DataWatch Choice Of Health Insurance And The Two-Worker Household by Claudia L. Schur and Amy K. Taylor The past decade has seen a dramatic rise in the number of families in which both the husband and wife are wage earners. 1 The possibility that a family may be eligible for employment-related health benefits through more than one employer has important policy implications. Although an individual s choice between two plans offered at one job has been viewed as a means of increasing competition in the market for health insurance, a couple s choice between two plans from two different jobs raises the possibility that both plans could be chosen. In 1985, 65 percent of workers in medium and large firms had individual coverage fully paid for by their employer, with a corresponding figure of 45 percent for family coverage. 2 Given the size of employer contributions relative to the premium, the availability of employment-related plans to both spouses might well encourage double coverage (coverage by more than one policy), in effect eliminating cost sharing and weakening employer cost containment. Even with coordination of benefits provisions, a family may be able to increase the coverage of many services to 100 percent and, in some instances, eliminate or reduce deductibles. This increased coverage may then encourage increased consumption of health care services. While the magnitude of the extra use stemming from double coverage, is difficult to estimate with existing data sets, the results of the RAND Health Insurance Experiment demonstrated that when insurance pays a larger share of medical care costs, there is a significant increase in the total amount spent for these services. 3 If double coverage does indeed increase use of medical care, then employers may find themselves paying an increasing health care bill, even with cost containment provisions internal to each plan. Estimates presented in this DataWatch show that, as of 1987, 13.8 million persons in two-worker households were covered by two employment-related plans. Current legislative proposals aimed at broadening access to health Claudia Schur is a senior policy analyst at the Project HOPE Center for Health Affairs in Chevy Chase, Maryland. Amy Taylor is a senior economist at the Agency for Health Care Policy and Research in Rockville, Maryland.
156 HEALTH AFFAIRS Spring 1991 insurance coverage for those in the work force may exacerbate this problem of double coverage. The most recent versions of the Kennedy/ Waxman mandated coverage bill (H.R.1845/ S.768) would require that employers enroll all workers and their families in a health insurance plan offering a minimum package of benefits. While the enactment of this proposal would provide much-needed access to health insurance for some workers and their families, it would also have the side effect of increasing coverage options for two-worker households. With the stipulation that employers absorb 80 percent of the cost of this coverage (100 percent for low-wage workers), more two-worker households will have a financially viable option of coverage from two sources. 4 The rise of the two-worker household also raises issues of coordination of benefits and equity across firms. Large employers with generous health plans worry increasingly about subsidizing smaller firms that fail to offer benefits. 5 This concern was evident in a recent federal appeals court case in which a large employer tried to deny family coverage to the spouse of an employee. The court held that a firm could deny benefits to the spouse of an employee under certain circumstances, regardless of whether the spouse is eligible for benefits at his or her job. 6 Although these are important policy issues, little is actually known about the extent of choice faced by two-worker households. This Data- Watch examines the universe of married-couple families in the United States, in which both spouses are employed and under age sixty-five. We look at two-worker households with selected characteristics by the availability of and enrollment in employment-related health insurance coverage for 1977 and 1987. These descriptive statistics provide a preliminary assessment of the availability of insurance and the potential for increasing choice or increasing double coverage in the market for health insurance. For this study, we used data from the 1977 National Medical Care Expenditure Survey (NMCES) and Round 1 of the 1987 National Medical Expenditure Survey (NMES). NMCES collected data from about 40,000 persons in 14,000 households, in addition to surveys of medical care providers, employers, and insurance carriers for these persons. Household respondents were interviewed six times over eighteen months during 1977 1978. NMES collected similar data for 1987. While the data for 1987 used here are limited to Round 1 of NMES, the survey provides a snapshot of the U.S. population during the first part of that year. Data were collected from approximately 36,000 people in 15,000 households, with oversamples of the elderly and other subpopulations of policy interest. 7 It is important to stress that the NMES data are still being edited and are subject to change with verification based on subsequent rounds of data collection.
D ATAWATCH 157 Availability Of Employment-Related Plans Overall, in the 26.5 million households in which both spouses were under age sixty-five and employed in 1987, 45 percent had access to employment-related coverage through only one working spouse (Exhibit 1). In another 42 percent of households, both workers had coverage available, while 13 percent of households were offered no coverage. The availability of health insurance through the workplace varied significantly with a number of characteristics. Several of the most important determinants of availability were job- and/ or firm-related, including income, firm size, and employment status. As shown by Alan Monheit and colleagues, certain classes of workers those earning low wages, employed by firms with twenty-five or fewer employees, and working part time were less likely to be offered employment-related health coverage. 8 The relationship between earnings and the availability of health benefits to both spouses is positive and quite strong. In terms of the combined income of both spouses, the probability of both workers being offered health insurance increased markedly as income increased. Households in the lowest earnings category ($20,000 or less) were significantly less likely to be offered insurance from both spouses jobs than were other households. Low-income families also were much more likely to have neither spouse eligible for coverage (41 percent) than were families in the highest earnings category (6 percent). Closely related to earnings in determining the availability of health benefits is full-time versus part-time status and firm size. Almost twothirds of households with two full-time workers were eligible for health insurance coverage from both spouses jobs, and only 6 percent had no employment-related coverage available, compared to 26 percent and 41 percent, respectively, of households in which neither spouse worked full time. The contrast between availability to households with both spouses employed by large firms versus small firms is similarly striking. Job-related parameters were highly correlated with the availability of health insurance coverage in both 1977 and 1987 (Exhibit 1). While the distribution of two-worker households across income categories shifted up between 1977 and 1987, the distribution of availability across years is surprisingly similar. 9 One exception is the percentage not offered any plan in the lowest income group, which rose from 30 percent in 1977 to 40 percent in 1987. The relationship of firm size to access remained surprisingly constant across the decade, with the exception of households in which both spouses worked for small firms. For this group, the proportion of households in which both spouses were offered health insurance coverage
158 HEALTH AFFAIRS Spring 1991 Exhi b it 1 Working Married Couples Age 65 Or Younger, By Availability Of Employment-Related Insurance, 1987 And 1977 Characteristics of working couples, 1987 Total population Combined earned income a $20,000 or less $20,001 $30,000 $30,001 $40,000 $40,001 $50,000 $50.001 or more Num ber of household s Employment-related insurance offered (thousands) One spouse Neither spouse 26,481 42.3% 44.8% 12.9% 2,994 4,354 20.3 30.0 38.9 53.9 40.8 16.1 5,453 41.1 48.5 10.4 4,822 8,278 47.1 56.2 44.7 38.1 6.2 5.6 Firm size Large firm (26 or more employees) 9,561 65.3 29.6 5.1 Husband only 5,348 27.3 66.7 6.0 Wife only Small firm (under 26) 5,284 34.5 54.9 10.5 6,253 26.9 40.5 12.6 Employment status Full time Husband only Wife only Neither Self-employed, either 1977 Total population Combined earned income $10,000 or less $10,001 $15,000 $15.001 $20,000 $20,001 $25,000 $25,001 or more Firm size Large firm (50 or more employees) Husband only Wife only Small firm (under 50) Employment status Full time, all year Husband only Wife only Neither Self-employed, either 13,839 62.7 31.1 6.2 5,301 21.4 68.2 10.4 576 24.4 61.3 14.5 419 25.8 33.0 41.3 6,346 18.1 54.4 27.5 21,347 41.7% 48.9% 9.4% 3,047 16.2 54.3 29.5 4,231 29.9 60.5 9.6 4,826 44.6 51.1 4.3 3,662 5,488 55.4 53.8 40.8 39.8 3.7 6.3 8,232 3,549 3,149 2,631 8,388 7,712 762 730 3.755 67.0 30.9 2.1 b 29.5 67.7 2.8 b 36.4 52.9 10.9 15.9 54.2 30.0 76.3 20.9 2.9 22.5 68.7 8.7 48.8 47.9 3.3 b 25.2 52.7 22.1 5.6 70.1 24.2 Sources: Agency for Health Care Policy and Research, National Medical Expenditure Survey, Household Survey, Round 1, 1987; and National Medical Care Expenditure Survey, Household and Health Insurance Employer Survey, 1977. a Excludes couples for whom self-employed income is missing for one spouse. b Relative standard error greater than or equal to 30 percent.
D ATAWATCH 159 increased from 16 percent in 1977 to 27 percent in 1987. 10 The relationship is less constant over time with respect to employment status. 11 When both spouses in a couple work full time, there seems to be a significant drop in the proportion who have health insurance offered by two employers (76.3 percent in 1977 versus 62.7 percent in 1987). And, in households in which neither spouse works full time, the percentage of cases in which neither spouse was eligible for coverage almost doubled. When one spouse works full time and the other part time, gender differences have narrowed over time. While in 1977 it looked as if men employed part time or part year were more likely than women to get benefits, that difference is notably lacking in 1987. Enrollment In Employment-Related Plans In 1987, 13.8 million individuals, or just over 60 percent of households in which both workers were eligible for insurance, chose to enroll in both of those plans (Exhibit 2). With a choice of two family plans, both spouses and dependents are then double-covered; a choice of one family plan and one individual plan implies double coverage for one family member. Of households with two plans, the two most frequent choices were to enroll both spouses in family coverage or to enroll only the husband in a family plan. At the other end, very few families chose to cover only one of the two spouses or to enroll neither spouse in the employment-related coverage available. While no firm conclusion can be drawn due to the large relative standard errors on these estimates in 1977, the data in these categories suggest some decrease in enrollment over the decade. Enrollment status varied somewhat by family size; most notably, families with no dependents were more likely to choose two individual plans than were families with children (22 percent versus 1.5 percent). Fewer coverage combinations were available to families in which only one worker was offered job-related health benefits. Over 60 percent of these households chose family coverage through the husband s place of employment, while 26 percent chose family coverage through the wife s job. Clearly, even in households with two workers, it is still more likely for the husband to be holding the type of job at which health benefits are available. In terms of the distinction between families with children and those without, it seems that women with no children are more likely to hold jobs that offer health benefits. Thirty-one percent of two-spouse families with no dependents where only one spouse was offered coverage purchased a family plan through the wife s job, compared to 24 percent of these families with dependents. Examination of the enrollment status of two-worker families between
160 HEALTH AFFAIRS Spring 1991 Exhi b it 2 Enrollment In Employment-Related Plans, Married Couples With Both Spouses Employed, 1987 And 1977 1987 Total No d ep endents With dependents Both One Both One Both O n e offered offered offered offered offered offered Number of households a 11,211 11,857 4,542 3,627 6,670 8,230 Type of employment-related plan Both family 28.4% NA 23.7% NA 31.6% NA Husband family, wife individual 17.6 NA 15.6 NA 19.0 NA Wife family, husband individual Borh individual Husband only, family Wife only, family Both not enrolled One individual, one not enrolled 1977 7.2 NA 4.9 NA 8.7 NA 9.8 NA 22.0 NA 1.5 b NA 27.3 63.3 23.9 54.9 29.6 67.0 6.9 25.7 4.9 30.5 0.4 b 23 6 0.6 b 4.3 0.8 b 4.5 0.4 b 4:3 2.2 5.5 4.3b a.9 0.8 b 4.0 Number of households a 8,901 10,436 3,887 2,875 5,014 7,560 Type of employment-related plan Both family 3 5. 0 % N A 3 2. 0 % N A 37.3% NA Husband family, wife individual 29.1 N A 27.7 NA 30.1 NA Wife family, husband individual 7.1 NA 8.0 NA 6.4 NA Both individual 7.0 NA 12.3 NA 2.9 b NA Husband only, family 18.5 79.0 15.3 66.2 21.0 83.9 Wife only, family 1.9 15.0 2.1 b 26.0 1.8 10.9 Both not enrolled 1.2 b 2.5 2.3 b 3.3 b 0.3 b 2.2 b One individual, one not enrolled 0.3 b 3.3 0.3 b 4.6 b 0.3 b 2.8 Sources: Agency for Health Care Policy and Research, National Medical Expenditure Survey, 1987, Household Survey, Round 1, 1987; and National Medical Care Expenditure Survey, Household and Health Insurance Employer Survey, 1977. a Thousands. b Relative standard of error greater than or equal to 30 percent. 1977 and 1987 suggests two trends. First, there is some lessening in the tendency toward enrollment in more than one plan. While almost 80 percent of households where both spouses were offered coverage chose to enroll in two plans in 1977, only 63 percent made that choice ten years later. For those who did choose two plans, the proportion electing the most generous choice enrollment in two family plans dropped somewhat, from 35 percent to 28 percent. Several explanations exist for this drop in enrollment. Not only did the overall cost as well as the required
D ATAWATCH 161 employee contribution to health insurance rise from 1977 to 1987, but marginal tax rates and earnings per worker fell. For households in which only one spouse had employment-related coverage available, one can again note some equalizing in terms of gender. While the proportion choosing only the husband s family coverage fell, the group selecting the wife s family plan increased substantially. This trend carried through the families with and without dependents. From the present analysis, it is not clear whether this is due to changes in offering patterns by firms or in women s employment characteristics. Conclusions The past decade has produced a number of changes in the structure of employment-related insurance and in the demographics of the population covered. With respect to two-spouse families with two wage earners, we have found higher earned incomes, a move toward smaller firms, and an increase in women working full time. Growth in this segment of the population suggests potential for increased availability and choice of benefits to American families. We have found, however, that despite such changes, the percentage of households in which both spouses were offered employment-related coverage has remained constant over the decade. And, although access to coverage increased for some families, the proportion of households in which neither spouse has job-related health benefits available has actually increased. In fact, the increase in availability due to the growth in this segment of the population seems not to have materialized as one might have expected. Instead, it seems that other forces underlying the availability of health insurance have counteracted the rise in labor force participation among women. In particular, it seems likely that the increased proportion of households with no access to work-related coverage reflects a general trend observed in the population at large over this same time period. 12 Moreover, we suggest that changes in the economy, such as a shift toward the service sector, have worked to keep the level of availability roughly constant over this time period (instead of the expected increase) and that a general reduction in the generosity of employment-related benefits has redirected the selections made by workers If these trends continue, concerns about coverage by more than one plan will remain a problem to be grappled with by individual insurers and employers rather than an issue requiring the attention of public policymakers. On the other hand, with the enactment of a proposal such as the Kennedy/ Waxman bill, double coverage would emerge as an issue of policy concern. At a minimum, this would result in some increase in the
162 HEALTH AFFAIRS Spring 1991 number of individuals with two plans. The extent to which the rise in availability would lead families to choose to be covered by more than one health insurance plan is unclear, although currently over half of households offered two plans choose to enroll in both. Clearly, such a scenario of double coverage could negate changes in benefits intended to moderate the rise in medical care costs, with important implications for the use of medical care and associated expenditures. Data from the NMES Health Insurance Plan Survey should provide a more complete picture of the health insurance choices made by families and the factors that influence these decisions. The additional data will allow examination of the impact of many changes that have occurred in the market for health insurance over the past decade, including changes in the scope and structure of benefits offered by employers and changes in the level of employer contributions. Multivariate analysis of the choice of health insurance plan by two-worker families should enable us to disentangle the effects of the increase in labor force participation of women, changes in the availability of employment-related benefits, and employer cost containment measures. The views expressed in this DataWatch are those of the authors, and no official endorsement by the Project HOPE Center for Health Affairs, the Agency for Health Care Policy and Research, or the Department of Health and Human Services is intended or should be inferred. A preliminary version of this research was presented at the Annual Meetings of the American Public Health Association, November 1988, in Boston, Massachusetts. NOTES 1. U.S. Bureau of the Census, Statistical Abstract of the United States: 1986, 106th ed. (Washington, D.C.: U.S. Government Printing Office, 1985). Two-spouse families with two earners were 49 percent of all such families in 1977 and 56 percent in 1986. Figures are from the Bureau of Labor Statistics, Division of Family and Marital Characteristics of the Labor Force, and were calculated from the March 1978 and March 1987 Current Population Survey. 2. G.A. Jensen, M.A. Morrisey, and J.W. Marcus, Cost-Sharing and the Changing Pattern of Employer-Sponsored Health Benefits, The Milbank Quarterly 65, no. 4 (1987): 521 550. 3. See, for example, W. Manning et al., Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment, American Economic Review (June 1987): 251 277; M. Feldstein, Hospital Cost Inflation: A Study of Nonprofit Price Dynamics, American Economic Review (December 1971): 853 872; A. Scitovsky and N. Snyder, Effect of Coinsurance on Use of Physician Services, Social Security Bulletin (June 1972): 3 19; and C. Phelps and J. Newhouse, Effects of Coinsurance: A Multivariate Analysis, Social Security Bulletin (June 1972): 20 29. 4. The bill requires that the employee enroll in the health plan and allows an exception only for a spouse or children covered under another employment-related plan. This implies that every two-worker household with dependent children will, at a minimum,
D AT AW AT C H 1 6 3 be enrolled in two plans -one family and one individual so at least one family member will have double coverage. In the most recent version of the bill, employees working fewer than twenty-five hours per week would be entitled to waive coverage. 5. While the idea of large firms subsidizing small firms contradicts the economic literature on choice of compensation arrangement, it is somewhat akin to a transfer between large firms that provide subsidized benefits to workers and their families and small firms that provide no health benefits. Because small firms cannot offer the same wage/ benefit tradeoff as large firms (due to higher administrative costs and less ability to pool risks), the provision of family health coverage to large-firm workers enables small firms to maximize wage compensation. At the same time, secondary workers in small firms are still able to get employment-related coverage through a spouse s job, with some portion of the premium being paid by the large firm. It should also be noted that the contribution to a firm for a family plan is generally in excess of the contribution to an individual plan. 6. The Washington Post, 10 April 1988. The case involved J.C. Penney Co., which covers spouses of employees only if the employee is head of the household and earns more than 50 percent of household income. 7. For additional information on the design of NMES, see W. Edwards and M. Berlin, Questionnaires and Data Collection Methods for the Household Survey and the Survey of American Indians and Akrsku Natives, DHHS Pub. no. 89-3450, NMES Methods 2 (September 1989). Private insurance coverage was assigned based on responses by household survey respondents concerning their coverage at the time of the Round 1 NMES interview (sometime between February and April 1987). These estimates can consequently be viewed as point-in-time estimates of persons with private health insurance coverage. Estimates of employment status, also based on information provided by household respondents, cover employment at any time during the Round 1 reference period (from 1 January 1987 to the interview date). Private coverage was considered to be employment-related if plan information could be linked to a job or union previously reported by that respondent. All of the estimates are based on persons under age sixty-five as of the Round 1 interview date, who reported themselves as married and were living with their spouse. 8. A.C. Monheit et al., The Employed Uninsured and the Role of Public Policy, Inquiry (Winter 1985): 348 364. 9. Earnings categories for 1987 were calculated to be comparable to those for 1977 after accounting for inflation. In fact, because categories for 1987 are twice as high as in 1977, while earnings increased by a factor of 1.8, these figures tend to understate the upward shift in earnings of two-worker families. 10. Although the definition of a small firm varies from 1977 (fewer than fifty employees) to 1987 (fewer than twenty-six employees), the direction of the difference is such that the change is even more dramatic than the numbers would suggest. 11. The employment status categories are not strictly comparable due to the difference in time periods for the two data sets. Because the 1987 estimates are based on first-quarter data, this group includes some persons who will not work full time for the entire year. Since these persons may be generally less likely to be offered coverage, this difference may be somewhat overstated. 12. The uninsured represented about 15.5 percent of the civilian noninstitutionalized population in the early part of 1987, compared to 12.3 percent in the first part of 1977. See P. Short, A. Monheit, and K. Beauregard, A Profile of Uninsured American, DHHS Pub. no. (PHS) 89-3443, National Medical Expenditure Survey Research Findings 2 (Hyattsville, Md.: National Center for Health Services Research and Health Care Technology Assessment, September 1989).