EBRI issue brief最新文献

ABOUT CDHPs: Employers began offering consumer-driven health plans (CDHPs) in 2001 when a handful started offering health reimbursement arrangements (HRAs). They then started offering health savings account (HSA)-eligible plans after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included a provision to allow individuals with certain high-deductible health plans to contribute to an HSA. This report summarizes what is known about CDHPs, which include both HRAs and HSAs. OFFER RATES: Surveys show that employers offering a CDHP increased from less than 5 percent in 2005 to between 12-15 percent by 2009. Growth in offer rates can be seen across all firm sizes. Recently, the percentage of small firms that offered a CDHP declined while larger firms continued to add a CDHP as an option.

Enrollment: Overall, 19.1 million, or 11 percent of individuals with private insurance, were enrolled in a CDHP in 2009. More recent data suggest that by 2010, 10 million people were in an HSA-eligible plan. PREMIUMS: Generally, premiums for CDHPs were lower than premiums for non-CDHPs. A number of studies have tried to explain the differences in premiums. One found savings ranged from 15.5 percent to a low of -4.7 percent, with average savings of 4.8 percent. However, the study found that most of the savings was due to younger, healthier workers choosing CDHPs and concluded that once typical risk- and benefit-adjustment factors were taken into account, CDHPs saved only 1.5 percent. There is strong evidence that initially CDHP enrollees will be healthier than non-CDHP enrollees, but that over time the CDHP population has a significantly higher illness burden. IMPACT OF CDHPS ON PREVENTIVE SERVICES: The studies agree that use of preventive services did not change (upward or downward) as a result of the CDHP. IMPACT OF CDHPS ON MEDICATION ADHERENCE: The studies found that overall use of brand-name prescription drugs fell and, while there was some offset from increased use of generic drugs, some enrollees stopped their use of prescription drugs. CDHP enrollees increased their use of the mail-order pharmacy option. Overall use of prescription drugs among CDHP enrollees with certain chronic conditions fell, or did not increase when enrollees met their deductible. One study found that the financial incentives of the plan are not sufficient in driving behavior, and that educational outreach also matters. NEED FOR FURTHER RESEARCH: Despite the growing body of evidence on the effect of CDHPs on cost and quality, there are many unanswered questions about these plans. Most of the research to date has focused on HRA-based plans. Little systematic research has been conducted on HSA-eligible enrollees. The differences between these plans are significant enough to warrant separate analyses. Also, most of the research to date has ignored the impact of the account on the use of services and on spending. Individuals may use health c

ASSET LEVELS GROWING: In 2009, there was $7.1 billion in consumer-driven health plans (CDHPs), which include health savings accounts (or HSAs) and health reimbursement arrangements (or HRAs), spread across 5 million accounts. This is up from 2006, when there were 1.2 million accounts with $835.4 million in assets, and 2008, when 4.2 million accounts held $5.7 billion in assets. AVERAGE ACCOUNT BALANCE LEVELING OFF: Increases in average account balances appear to have leveled off. In 2006, account balances averaged $696. They increased to $1320 in 2007, a 90 percent increase. Account balances averaged $1356 in 2008 and $1419 in 2009, 3 percent and 5 percent increases, respectively. TYPICAL ENROLLEE: The typical CDHP enrollee was more likely than traditional plan enrollees to be young, unmarried, higher-income, educated, and exhibit healthy behavior. No differences were found between CDHPs enrollees and traditional plan enrollees with respect to gender, race, and presence of children. MORE ROLLOVERS: Overall, the number of people with a rollover, as well as the total level of assets being rolled over, have been increasing. The average rollover increased from $592 in 2006 to $1295 in 2009. DIFFERENCES IN ACCOUNT BALANCES: Men tend to have higher account balances than women, account balances increase with household income, education has a significant impact on account balances independent of income and other variables, and no statistically significant differences in account balances were found by smoking, obesity, or the presence of chronic health conditions. Individuals who developed a budget to manage their health care expenses had a higher account balance ($1726) than those who did not ($1428), but otherwise, no statistically significant differences in average account balances were found between individuals who exhibited various aspects of cost-conscious decision-making behaviors and those who did not. DIFFERENCES IN ROLLOVER AMOUNTS: Men rolled over more money than women, whites have higher rollover amounts than minorities, and the youngest adults and the oldest adults had the largest rollover amounts in 2009. Rollover amounts increase with household income and education, and individuals with single coverage rolled over a slightly higher average amount than those with family coverage. There was no statistically significant difference in rollover amounts by health status, although individuals who smokes ad higher rollover amounts than those who do not and obese individuals had lower average rollover amounts than nonobese individuals. Individuals who talked to their doctor about treatment options and costs, those who used an online cost-tracking tool provided by the health plan, and those who asked their doctor to recommend a less costly prescription drug had higher rollover amounts than those who did not take such actions.

HEALTH COVERAGE AND THE RECESSION: This Issue Brief examines changes in health coverage among workers during the recession that started in December 2007. Data from the Survey of Income and Program Participation are used to examine health coverage prior to the recession, and as recently as July 2009. Monthly changes are examined for 2007 and May 2008-July 2009, with emphasis on changes that occurred between September 2007 and April 2009. EMPLOYMENT-BASED COVERAGE STILL DOMINANT: Health coverage through the work place is by far the most common source of health insurance among the population under age 65. In 2008, 160.6 million individuals under age 65, or 61.1 percent of that population, were covered by employment-based health benefits. Fifteen percent were covered by Medicaid or the State Children's Health Insurance Program (SCHIP), 6.3 percent purchased coverage directly from an insurer, and about 3 percent were covered by Medicare or Tricare/CHAMPVA. Nearly 17.5 percent were uninsured. UNINSURED GROWING: Since the recession started in December 2007, the uninsured have grown. The unemployment rate was as low as 4.4 percent in May 2007, but by July 2009 it had reached 9.4 percent. The percentage of the nonelderly population with employment-based coverage was 61.3 percent in May 2007, and by July 2009 it was down to 58.2 percent. The uninsured rate was 12.3 percent in May 2007, and by July 2009 it was up to 16.4 percent. EMPLOYMENT-BASED COVERAGE ERODING: Between December 2007-May 2008, the percentage of workers with coverage in their own name (the policyholder) fell from 60.4 percent to 56.8 percent. The period between May 2008-July 2009 shows a continuing decline in the percentage of workers with employment-based coverage in their own name, falling to 55.9 percent. CHANGES TO THE BENEFITS PACKAGE: The benefits that are being offered have also changed. Deductibles, copayments for office visits, and prescription drug copayments have been increasing. VULNERABLE POPULATION LOSES THE MOST: In general, workers least likely to have employment-based coverage at the beginning of the recession were more likely than other workers to experience a decline in the percentage with such coverage one year later. Younger workers were more likely to lose coverage than older workers. Hispanic workers were more likely to lose coverage than whites or blacks. Part-time workers were more likely than full-time workers to have lost employment-based coverage. EMPLOYMENT SECTOR: The percentage of workers with own name employment-based coverage declined the most among those employed by for-profit private-sector employers and those employed by the federal government. Workers with the lowest earnings were the least likely to have employment-based coverage in their own name and experienced the largest decline in coverage.

SIGNIFICANCE OF AUTO-ENROLLMENT: Automatic enrollment of participants in 401(k) plans, which was encouraged by provisions in the Pension Protect Act of 2006, is designed to overcome the drawbacks of voluntary enrollment by getting more workers to save in their work place retirement plan. Auto-enrollment for 401(k) plans has been demonstrated by previous EBRI research to have substantial potential benefits for some employees. NEW EBRI RESEARCH: This EBRI study analyzes plan-specific data of 1,000 large defined contribution plans for salaried employees from Benefit SpecSelect (Hewitt Associates LLC) in 2005 and 2009 to compare a subsample of plan sponsors that did not have auto-enrollment in 2005 but that had adopted it in 2009. Actual plan information on both actual auto-enrollment and actual match rate information were coded both before and after adoption of auto-enrollment from 225 large 401(k) plan sponsors and found that the average change was positive under auto-enrollment in each of the following three categories: The first-tier match rate, the effective match rate, the average total employer contribution rate. MODELING ANALYSIS: This analysis created a series of simulation programs using these data. The analysis indicates that the adoption of automatic enrollment in 401(k) plans is likely to have a very significant positive impact (even greater than EBRI projected in 2008) in generating additional retirement savings for many workers, especially for young and low-income workers: Under baseline assumptions, the median 401(k) accumulations for the lowest-income quartile of workers currently age 25-29 (assuming all 401(k) plans were voluntary enrollment plans as typified by the 225 large plan sponsors described above) would only be 0.08 times final earnings at age 65. However, if all 401(k) plans are assumed to be using the large plan sponsor auto-enrollment provisions, the median 401(k) accumulations for the lowest-income quartile jumps to 4.96 times final earnings (if 401(k) participants revert back to the default contribution when they change jobs) and 5.33 times final earnings (if they retain their previous contribution level when they change jobs). There are also large increases even for high-income workers: The multiple under a voluntary enrollment scenario is 2.41 times final earnings compared with 9.15 or 9.81 under auto-enrollment, depending on the assumptions for employee reversion to default contribution rates upon job change. Future EBRI research will examine the extent to which the increased 401(k) generosity resulted from modifications to defined benefit plans as pension plans were closed or frozen.

20TH ANNUAL RCS: The 2010 Retirement Confidence Survey-the 20th annual wave of this survey-finds that the record-low confidence levels measured during the past two years of economic decline appear to have bottomed out. The percentage of workers veryconfident about having enough money for a comfortable retirement has stabilized at 16 percent, which is statistically equivalent to the 20-year low of 13 percent measured in 2009 (Fig. 1, pg. 7). Retiree confidence about having a financially secure retirement has also stabilized, with 19 percent saying now they are very confident (statistically equivalent to the 20 percent measured in 2009) (Fig. 2, pg. 8). Worker confidence about paying for basic expenses in retirement has rebounded slightly, with 29 percent now saying they are very confident about having enough money to pay for basic expenses during retirement (up from 25 percent in 2009, but still down from 34 percent in 2008) (Fig. 3, pg. 9). PREPARATIONS STILL ERODING: Fewer workers report that they and/or their spouse have saved for retirement (69 percent, down from 75 percent in 2009 but statistically equivalent to 72 percent in 2008) (Fig. 11, page 14). Moreover, fewer workers say that they and/or their spouse are currently saving for retirement (60 percent, down from 65 percent in 2009 but statistically equivalent to percentages measured in other years) (Fig. 13, pg. 15). MORE PEOPLE HAVE NO SAVINGS AT ALL: An increased percentage of workers report they have virtually no savings and investments. Among RCS workers providing this type of information, 27 percent say they have less than $1,000 in savings (up from 20 percent in 2009). In total, more than half of workers (54 percent) report that the total value of their household's savings and investments, excluding the value of their primary home and any defined benefit plans, is less than $25,000 (Fig. 14, pg. 16). CLUELESS ABOUT SAVINGS GOALS: Many workers continue to be unaware of how much they need to save for retirement. Less than half of workers (46 percent) report they and/or their spouse have tried to calculate how much money they will need to have saved for a comfortable retirement by the time they retire (Fig. 23, pg. 22). AMERICANS EXPECTING TO WORK LONGER: Although the age at which workers report they expect to retire shows little change from 2009, a longer-term look finds significant change. In particular, the percentage of workers who expect to retire after age 65 has increased over time, from 11 percent in 1991 to 14 percent in 1995, 19 percent in 2000, 24 percent in 2005, and 33 percent in 2010 (Fig. 29, pg. 28). INSTITUTIONAL CONFIDENCE LAGGING: Americans continue to lack confidence in institutions. They are most likely to express confidence in private employers (23 percent of workers and 27 percent of retirees veryconfident) and least likely to feel confidence in the federal government (11 percent of workers and 8 percent of retirees) (Fig. 20, pg. 20). Just 19 percent of wo

EBRI'S BIANNUAL POLICY FORUM: This Issue Brief summarizes presentations at EBRI's 65th biannual policy forum, held in Washington, DC, on Dec. 10, 2009, on the topic, "Employers, Workers, and the Future of Employment-Based Health Benefits." The forum brought together a wide range of economic, benefits, management, and labor experts to share their expertise at a time when major health reform legislation was being debated in Congress. The focus: How might this affect the way that the vast majority of Americans currently get their health insurance coverage? THE EMPLOYMENT-BASED HEALTH INSURANCE SYSTEM: Most people who have health insurance coverage in the United States get it through their job: In 2008, about 61 percent of the nonelderly population had employment-based health benefits, 19 percent were covered by public programs, 6 percent had individual coverage, and 17 percent were uninsured.

Differences, agreements: Not surprisingly, given the deep conflicts that exist over President Obama's health reform plan and the different bills that have passed the House and Senate, benefits experts also do not agree on what "health reform" will mean for either workers or employers. Views ranged from "Will anyone notice?" to predictions of great upheaval for workers and their employers, patients and health care providers, and the entire U.S. health care system. One point of consensus among both labor and management representatives: Imposing a tax on health benefits is likely to cause major cuts in health benefits and might result in structural changes in the employment-based benefits system. A common disappointment voiced at the forum was that the initial effort to reform the delivery and cost of health care in America gradually became focused on just financing and coverage of health insurance.

Recent trends: The ever-rising cost of health insurance affects different employers and workers in different ways--with small employers and low-wage workers being the most disadvantaged. With health premiums having risen almost five times as much as the overall rate of inflation since 2000, employers face unsustainable cost increases in health benefits. For a minimum-wage worker, the cost of family coverage (averaging about $13,700 a year in a small firm) exceeds their total annual income (about $11,500 a year). Small employers, if they offer health benefits at all, pay proportionately more than large employers for the same health coverage.

Public opinion: As reflected by the debate in Congress, the American public has conflicted opinions on both the U.S. health care system and on reform: Surveys find that people tend to be satisfied with the quality of their own care but not with costs and access, and a majority rates the system as fair or poor. Opinions divide sharply along partisan lines.

Perspectives: While large employers tend to express continued commitment to health

This Issue Brief examines how current health reform legislation being debated in Congress will impact the future of retiree health benefits. In general, the proposals' provisions will have a mixed impact on retiree health benefits: In the short term, the reinsurance provisions would help shore up early retiree coverage and Medicare Part D coverage would become more valuable to retirees. In the longer term, insurance reform combined with new subsidies for individuals enrolling for coverage through insurance exchanges, the maintenance-of-effort provision affecting early retiree benefits, increases to the cost of providing drug benefits to retirees, and enhanced Medicare Part D coverage, would all create significant incentives for employers to drop coverage for early retirees and drug coverage for Medicare-eligible retirees. REINSURANCE PROGRAM FOR EARLY RETIREES: Proposed legislation includes a provision to create a temporary reinsurance program for employers providing health benefits to retirees over age 55 and not yet eligible for Medicare. Given the temporary nature of the program, it is intended to provide employers an incentive to maintain benefits until the health insurance exchange is fully operational. At that point, employers will have less incentive to provide health benefits to early retirees, and retirees will have less need for former employers to maintain a program. MEDICARE DRUG BENEFITS: The House-passed bill would initially reduce the coverage gap (the so-called "doughnut hole") for individuals in the Medicare Part D program by $500 and eliminate it altogether by 2019. The bill currently before the Senate would also reduce the coverage gap by $500, but does not call for eliminating it. Both would also provide a 50 percent discount to brand-name drug coverage in the coverage gap. These provisions increase the value of the Medicare Part D drug program to Medicare-eligible beneficiaries relative to drug benefits provided by employers. TAX TREATMENT OF EMPLOYER SUBSIDIES UNDER MMA: The Medicare Modernization Act provides subsidies to employers that continue to offer prescription drug coverage through a retiree health benefits program. This subsidy is currently not counted as taxable income to the employer receiving it. Both the House and Senate bills would effectively repeal this tax exclusion. This would have two effects: The real cost of providing retiree health benefits to Medicare-eligible retirees would increase, and an employer's FAS 106 liability would increase immediately. The increase in the cost of retiree drug benefits will cause employers to re-evaluate the subsidy, compared with other available options. Moving retirees to Medicare Part D may become even more attractive to employers if the coverage gap is reduced and/or eliminated. POSTRETIREMENT BENEFIT CHANGES: With some exceptions, the House-passed legislation would prohibit employers from changing the benefits offered to retirees and their beneficiaries once a per

FIFTH ANNUAL SURVEY: This Issue Brief presents findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey, which provides nationally representative data regarding the growth of consumer-driven health plans (CDHPs) and high-deductible health plans (HDHPs), and the impact of these plans and consumer engagement more generally on the behavior and attitudes of adults with private health insurance coverage. Findings from this survey are compared with four earlier annual surveys. ENROLLMENT LOW BUT GROWING: In 2009, 4 percent of the population was enrolled in a CDHP, up from 3 percent in 2008. Enrollment in HDHPs increased from 11 percent in 2008 to 13 percent in 2009. The 4 percent of the population with a CDHP represents 5 million adults ages 21-64 with private insurance, while the 13 percent with a HDHP represents 16.2 million people. Among the 16.2 million individuals with an HDHP, 38 percent (or 6.2 million) reported that they were eligible for a health savings account (HSA) but did not have such an account. Overall, 11.2 million adults ages 21-64 with private insurance, representing 8.9 percent of that market, were either in a CDHP or were in an HDHP that was eligible for an HSA, but had not opened the account. MORE COST-CONSCIOUS BEHAVIOR: Individuals in CDHPs were more likely than those with traditional coverage to exhibit a number of cost-conscious behaviors. They were more likely to say that they had checked whether the plan would cover care; asked for a generic drug instead of a brand name; talked to their doctor about prescription drug options, other treatments, and costs; asked their doctor to recommend a less costly prescription drug; developed a budget to manage health care expenses; checked prices before getting care; and used an online cost-tracking tool. CDHP MORE ENGAGED IN WELLNESS PROGRAMS: CDHP enrollees were more likely than traditional plan enrollees to report that they had the opportunity to fill out a health risk assessment, whereas they were equally likely to report that they had access to a health promotion program. CDHP enrollees were more likely than traditional plan enrollees to participate when a program was offered. Among those not participating, they did not participate because they could make changes on their own; they lacked time; and they were already healthy. FINANCIAL INCENTIVES MATTER: Financial incentives for healthy behavior mattered more to CDHP enrollees than traditional plan enrollees. Financial incentives were a larger factor for CDHP enrollees than for traditional plan enrollees when it came to participating in wellness programs, choice of doctor, and the use of health information technology, as well as patient engagement using e-mail and the Web. HEALTH STATUS IS BETTER, INCOME HIGHER: Adults in CDHPs were significantly less likely to have a health problem than were adults in HDHPs or traditional plans. Adults in CDHPs and HDHPs were significantly less likely to smoke than were adults

Because 401(k) balances can fluctuate with market returns from year to year, meaningful analysis of 401(k) plans must examine how participants' accounts have performed over the long term. Looking at consistent participants in the EBRI/ICI 401(k) database over the five-year period from 2003 to 2008 (which included one of the worst bear markets for stocks since the Great Depression), the study found: After rising in 2003 and for the next four consecutive years, the average 401(k) retirement account fell 24.3 percent in 2008. The average 401(k) account balance moved up and down with stock market performance, but over the entire five-year time period increased at an average annual growth rate of 7.2 percent, attaining $86,513 at year-end 2008. The median (mid-point) 401(k) account balance increased at an average annual growth rate of 11.4 percent over the 2003-2008 period to $43,700 at year-end 2008. THE BULK OF 401(K) ASSETS CONTINUED TO BE INVESTED IN STOCKS. On average, at year-end 2008, 56 percent of 401(k) participants' assets were invested in equity securities through equity funds, the equity portion of balanced funds, and company stock. Forty-one percent was in fixed-income securities such as stable-value investments and bond and money market funds. THREE-QUARTERS OF 401(K) PLANS INCLUDED LIFECYCLE FUNDS IN THEIR INVESTMENT LINEUP AT YEAR-END 2008. At year-end 2008, nearly 7 percent of the assets in the EBRI/ICI 401(k) database were invested in lifecycle funds and 31 percent of 401(k) participants held lifecycle funds. Also known as "target-date" funds, they are designed to simplify investing and automate account rebalancing. NEW EMPLOYEES CONTINUED TO USE BALANCED FUNDS, INCLUDING LIFECYCLE FUNDS. Across all age groups, more new or recent hires invested their 401(k) assets in balanced funds, including lifecycle funds. At year-end 2008, 36 percent of the account balances of recently hired participants in their 20s were invested in balanced funds, compared with 28 percent in 2007, and about 7 percent in 1998. At year-end 2008, almost 23 percent of the account balances of recently hired participants in their 20s were invested in lifecycle funds, compared with almost 19 percent at year-end 2007. 401(K) PARTICIPANTS CONTINUED TO SEEK DIVERSIFICATION OF THEIR INVESTMENTS. The share of 401(k) accounts invested in company stock continued to shrink, falling by nearly 1 percentage point (to 9.7 percent) in 2008. That continued a steady decline that started in 1999. Recently hired 401(k) participants contributed to this trend: they were less likely to hold employer stock. PARTICIPANTS' 401(K) LOAN ACTIVITY WAS STABLE. In 2008, 18 percent of all 401(k) participants eligible for loans had a loan outstanding against their 401(k) account, the same percentage as at year-end 2007 and year-end 2006. Loans outstanding amounted to 16 percent of the remaining account balance, on average, at year-end 2008; this is similar to the year-end 2002 level.

This Issue Brief provides historical data through 2008 on the number and percentage of nonelderly individuals with and without health insurance. Based on EBRI estimates from the U.S. Census Bureau's March 2009 Current Population Survey (CPS), it reflects 2008 data. It also discusses trends in coverage for the 1994-2008 period and highlights characteristics that typically indicate whether an individual is insured. HEALTH COVERAGE RATE CONTINUES TO DECREASE: The percentage of the nonelderly population (under age 65) with health insurance coverage decreased to 82.6 percent in 2008. Increases in health insurance coverage have been recorded in only four years since 1994, when 36.5 million nonelderly individuals were uninsured; in 2008, the uninsured population was 45.7 million. EMPLOYMENT-BASED COVERAGE REMAINS DOMINANT SOURCE OF HEALTH COVERAGE, BUT CONTINUES TO SLOWLY ERODE: Employment-based health benefits remain the most common form of health coverage in the United States. In 2008, 61.1 percent of the nonelderly population had employment-based health benefits, down from 68.4 percent in 2000. Between 1994 and 2000, the percentage of the nonelderly population with employment-based coverage expanded. PUBLIC PROGRAM COVERAGE IS GROWING: Public program health coverage expanded as a percentage of the population in 2008, accounting for 19.4 percent of the nonelderly population. Enrollment in Medicaid and the State Children's Health Insurance Program increased, reaching a combined 39.2 million in 2008, and covering 14.9 percent of the nonelderly population, significantly above the 10.5 percent level of 1999. INDIVIDUAL COVERAGE STABLE: Individually purchased health coverage was unchanged in 2008 and has basically hovered in the 6-7 percent range since 1994. MOST/LEAST LIKELY TO HAVE HEALTH INSURANCE: Full-time, full-year workers, public-sector workers, workers employed in manufacturing, managerial and professional workers, and individuals living in high-income families are most likely to have employment-based health benefits. Poor families are most likely to be covered by public coverage programs such as Medicaid or S-CHIP. RETHINKING THE VALUE OF OFFERING HEALTH INSURANCE: Research illustrates the advantages to consumers of having health insurance and the benefits to employers of offering it. In general, the availability of health insurance allows consumers to avoid unnecessary pain and suffering and improves the quality of life, and employers report that offering benefits has a positive impact on worker recruitment, retention, health status, and productivity. Employers may believe in the business case for providing health benefits today, but in the future they may rethink the value that offering coverage provides, especially if health costs continue to escalate sharply or if health reform changes the value proposition.