Health Economics Program

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1 Heath Economics Program Issue Brief Juy 2001 Mandated Heath Insurance Benefits and Heath Care Costs Mandated heath insurance benefits are often a matter of significant poicy debate. Proponents of mandates argue that they assist in providing access to necessary services and often reduce pubic costs for heath care, particuary in the case of preventive heath services. Opponents of mandated benefit aws contend that mandates raise the costs of premiums, potentiay causing empoyers to discontinue their heath insurance and utimatey increasing the number of uninsured persons. This issue brief expains what mandated benefit aws are and who they impact, and reviews the evidence on how they affect heath care costs. There are a variety of other issues reated to mandated benefits not addressed by this brief incuding quaity impications, the use of evidence-based medicine in making covered benefit decisions, and the appropriate roe of state and federa awmakers in determining heath benefits. Rather, this issue brief focuses on describing what benefit mandates are, reviewing the evidence on the costs of mandates, and the examining research around empoyer coverage and benefit mandates. The primary findings contained in this issue brief are: mandated heath benefits raise premium costs to some degree; however, these increases are generay more modest than commony cited figures; the type of mandate appears to have a much greater impact on cost than the sheer number of mandates enacted; benefit packages offered through sef-funded or fuy-insured pans are generay quite simiar to one another and the evidence suggests that most sef-insured pans cover the majority of mandated benefits; and, mandates do not appear to pay a major roe in a firm s decision to sef-insure. What are Mandated Benefits? Mandated benefits are requirements put into pace by the federa or state governments. These requirements reguate the terms of coverage in the heath pans sod by private insurance companies and HMOs, or provided by empoyers under sef-funded pans. Mandates fa into severa categories, incuding benefit mandates, provider mandates, specia-popuation mandates, and to a esser extent, market mandates. Benefit or treatment mandates require insurers to cover certain treatments, services or procedures. Exampes incude chid immunizations, ora contraceptive coverage, and prostate cancer screenings. Provider mandates require insurers to pay for services provided by specific providers, such as nurse practitioners or chiropractors. Mandates which are popuation-based require coverage of certain categories of peope, such as handicapped dependents. Finay, market mandates incude certain insurance reform efforts such as disaowing restrictions on coverage for pre-existing conditions. (For a categorization of mandated benefits in Minnesota, see tabe 1). Minnesota Department of Heath

2 Mandated Heath Insurance Benefits and Heath Care Costs Tabe 1 Mandated Benefits in Minnesota BENEFITS PROVIDERS POPULATION maternity benefits minimum maternity stay TMJ treatment we-chid visits (incuding immunizations) pre-nata care residentia treatment for handicapped chidren parity treatment for menta heath and chemica dependency DES-reated cancers PCA or private nurse for ventiator dependents in home reconstructive surgery PLK treatment yme disease treatment osteopaths optometrists chiropractors podiatrists dentists marriage therapists advanced practice nurses physica and occupationa therapists psychoogists socia workers newborns from moment of birth adopted chidren from time of adoption handicapped dependents scap-hair prostheses for aopecia areate port-wine stain remova high-dose chemotherapy with autoogous bone marrow transpant diabetic equipment and suppies prostate cancer screening coverage for off-abe drugs to treat cancer coverage for emergency services cervica cancer screening ceft paate mammography MARKET cannot terminate handicapped chidren's coverage when they reach poicy's imiting age no denia of coverage due to fibrocystic breast condition poicy rates cannot be based on gender no denia of coverage for pre-authorized services Minnesota Department of Commerce, Bue Cross and Bue Shied Association. direct access to OB/GYN cost-sharing and co-payment imits Who is Affected by Mandated Benefit Laws? The size of the popuation affected by a mandated benefit requirement depends upon the egisative body which enacts the mandate. In the case of aws enacted by the federa government, the mandate generay supersedes state aw uness state aw is more stringent. Mandates enacted by the federa government generay cover every individua enroed in a private heath insurance pan in the United States. When a state government enacts a mandated benefit aw, the mandate does not generay cover every state resident who is enroed in a private heath insurance pan. This is due to the Empoyee Retirement Income Security Act (ERISA) of 1974, a federa aw which pre-empts state reguation of empoyer sef-funded pans. 1 In Minnesota, mandates for private heath insurance pans ony affect percent of the state s popuation. This is because a state mandate does not cover peope who are uninsured (five percent), covered by a pubic program such as Medicare, Medicaid, or MinnesotaCare (23 percent), or, as expained above, covered through an ERISA sef-funded pan (37 percent). 1 However, reguations governing HMOs require simiar treatment of pubic and private program members. This resuts in certain pubic program enroees being covered by enacted mandates due to the fact that they are receiving heath coverage through an HMO. The State Empoyee Group Insurance Program (SEGIP), which covers empoyees of State government and the University of Minnesota, is an exception to the genera rue that empoyer sef-funded pans are exempt from benefit mandates. Athough sef-funded, SEGIP is required by state aw (M.S. 43A.23) to abide by a coverage mandates. Federa Benefit Mandates Prior to 1996, insurance reguation had been eft primariy to the states. In recent years, however, the federa government has enacted severa mandated benefits aws. This incudes 48-hour maternity stay egisation, parity for menta heath benefits, and the Heath Insurance Portabiity and Accountabiity Act (HIPAA). HIPAA is a wide-reaching aw that guarantees issue of 2

3 Mandated Heath Insurance Benefits and Heath Care Costs heath insurance to sma businesses, guarantees renewa of sma business insurance poicies, increases the tax-deductibiity of heath insurance for the sef-empoyed, and paces imits on the amount of time group insurance pans can excude someone from coverage due to a pre-existing medica condition. In the case of HIPAA, 36 states, incuding Minnesota, had aready enacted equivaent reforms by the time they were in pace on the federa eve. Thus, sef-insured ERISA pans were those most affected by these new aws. 2 What are the Costs Associated with Mandates? In order to examine the estimated cost of benefit mandates, we reviewed current iterature and spoke with experts in the fied. The financia costs of benefit mandates are not we documented and estimates vary widey, athough studies agree that mandating a heath benefit raises costs to some degree depending on the mandate. Recenty reeased comprehensive studies which we examined showed that in some cases individua mandates actuay decrease costs and in the cases where costs increase, the increase is generay between six and seven percent for a broad package of mandates. Perhaps one expanation for the variation in cost estimates often cited is that many studies cacuate the cost of mandates by reviewing insurance caims and reporting the amount of money spent on a specific benefit in a given year. In many cases, the fu share of caims shoud not be attributed to the cost of a mandate, however, because some coverage may have been provided anyway. A more accurate measure of mandate cost is the margina cost, that is, the difference between actua costs and the costs that woud have been incurred without the mandates. 3 One of the most comprehensive and we-documented studies of the cost of benefit mandates was a September 2000 actuaria study commissioned by the Texas Department of Insurance and conducted by Miiman and Robertson. The study examined 13 mandated benefits: chemica dependency, compications of pregnancy, ora contraceptives, congenita defects, HIV/AIDS, mammography and prostate screening, serious menta iness, minimum hospita stays for maternity and mastectomy, reconstructive breast surgery, handicapped dependents, and chidhood immunizations. Among the measures empoyed to determine costs of individua mandates were utiization statistics, incidence rates, physica and economic consequences of not providing care, current and future medica cost savings, and impact on utiization of sick days or disabiity benefits. Athough this study excusivey examines benefits in the state of Texas, it is pertinent to the genera debate regarding mandated benefits because the benefits studied are some of the most widey mandated. Additionay, they are ikey to be some of the most costy, since they invove arge numbers of patients and/or reativey expensive treatments. 4 This study found that direct premium costs of the mandates were estimated to account for a combined tota of 7.6 percent for arge group premiums and 7.2 percent for sma group premiums, before accounting for the fact that many of these services woud ikey be covered at some eve even if there were no mandate (see Tabe 2). As a resut, these figures coud be viewed as upper-end cost estimates. This number is reduced to 6.5 percent of arge group premiums and 6.3 percent of sma group premiums when indirect heath care costs (foow-up testing and treatment) and offsetting savings (decreased hospitaization, earier detection) are taken into account. 5, 6 3

4 Mandated Heath Insurance Benefits and Heath Care Costs Mandate Miiman and Robertson, September Tabe 2 Premium Impact of Seected Mandates Direct and Indirect Percent Premium Cost: Large Group Direct and Indirect Percent Premium Cost: Sma Group Chemica Dependency 0.4% 0.4% Compications of Pregnancy 0.5% 0.5% Ora Contraceptives 0.2% 0.2% Congenita Defects 1.3% 1.4% HIV/AIDS/HIV-Reated Inesses 1.1% 1.1% Mammography 0.5% 0.5% Prostate Screening 0.2% NA Serious Menta Iness 1.6% 1.5% Minimum Hospita Stay-Maternity 0.3% 0.3% Minimum Hospita Stay-Mastectomy 0.0% NA Reconstructive Surgery for Mastectomy 0.1% 0.1% Handicapped Dependents 0.3% 0.3% Chidhood Immunizations 0.0% NA Tota 6.5% 6.3% Henderson et. a. (2000) recenty competed a study invoving mandate-reated data from a 50 states and found that poicyhoders in a state with an average number of mandates (20) coud experience anywhere from a 5.3 percent decrease in premiums to a 4.6 percent increase in premiums because of mandates, depending on the mix of mandates. The study authors found that, in the case of HMO and indemnity premiums, mandating specific benefits or requiring that certain popuations be covered generay increases costs. The study isted bone-marrow transpants, drug abuse treatment, infertiity services, and off-abe drug use among the most expensive mandates. However, some benefits, such as acohoism treatment and provision of diabetic suppies, were associated with reduced costs. In most cases, mandating coverage for aternative providers, such as psychiatric nurses and speech/hearing therapists, was found to decrease costs for HMOs and was neutra for indemnity companies. 7 Some observers have argued that a higher number of mandates eads to higher eves of premiums and overa heath care costs. There are numerous factors that infuence premium costs in a given state, incuding the heath of the popuation, genera business costs, generosity of benefits, and potentiay, mandates. We examined the reationship between empoyer heath insurance premiums and the number of mandates in each state, shown in Figure 1. As the figure shows, there appears to be imited correation between the eve of premium paid by empoyers and the number of mandated benefits. This suggests that the type of mandate passed may have a more significant effect on premiums than the sheer number of mandates. 4

5 Mandated Heath Insurance Benefits and Heath Care Costs Figure 1 $6500 Average Yeary Empoyer Premiums vs. Number of Mandates, by State Average Yeary Famiy Premium $6000 $5500 $5000 AL DE IA MI NH WY INWI NJ MA NY FL CT WA CO PA TX AZ WV NEOR LAUT CA SC OH GA VA OK KS MO KY IL HI TN MN NC NM AR MD $ Number of Mandates Bue Cross and Bue Shied Association, December 1999, and Department of Heath and Human Services, Medica Expenditure Pane Survey, Wi Empoyers Offer Certain Benefits if They are not Mandated? 15 One concern often raised about mandates is that they require coverage of benefits that woudn't be offered vountariy. The Miiman and Robertson study examined this issue by conducting a survey of sef-funded pans not subject to the mandate. According to the survey, over 90 percent of sef-funded empoyers covered a of the thirteen benefits being studied at some eve. The study authors estimated that in the absence of a mandate, ten of the benefits woud ikey be covered at the mandated eve, but that chemica dependency, serious menta iness, and chidhood immunizations woud ikey be covered at a reduced benefit eve. Other studies over time support the finding that ERISA pans offer coverage simiar to purchased pans despite the fact that they are not subject to mandates. A study which examined data from 1995 indicates that in states with mandated menta heath benefits, amost a arge sef-insured firms chose to cover menta heath care: 97 percent had coverage for in-patient care and 98 percent had coverage for outpatient care. 8 A simiar study, which was focused on chiropractic benefits, found that 88 percent of sef-insured firms in states with chiropractic mandates offered a simiar benefit to their empoyees. 9 Additionay, a nationwide study conducted in 1993, found that sef-insured pans offered coverage neary identica to that in state-reguated pans. 10 Finay, a study conducted by the Minnesota Office of the Legisative Auditor in 1988 examined benefits offered by sef-insured empoyers. 11 The Legisative Auditor found that the majority of enroees in sef-insured pans receive benefits simiar to those in fuy insured pans, particuary in the case of arger firms. This coud be evidence that sef- 5

6 Mandated Heath Insurance Benefits and Heath Care Costs insured empoyers beieve they need to offer a benefit package as generous as fuy insured pans in order to attract empoyees. It coud aso simpy be a resut of the fact that most sef-insured firms are arge empoyers and arge empoyers generay offer more generous benefit pans than smaer firms. In either case, the evidence suggests that sef-insured pans offer benefit packages that are simiar to fuy-insured pans, and have done so over time. Do Mandates Encourage Firms to Sef- Insure? A concern often raised about insurance mandates is that they encourage firms to sef-insure in order to avoid the mandates. As noted above, most sef-insured empoyers incude mandated benefits in their heath benefits packages even though they are not required to do so. In a study which anayzed firm data from most of the 1980 s, Jensen, et. a. found that state benefit mandates had a positive but statisticay insignificant effect on the ikeihood of a firm with more than 50 workers deciding to sef-insure. The same study found that premium taxation had stronger effects on the decision to sef-insure. 12 A component of the Miiman and Robertson study was a survey of empoyers who choose to sef-fund their heath benefits. Of those surveyed, 72.6 percent said that mandated benefit requirements did not infuence their decision to sef-insure, 17.9 percent reported that it was one of severa factors and for the remaining 9.6 percent, it was a very important factor in their decision-making process. The eve of sef-funding in Minnesota is very simiar to the nationa average: in 1998, the percentage of businesses with sef-funded pans was 26.0 percent in Minnesota and 26.9 percent nationay. For firms with fewer than 50 empoyees, 8.3 percent of those that offered coverage were sef-insured compared to 11.2 percent nationay. For empoyers with 50 or more empoyees, 59.6 percent of those offering coverage in Minnesota were sef-insured compared to 52.3 percent nationay. However, in a three cases, the differences between Minnesota and the nationa average were statisticay insignificant. 13 Catastrophic or No-Mandate Heath Pans A concern that some have raised about insurance mandates is that the resuting increase in costs due to mandates is high enough that it prohibits sma businesses from purchasing heath coverage, makes maintaining coverage for those that offer coverage more difficut, or forces those that aready have coverage to discontinue offering insurance. Some have caimed that by eiminating requirements for mandated benefits, sma firms coud achieve substantia reductions in premium costs. 14 In response to this concern, the Minnesota Legisature passed a aw in 1999 which aows firms with fewer than 50 workers to purchase insurance pans that don t incude a of the state s mandated benefits. Thus far, no insurer has begun to market this type of pan. Many companies have said that initia marketing and administrative costs of these pans woud be quite high, making it difficut to se to sma empoyers because there woud not be a great difference in cost between the scaed-back coverage and a more generous poicy. Business groups and other trade associations argue that the high price of the scaed-down pan is due to the fact that maternity services are required to be offered as part of the insurance package. The requirement is based upon interpretation of state and federa human rights and discrimination aws which state that maternity coverage must be part of any heath benefits package. 15 One recent study of nationa proposas to exempt certain sma empoyer pans from offering mandated benefits concuded that premiums paid by sma empoyers that choose to purchase these no-mandate pans woud be about 13 percent ower than the premiums they woud otherwise pay. Five percentage points of the decine was estimated to come from the benefit mandate exemption. Most of the decine (the remaining eight percentage points) woud come from the fact that firms taking advantage of the proposa woud ikey have heathier empoyers on average than other sma firms. As a resut, the popuation that remained in pans subject to mandates woud be sicker on average than before, and premiums for this group woud rise by two percent. 16 Concusion This issue brief was intended to evauate and synthesize the existing evidence on the effect that mandated benefits have on the cost and avaiabiity of insurance coverage. Overa, we found that: mandated heath benefits raise premium costs to some degree; however, these increases are generay more modest than commony cited figures; the type of mandate appears to have a much 6

7 Mandated Heath Insurance Benefits and Heath Care Costs greater impact on cost than the sheer number of mandates enacted; benefit packages offered through sef-funded or fuy-insured pans are generay quite simiar to one another; and, mandates do not appear to pay a major roe in a firm s decision to sef-insure. The Heath Economics Program wi continue to monitor the issue of mandated benefits to ensure that accurate and timey information is avaiabe to poicymakers and the pubic as Minnesota continues its efforts to make heath insurance affordabe for a Minnesotans. 1 For more information, see Sef-Funding of Heath Care Benefits, March, Minnesota Department Of Heath, Heath Economics Program. 2 Gai Jensen and Michae Morrisey, Empoyer-Sponsored Heath Insurance and Mandated Benefit Laws, The Mibank Quartery, Voume 77, Number 4, For an exampe of a study that utiizes tota caims costs, see: Dyckman, Z. and Anderson-Johnson, J The Cost of Mandated Insurance Benefits: The Maryand Experience. American Pubic Heath Association Meeting, Coumbia, Maryand. 4 Susan Abee, Esther Bout, Muoy Hansen, Tim Lee, Mark Litow, and Mike Sturm, Cost Impact Study of Mandated Benefits in Texas, Miiman & Robertson, Inc., September 28, Screening benefits often resut in a sight increase in indirect costs for three reasons. First, the benefit increases the overa number of peope screened, which in turn increases the number of peope referred for foow-up testing, many of whom are fase positives. Second, athough there is a cost savings due to earier diagnosis and ess costy treatment, the greater number of peope receiving treatment outweighs this benefit. Finay, aso reated to earier diagnosis, some cases which woud have been paid for by Medicare are shifted to the commercia popuation. 6 Benefits considered to have offsetting savings incude chemica dependency, ora contraceptives, serious menta iness, and chidhood immunizations. Benefits associated with indirect heath care costs are mammography and prostate screening. 7 James Henderson, J. Aen Seward, and Beck Tayor, State- Leve Mandates and Premium Costs, December 2000, Presented at the American Economic Association Annua Meeting. 8 Gai Jensen, Kathryn Rost, Russe Burton, and Maria Buycheva, Menta Heath Insurance in the 1990s: Are Empoyers Offering Less to More?, Heath Affairs, May/June Gai Jensen, Canopy Roychoudhury, and Danie Cherkin, Empoyer-Sponsored Heath Insurance for Chiropractic Services, Medica Care, Voume 36, Number 4, Apri Gregory Acs, Stephen Long, Susan Marquis, and Pamea Farey Short, Sef-Insured Empoyer Heath Pans: Prevaence, Profie, Provisions, and Premiums, Heath Affairs, Summer Office of the Legisative Auditor, Heath Pan Reguation, February Gai Jensen, K.D. Cotter, and Michae Morriesy, State Insurance Reguation and an Empoyer s Decision to Sef Insure, Journa of Risk and Insurance 62: Department of Heath and Human Services, Medica Expenditure Pane Survey, For exampe, see St. Pau Pioneer Press, November 17, 2000, Cut Mandated Benefits, Heath Cost Contro Shoud be Priority. 15 Persona communication, Minnesota Department of Commerce, February Congressiona Budget Office, Increasing Sma-Firm Heath Insurance Coverage Through Association Heath Pans and Heathmarts, January

8 Mandated Heath Insurance Benefits and Heath Care Costs The Heath Economics Program conducts research and appied poicy anaysis to monitor changes in the heath care marketpace; to understand factors infuencing heath care cost, quaity and access; and to provide technica assistance in the deveopment of state heath care poicy. For more information, contact the Heath Economics Program at (651) This issue brief, as we as other Heath Economics Program pubications, can be found on our website at: h eath e conomics p rogram Minnesota Department of Heath Heath Economics Program 121 East Seventh Pace, P.O. Box St. Pau, MN (651) Upon request, this information wi be made avaiabe in aternative format; for exampe, arge print, Braie, or cassette tape. Printed with a minimum of 30% post-consumer materias. Pease recyce.

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