty level. Workers in lowincome households also lack access to other employer-based insurance, either because they are the only worker in the household, other family members are without employer-sponsored coverage, or other family members job-based insurance does not cover dependents. Only 5% of the poorest workers are covered through someone else s employer, meaning that nearly 70% of this group of workers is outside the employer-based system. About 1.2 million workers in the lowest-income category are insured through the Medicaid program and 2.2 million are uninsured (data not shown). Things improve only slightly for workers with somewhat higher incomes: half of those in households at 100% to 199% of poverty are insured by their own employers. Just over one million are insured through the Medicaid program and 4.3 million are uninsured (data not shown). Having a spouse increases the likelihood that someone will have employment-based coverage (Table 2). Married workers are no more likely to have coverage through their jobs than single workers, but their rate of coverage under other employers is triple that of single workers. 2 About one of five workers who are married, or more than 13 million workers, have coverage through another employer s health plan (data not shown). Young workers. Youth is also a risk factor for not having coverage through a job. The rate of own-employer coverage among workers age 50 and older is more than 40% higher than the rate for workers in their 20s (Table 2). About 14% of workers between 19 and 29 gain coverage through family members employer plans, about the same rate as older workers. Young workers are covered through Medicaid and the private individual insurance market at a slightly higher rate than older workers, but most without coverage through their jobs are uninsured 5.2 million, or 19%. Coverage of Employees When They Are Not Covered By Their Own Employers Of the 35.9 million workers who do not have health insurance through their own employers at any time during the year, 22 million lack coverage through their jobs because their employers do not offer it to them (Table 3). About 11.2 million workers are offered coverage by their employers but decline to take it up. 3 Whether one has coverage through another employer clearly makes it easier to decline coverage: 63% of those who decline their companies coverage are insured through a family member s employer plan. In contrast, only one-third of those who are not offered coverage are insured under another family member s employer plan and 43% are uninsured. Those who are not offered coverage also are more likely to buy private coverage or be insured under a public program than those who decline coverage offers from their employers. 9

5 Inquiry/Volume 42, Spring 2005 Table 4. Per capita health care expenditures by primary source of coverage and source of payment Primary source of coverage Total spending ($) Private insurance ($) Source of payment Public insurance ($) Self/ family ($) Other sources ($) Total 2,375 1, Own employer 2,645 1, Other employer 2,592 1, Medicaid 2, , Other private 1, Other public 2, , Uninsured Source: Analysis of 2001 Medical Expenditure Panel Survey. Note: 2000 per-capita health care expenditures are inflated to 2004 dollars using actual and projected annual rates of growth in national health expenditures, as reported by the Office of the Actuary, Centers for Medicare and Medicaid Services. Growth rates are projected for 2003 and The Initial Incidence of Worker Health Insurance Costs Ultimately, all health expenses are paid by individuals. Government and employer spending on health care are eventually borne by someone: taxpayers, workers (through lower wages if employers shift costs to workers), consumers (if employers raise prices and shift costs to consumers), or investors (if employer health costs affect firm profits or if government deficit financing affects interest rates) (Brittain 1972; Rosen 1986; Summers 1989; Gruber 1994, 1998; Blumberg 1999). But the initial incidence of health care costs is important because it has both economic and equity implications. The rising chorus of employers calling for relief from rising health care costs indicates that they are bearing at least part of their employees health care bill. Health spending varies markedly by primary source of coverage, with expenditures highest for people covered by their own employers and lowest for those who are uninsured all year (Table 4). While health status accounts for some of the variation in expenditures by source of coverage, spending also varies because different forms of insurance coverage afford differential financial access to care. On average, individuals or families pay one-fifth of their expenses out of pocket under own-employer and other-employer coverage, and 34% under other-private insurance. The full-year uninsured, meanwhile, pay 62% of their medical expenses out of pocket (Table 4). Payments from other sources, including bad debt and charity care, particularly assist those who are uninsured. 4 Not surprisingly, health spending is lower for the uninsured ($700) and those covered under other-private insurance ($1,677), for which out-of-pocket costs are higher and likely depress use of services. In contrast, spending by workers with own-employer-sponsored coverage is about $2,600 per year, of which $1,945 is covered by insurance. When employers do not provide their own employees with health insurance, those workers medical expenses are met by other sources other employers, public programs, family out-ofpocket spending, and charity or bad-debt care. The cost of health care is about $2,592 per adult covered by an employer other than his or her own, of which $1,926 is covered by insurance provided by the employer of another family member. Assuming these employers contribute about three-fourths of the premium (as national studies suggest is the case for family coverage), the direct cost to employers averages about $1,400 per adult employed by another firm but covered as a dependent under those employers plans (Kaiser/HRET 2004). Of an estimated $268 billion in health care spending on working adults ages 19 to 64 in 2004, just over half ($150 billion) was financed through own-employer private insurance, leaving the remaining $118 billion to be covered by other sources (Table 5). Employers who cover workers employed elsewhere spend an estimated $31 billion on these workers private insurance. Public programs spend $8 billion on health insurance 10

6 Shared Responsibility Table 5. Distribution of total costs of care by primary source of coverage and source of payment, workers Primary source of coverage Total workers (in millions) Private insurance Employer/insurer Individual share a share a Public insurance Self/family Other sources Total spending Total $ (billions) % c $ (billions) % $ (billions) % $ (billions) % $ (billions) % $ (billions) % $ (billions) % Total Own employer Other employer Other private Public programs b Uninsured Source: Analysis of 2001 Medical Expenditure Panel Survey. Note: 2001 per-capita health care expenditures are inflated to 2003 dollars using actual and projected annual rates of growth in national health expenditures, as reported by the Office of the Actuary, Centers for Medicare and Medicaid Services. Growth rates are projected for 2003 and Total spending figures are the product of the total number of workers and per-capita health care expenditures shown in Table 4. Figures may not sum to total due to rounding. a c Calculated based on Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits: 2004 Annual Survey (Menlo Park, Calif.: Kaiser Family Foundation), 74. Average employer contribution for single coverage in 2004 is 84% of the premium cost, which we assume is the share for own-employer coverage. Average employer contribution for family coverage in 2004 is 72% of the premium cost, which we assume is the share for other-employer coverage. b Includes Medicaid and other public programs, excluding Medicare. Percentage of total spending of $267.8 billion. 11

7 Inquiry/Volume 42, Spring 2005 for full-year workers not covered by their own employer. 5 Workers contribute $58 billion directly out of pocket for their own health care, and about $3 billion for private individual health insurance premiums. An estimated $13 billion of expenses are covered by other uncompensated sources that include charity and bad debt. Thus, while employers that sponsor insurance cover 74% of their own insured employees health care spending, that insurance covers only 56% of the total health care costs of all U.S. workers. The remaining costs are borne, at least initially, by other employers, public programs, workers themselves, and sources of uncompensated care. Charity care costs also may be shifted onto the privately insured as hospitals and other health care providers attempt to recover losses through higher charges to these patients. Strengthening Employer Coverage Between 2000 and 2003, the number of Americans without health insurance coverage grew by five million to a total of 45 million, with nearly all of the increase attributed to a decline in employer-sponsored coverage (DeNavas- Walt, Proctor, and Mills 2004). Recent case studies indicate that even very large firms have imposed complex eligibility rules that exclude employees from coverage. For example, long waiting periods and high deductibles for insurance offered by Wal-Mart, the nation s largest private employer, mean that less than half the workforce is covered by the company s health benefits plan (AFL-CIO 2003). Analyses of national data also show that the share of uninsured workers employed in large firms has steadily increased over the past decade (Glied, Lambrew, and Little 2003). If more major U.S. companies weaken or eliminate coverage to reduce their labor costs, we may see a rapid decline in employer-sponsored coverage (Gabel et al. 2004). In fact, new federal tax incentives for high-deductible health plans and health savings accounts are driving employers in the direction of yet greater employee responsibility for health care costs, potentially making health care even less affordable for low-wage workers (Davis, Doty, and Ho 2005; Glied and Remler 2005). Reflecting these concerns as well as federal fiscal constraints, recent policy proposals to expand health insurance coverage set forth by the 2004 presidential candidates, the private sector, academia, and the states largely have emphasized the central importance of the employer-based system within an overall strategy to increase coverage (Collins, Davis, and Lambrew 2004; Davis and Schoen 2003). Proposals have included employer requirements and incentives, such as employer mandates to offer or contribute to employee health insurance, reinsurance pools, new group options for small employers and low-wage workers, and tax credits for premium support. Whether part of a broader plan to achieve near-universal coverage for Americans or implemented on their own, targeted policy strategies could help curb the recent erosion in employer-sponsored coverage. An immediate strategy would be to provide financial assistance to low-wage workers in taking up offers of employer coverage. About 11 million workers are offered but fail to take up employer coverage. While many of these obtain coverage through another employer, about 22% (2.5 million workers) are uninsured. Financial assistance in the form of tax credits or premium assistance could make coverage affordable for these workers. Another strategy, advanced by both Sen. John Kerry (D-Mass.) and Sen. Bill Frist (R-Tenn.), is the provision of reinsurance or stop-loss coverage to reduce and stabilize insurance premiums, especially for smaller firms. New York state has successfully enrolled about 123,000 individuals in Healthy New York by making such stop-loss coverage available to small businesses and uninsured individuals (Swartz 2001, 2005; EP&P Consulting, Inc. 2004). Kerry s proposal would finance reinsurance through government revenues (Collins, Davis, and Lambrew 2004). Frist s proposal would create a Healthy Mae analog to Fannie Mae and spread the cost of reinsurance across participating insurers and firms (Frist 2005). A third strategy is the creation of larger purchasing pools for smaller businesses to obtain better premiums, better benefits, and wider choices. This might include creating a parallel to the Federal Employees Health Benefits Program (FEHBP) and linking insurer participation in the pool to eligibility to participate in FEHBP (Davis, Cooper, and Capasso 2003). Finally, there are a host of incremental policies that could make modest additions to employer 12

8 Shared Responsibility coverage. Young adults could be covered under parents insurance policies up to age 23 or 25 whether or not they are full-time college students (Collins et al. 2004d). In recent years, many firms have extended the waiting periods for coverage upon new employment (Gabel et al. 2001). This trend could be reversed by setting maximum waiting periods. Further, the gap in coverage as individuals changed employers could be closed by requiring employers to continue coverage for two months following termination of employment (Davis and Schoen 2003). Policy options like these, designed to strengthen the employer-based system, would help stem the rising tide of uninsured Americans and spread the costs of coverage more equitably across workers, employers, and government. Notes The authors gratefully acknowledge Sherry Glied, Douglas Gould, and Kathrine Jack, of Columbia University, Mailman School of Public Health, for computer programming and data runs off the 2001 Medical Expenditure Panel Survey. They also thank Sherry Glied, Cathy Schoen, and Kathy Swartz for helpful comments on the paper. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff. 1 We analyzed the 2001 Medical Expenditure Panel Survey Household Component Full-Year Consolidated data file. The sample size in 2001 was 12,852 families, representing 33,556 people. More information on the survey methodology is reported elsewhere (AHRQ 2004). The analysis is limited to workers ages 19 to 64 who were employed full time or part time, and not self-employed, and excludes those workers covered by Medicare and in active military service. In addition, the analysis is restricted to a subset of workers who were employed all year in 2001; in other words, they must have said they were employed in each of three interviews. Respondents indicated the size of the establishment in which they worked and whether their employer had employees in other locations. The survey, however, did not include total numbers of employees in the overall firm. Per-capita health care expenditures were inflated to 2004 dollars using actual and projected annual rates of growth in national health expenditures as reported by the Centers for Medicare and Medicaid Services (CMS) (Heffler et al. 2004). The expenditure data for years 2003 and 2004 were projected. Insurance status was defined hierarchically such that each worker was assigned one source of health insurance coverage, even when more than one source was reported. Because workers were interviewed three times over the year, coverage also was defined by whether a worker ever had a source of coverage, using the hierarchical definition. This means, for example, that if a worker reported own-employer coverage in at least one of the three interviews, he or she would be defined as having own-employer coverage all year. We used a similar approach to define offers of own-employer coverage. Those workers who were offered coverage by their employers in any period were defined as taking up coverage if they had own-employer coverage in any period. Workers were defined as not taking up coverage when they received an offer in any period but never had own-employer coverage. Workers without an offer of own-employer coverage in any period were defined as not being offered coverage by their employers. 2 Single workers may obtain other employer coverage from a parent s policy, a former employer s coverage, or a divorced/separated/deceased spouse s employer, as established by the 1985 Comprehensive Omnibus Budget Reconciliation Act. COBRA coverage provides the option of continuing coverage under an employer s plan to an individual who otherwise would lose coverage by reason of termination of employment or the divorce/separation/death of a spouse, or to a young adult who is not a full-time college student and turns age 19. While individuals electing coverage under COBRA are guaranteed coverage at the employer group premium, they are responsible for the full premium plus a 2% administrative fee. 3 Whether an employee has received an offer of insurance is unknown for 2.6 million workers not covered by their own employers. 4 The spending category other sources includes workers compensation, other private sources, and sources unknown. While MEPS does not explicitly identify charity care or uncompensated care, some researchers have assumed that at least some of the spending in this category is uncompensated care. See Hadley and Holahan (2003). 5 These costs are high because they include Medicaid beneficiaries with significant health problems. Medicare beneficiaries with end-stage renal disease or disability are excluded from the analysis. 13

9 Inquiry/Volume 42, Spring 2005 References American Federation of Labor-Congress of Industrial Organizations (AFL-CIO) Wal-Mart: An Example of Why Workers Remain Uninsured and Underinsured. Available at: issuespolitics/healthpolicy/upload/wal-mart_ final.pdf Agency for Healthcare Research and Quality (AHRQ) MEPS HC-060: 2001 Full Year Consolidated Data File, Center for Financing, Access and Cost Trends. Available at: meps.ahrq.gov/puffiles/h60/h60doc.htm Blumberg, L Who Pays for Employer- Sponsored Health Insurance? Health Affairs 18(6): Brittain, J.A The Payroll Tax for Social Security. Washington, D.C.: The Brookings Institution. Collins, S.R., C. Schoen, M.M. Doty, and A.L. Holmgren. 2004a. Job-Based Health Insurance in the Balance: Employer Views of Coverage in the Workplace. New York: The Commonwealth Fund. Collins, S.R., K. Davis, M.M. Doty, and A. Ho. 2004b. Wages, Health Benefits, and Workers Health. New York: The Commonwealth Fund. Collins, S.R., M.M. Doty, K. Davis, C. Schoen, A.L. Holmgren, and A. Ho. 2004c. The Affordability Crisis in U.S. Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey. New York: The Commonwealth Fund. Collins, S.R., C. Schoen, K. Tenney, M.M. Doty, and A. Ho. 2004d. Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help. New York: The Commonwealth Fund. Collins, S.R., K. Davis, and J.M. Lambrew Health Care Reform Returns to the National Agenda: The 2004 Presidential Candidates Proposals. New York: The Commonwealth Fund. Davis, K Making Health Care Affordable for All Americans. Testimony before the Senate Committee on Health, Education, Labor, and Pensions. January 28. Davis, K., and C. Schoen Creating Consensus on Coverage Choices. Health Affairs Web Exclusive (April 23): W Available at: abstract/hlthaff.w3.199v1 Davis, K., B.S. Cooper, and R. Capasso The Federal Employee Health Benefits Program: A Model for Workers, Not Medicare. New York: The Commonwealth Fund. Davis, K., M.M. Doty, and A. Ho How High is Too High: Implications of High Deductible Health Plans. New York: The Commonwealth Fund. DeNavas-Walt, C., B.D. Proctor, and R.J. Mills Income, Poverty, and Health Insurance Coverage in the United States: Washington, D.C.: U.S. Census Bureau. Duchon, L., C. Schoen, E. Simantov, K. Davis, and C. An Listening to Workers: Findings from The Commonwealth Fund 1999 National Survey of Workers Health Insurance. New York: Commonwealth Fund. EP&P Consulting, Inc Report on the Healthy NY Program Prepared for the State of New York Insurance Department. Available at: hnyepp2004.pdf Frist, W.H Shattuck Lecture: Health Care in the 21st Century. New England Journal of Medicine 352(3): Fronstin, P., and R. Helman Small Employers and Health Benefits: Findings from the 2002 Small Employer Health Benefits Survey. Washington, D.C.: Employee Benefit Research Institute. Gabel, J.R., J.D. Pickreign, H.H. Whitmore, and C. Schoen Embraceable You: How Employers Influence Health Plan Enrollment. Health Affairs 20(4): Gabel, J.R., G. Claxton, I. Gil, J. Pickreign, H. Whitmore, E. Holve, B. Finder, S. Hawkins, and D. Rowland Health Benefits in 2004: Four Years of Double-Digit Premium Increases Take Their Toll on Coverage. Health Affairs 23(5): Glied, S., J.M. Lambrew, and S. Little The Growing Share of Uninsured Workers Employed by Large Firms. New York: The Commonwealth Fund. Glied, S., and D. Remler The Effect of Health Savings Accounts on Health Insurance Coverage. New York: The Commonwealth Fund. Goetzel, R.Z., S.R. Long, R.J. Ozminkowski, K. Hawkins, S. Wang, and W. Lynch Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employers. Journal of Occupational and Environmental Medicine 46: Gruber, J The Incidence of Mandated Maternity Benefits. American Economic Review 84(3): Health Insurance and the Labor Market. NBER Working Paper no Cambridge, Mass.: National Bureau of Economic Research. Hadley, J., and J. Holahan, Who Pays and How Much? The Cost of Caring for the Uninsured. Menlo Park, Calif.: Kaiser Family Foundation. Heffler, S., S. Smith, S. Keehan, M.K. Clemens, M. Zezza, and C. Truffer Health Spending Projections through Health Affairs Web Exclusive (February 11): W Available at: abstract/hlthaff.w4.79v1 Henry J. Kaiser Family Foundation/Health Research and Educational Trust (Kaiser/HRET) Employer Health Benefits: 2004 Annual Survey. Menlo Park, Calif.: Kaiser Family Foundation. O Brien, E Employers Benefits from Workers Health Insurance. Milbank Quarterly 81(1): Rosen, S The Theory of Equalizing Differences. 14

10 Shared Responsibility In Handbook of Labor Economics, O.C. Ashenfelter and R. Layard, eds. Amsterdam: North Holland. Summers, L.H Some Simple Economics of Mandated Benefits. American Economic Review 79(2): Swartz, K Healthy New York: Making Insurance More Affordable for Low-Income Workers. New York: The Commonwealth Fund What States Need to Know to Implement Reinsurance for Individual and Small Group Insurance. New York: The Commonwealth Fund. U.S. House of Representatives, Committee on Ways and Means Health Care Resource Book. Figure 53. Washington, D.C.: U.S. Government Printing Office. 15