Class and benefits at the workplace

The health insurance status of low-wage workers: the role of workplace composition and marital status

Many of the provisions in the Affordable Care Act (ACA), such as tax credits and penalties for employers, vary by employer size and average wage level. Therefore, knowing the wage and firm size distribution of low-wage workers and how employer-sponsored insurance (ESI) characteristics vary by these dimensions is particularly important for understanding the extent to which low-wage workers and their employers may be affected by different provisions in the ACA. To inform this issue, the authors use data from the 2006 Medical Expenditure Panel Survey-Insurance Component to examine offers of coverage and cost-sharing requirements by the wage distribution and firm size dimensions of employers. They also draw on Medical Expenditure Panel Survey household-level data to describe the household circumstances of low-wage workers. The authors find that where low-wage workers are employed, who their colleagues are, and their spouses' wage levels are important factors in determining low-wage workers' access to coverage and the cost and generosity of such coverage.

The views of low-income employees regarding mandated comprehensive employee benefits for the sake of health

Socioeconomic factors stand in the way of good health for low-income populations. We suggest that employee benefits might serve as a means of improving the health of low-wage earners. We convened groups of low-income earners to design hypothetical employee benefit packages. Qualitative analysis of group discussions regarding state-mandated benefits indicated that participants were interested in a great variety of benefits, beyond health care, that address socioeconomic determinants of health. Long-term financial and educational investments were of particular value. These results may facilitate the design of employee benefits that promote the health of low-income workers.

The impact of states' small group health insurance reforms on uninsurance rates

The impact of states' small group market reforms on uninsurance rates was examined. Reform status was quantified on five reform dimensions: Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. These reform indices were calculated based on actuarial judgment of the market impact potential of each regulation. Regression analysis showed no association between uninsurance rates and the depth of reforms on any dimension, while controlling for income, foreign-born population, black population, and employment in the smallest businesses. Possible reasons for the lack of impact are discussed.

Reducing the Numbers of the Uninsured

The objective of the study described in this article was to identify a model that best predicts state uninsurance rates and quantifies the contribution of socio-economic factors to enable targeted state programs to reduce uninsurance. Linear regression analysis was carried out using state uninsurance rate as the dependent variable and state-level data on demographic, employment, income, and health care environment data (independent variables). For 2000 data, the model R is 0.77, indicating that 77% of the variation in uninsurance rates is explained by the percentage of immigrant population, the workforce in very small businesses, the Black population, the state's median income, and the Medicare-aged population (model R = 0.77 for 1999 and 0.68 for 1998 data). A 1% increase in immigrant population is associated with 0.18% increase in uninsurance rate. A 1% increase in workforce employed in very small businesses associates with 0.79% increase in uninsurance. The findings indicate substantial potential for reducing uninsurance through targeted state policies. Policy recommendations are made to alleviate the insurance hurdles faced by immigrant and small business employee populations.

Small group health insurance: ranking the states on the depth of reform, 1999

States are ranked based on the potential of their small group health insurance reforms to enhance health insurance uptake. Reforms were quantified based on their market impact potential. Five dimensions of reforms were identified, Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. The reform indices representing these dimensions were developed based on document review of state statutes, combined with actuarial judgment to identify and assign scores to market-relevant regulations in line with their impact potential. The distribution of the states' reform scores and rankings show wide variation in the depth and focus of their reforms. Only seven of the top ten states on the Total Reform index had consistently higher scores on two or more reform dimensions. The conceptual linkages between specific regulations and the documented small group market problems lead to normative expectations of an association between the depth of state reforms and the prevalence of uninsurance.

Reform and remembrance: the place of the private sector in the future of health care policy

Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak: that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system. there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.

Declining employer-sponsored coverage: the role of public programs and implications for access to care

Using data from the 1996/1997 Community Tracking Study household survey, this study examines the effects of public programs on the decision to take up employer coverage when offered versus enrolling in public coverage or being uninsured. The results show that among those with access to employer-sponsored coverage, low-income persons living in states with more expansive eligibility for Medicaid were more likely to decline employer coverage in favor of public coverage, while low-income persons in areas with public hospitals were more likely to decline coverage in favor of being uninsured. While persons who decline employer coverage in favor of public coverage maintain the same level of access to medical care, those who decline coverage in favor of being uninsured give up a considerable degree of access. Implications concerning policies to improve access to care for the uninsured are discussed.

No care for the caregivers: declining health insurance coverage for health care personnel and their children, 1988-1998

OBJECTIVES

This study examined trends in health insurance coverage for health care workers and their children between 1988 and 1998.

METHODS

We analyzed data from the annual March supplements of the Current Population Survey (CPS), a Census Bureau survey that collects information about health insurance from a nationally representative sample of noninstitutionalized US residents.

RESULTS

Of the health care personnel younger than 65 years, 1.36 million (90% confidence interval [CI] = 1.28 million, 1.45 million) were uninsured in 1998, up 83.4% from 1988; the proportion uninsured rose from 8.4% (90% CI = 7.8%, 9.1%) to 12.2% (90% CI = 11.5%, 12.9%). Declining coverage rates in the growing private-sector health care workforce---and declining health employment in the public sector, which provided health insurance benefits to more of its workers---accounted for the increases. Households with a health care worker included 1.12 million (90% CI = 1.05 million, 1.20 million) uninsured children, accounting for 10.1% (90% CI = 9.5%, 10.8%) of all uninsured children in the United States.

CONCLUSIONS

Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured.

Parental employment, family structure, and child's health insurance

OBJECTIVE

To examine the impact of family structure on the relationship between parental employment characteristics and employer-sponsored health insurance coverage among children with employed parents in the United States.

METHODS

National Health Interview Survey data for 1993-1995 was used to estimate proportions of children without employer-sponsored health insurance, by family structure, separately according to maternal and paternal employment characteristics. In addition, relative odds of being without employer-sponsored insurance were estimated, controlling for family structure and child's age, race, and poverty status.

RESULTS

Children with 2 employed parents were more likely to have employer-sponsored health insurance coverage than children with 1 employed parent, even among children in 2-parent families. However, among children with employed parents, the percentage with employer-sponsored health insurance coverage varied widely, depending on the hours worked, employment sector, occupation, industry, and firm size.

CONCLUSIONS

Employer-sponsored health insurance coverage for children is extremely variable, depending on employment characteristics and marital status of the parents.

What accounts for differences in uninsurance rates across communities?

Using data from the 1996-97 Community Tracking Study household survey, this study examines variations in uninsurance rates across communities in the United States. Specifically, regression-based decomposition is used to identify factors that account for high rates of uninsurance in some communities. Differences in explained rates between "high uninsurance" and "low uninsurance" communities are the result of differences in the racial/ethnic composition and socioeconomic status of the population (33%), differences in employment characteristics (26%), and state Medicaid eligibility requirements (12.7%). Although higher costs are associated with a higher likelihood that individuals are uninsured, high-cost communities tend to have lower rates of uninsurance as a result of other factors. Despite the large number of identifiable factors included in the analysis, there is still a substantial amount of unexplained regional variation in uninsurance rates.

Job-based health insurance, 1977-1998: the accidental system under scrutiny

This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research (AHCPR) in 1977, 1987, and 1996; and surveys of employers by the AHCPR in 1977, by the Health Insurance Association of America in 1988, and by KPMG Peat Marwick/Kaiser Family Foundation in 1998. During the study years, in 1998 dollars, the cost of job-based insurance increased 2.6-fold, and employees' contributions for coverage increased 3.5-fold. The percentage of nonelderly Americans covered by job-based insurance plummeted from 71 percent to 64 percent. This decline occurred exclusively among non-college-educated Americans. An information-based global economy is likely to produce not only greater future wealth but also greater inequalities in income and health benefits.