The Health Insurance Marketplace In Iowa: The Business Perspective
The HealthInsuranceMarketplace inIowa:The businessperspectiveFinal report to the IowaDept. of Public HealthPeter Damiano*Daniel Shane*†Suzanne Bentler*University of IowaPublic Policy Center* andCollege of Public Health†1
The Health InsuranceMarketplace in Iowa:The business perspectiveBackgroundIn addition to the individual Health Insurance Marketplace (HIM)established by the Affordable Care Act (ACA), the law establishedMarketplaces to assist small businesses in providing health insurance toemployees. The Small-Business Health Options Program (SHOP) exchanges(or Marketplaces as they are now called) are designed to offer smallbusinesses a web-based portal to compare insurance offerings on price,coverage, and quality. Businesses can decide how much to contribute toemployee premiums and the Marketplaces handle premium collection andother administrative functions. SHOP Marketplaces are initially open toemployers with fewer than 50 full-time employees but may be expanded toemployers with as many as 100 employees by 2016.SHOP Marketplaces are initially focused on small businesses given theiroverall lower rates of coverage and the more limited options they face interms of covering employee health care needs. Large businesses typicallyhave the option to self-insure or pay for all health care costs out of companyrevenues while contracting with third parties to handle the administrativetasks related to providing health care. Small businesses, by contrast,typically must purchase policies from a third-party carrier and are atsignificant disadvantage in terms of the cost of insurance per employeecompared to large businesses.To encourage small businesses to begin or continue offering healthinsurance to employees, tax credits worth up to 35% (in some cases up to50%) of the cost of insurance premiums were made available to companieswith fewer than 50 full-time employees. Starting in 2014, those tax creditsare only available for businesses purchasing employee coverage via SHOPMarketplaces.In collaboration with the Iowa Department of Public Health and theInteragency Workgroup on Health Care Reform, we conducted a survey ofbusinesses to assess the potential for the SHOP Marketplace to meet the3
needs of Iowa businesses in obtaining health insurance for employees. Wewere particularly interested in understanding the level of assistance thatbusinesses might seek as potential SHOP participants and how they mightprefer to obtain assistance. We further sought to assess how importantemployee choice was to potential SHOP participants. Employee choicewould allow businesses to choose a specific contribution level in theMarketplace while allowing employees the choice of a range of plans ratherthan a single plan. Such administrative complexity and potential adverseselection issues for third-party carriers make employee choice burdensomefor individual small employers. For 2014, SHOP Marketplaces operated bythe Federal government will not offer employee choice. As this feature wasconsidered a key selling point for SHOP Marketplaces, understanding Iowabusiness sentiments regarding this option provides important input forfuture SHOP plans.MethodsWe used a convenience sample of potential business participants in theSHOP marketplace to field our online survey. We polled this sample ofindividual Iowa businesses in late spring/summer 2013. Our sample ofindividual businesses included members of the Iowa Association of Businessand Industry, Professional Developers of Iowa, Iowa Chamber Alliance,Federation of Iowa Insurers, and the National Federation of IndependentBusinesses. Each organization made the online survey available to itsindividual members.The business survey had 42 questions with several sections devotedexclusively to businesses that currently provide health insurance coverageto employees (full survey available in Appendix B). Goals of the surveyincluded gauging current employer-sponsored insurance offerings, assessingbusinesses knowledge and support for the ACA in general and specificfeatures of the ACA, and understanding business comfort level andpreferences in using an online marketplace to potentially provide employeehealth insurance.We received 60 responses from businesses completing the online survey.Just over 2/3 of the businesses responding to the survey had 50 or moreemployees. Health care (45%) and professional/business services were theindustries (20%) most frequently listed by survey respondents. Overall,employers describe their workforces as in good health. Only 9% reportedworkforces that were in fair or poor health on average. The average age ofemployees in the businesses responding to the survey was concentrated inthe range between 35 to 55 years (80%) with an additional 19% ofbusinesses reporting an average age between 25-35 years.
In describing further results of the survey, we pinpoint differences betweenSHOP-eligible businesses with fewer than 50 employees and largeremployers with 50 or more employees that would not be eligible for SHOPmarketplaces in 2014.ResultsEmployee Insurance CoverageThe overwhelming majority of businesses (94%) responding to the surveyoffered at least some coverage to employees. Of the businesses offeringcoverage, 38% were self-insured with the remaining businesses purchasingcoverage from a third-party carrier. An often mentioned concern withrespect to adverse selection within the SHOP exchanges is the possibilitythat small businesses with relatively healthy workforces would considerbecoming self-insured, thus leaving the SHOP Marketplace with less healthy,and more costly participants. We asked companies currently purchasingfrom third-party carriers about their plans regarding self-insurance. Lessthan 10% of these businesses were considering becoming self-insured.For companies that purchased policies from a third-party carrier we askedwho helped them choose their coverage and whether they used aninsurance agent or broker to purchase coverage. Insurance agents/brokerswere providing assistance to 59% of the survey respondents. Humanresources personnel were cited as providing assistance for 28% ofbusinesses. Insurance agents/brokers were also involved with policypurchases for 77% of the companies purchasing through a third-partyvendor. These results highlight the tradeoffs SHOP exchanges face inconsidering the role of agents/brokers, a group traditionally heavily involvedin the small group insurance markets.Insurance Coverage DetailsFigure 1 documents the extent of health insurance coverage for businessescurrently offering coverage. Small businesses were slightly more likely tocover all employees (24%) compared to larger businesses (14%). Largeemployers, by contrast, were more likely to offer coverage to full-time andsome part-time employers compared to small employers. Both groups wereequally likely to offer coverage to full-time employees only.5
46% 47%50%39%40%30%20%24%24%14%10%0%All employeesFull-time onlyFull-time and some 50 employees 50 employees part timeFigure 1. Extent of employee health insurance coverageFew differences emerge between large and small employers in types ofcoverage offered to employees (Figure 2). Consistent with findings fromDavid P. Lind’s Iowa Employer Benefits Study 1, Preferred ProviderOrganization (PPO) plans are the most popular health plans offered andsmaller employers are slightly more likely to offer HMO plans. Unlike theresults from Lind’s study, smaller employers responding to our survey werealmost equally as likely as large employers to offer Health Savings Accounts(HSAs). In the Iowa Employer Benefits Study results, smaller employers weremuch more likely to offer HSA plans compared to large employers.80%71% 71%70%60%50%40%30%21% 24%21%20%18%7% 6%10%0%HMOPOS 50 employeesPPO 50 employeesFigure 2. Health insurance coverage offered1Iowa Employer Benefits Study, 2013, David P. Lind Benchmark.HSA
To better understand the potential for the SHOP marketplace to offer valueto small businesses, we asked a series of questions designed to measurehow satisfied businesses are with the insurance that they currently offer (ifany). We also sought to develop a picture of business responses to theincreasing cost of employee health insurance in recent years and plannedresponses in upcoming years.Large employers were more likely to feel that that current coverage wasmeeting the needs of employees than small employers although one in 10large employers only thought the coverage was fair (Figure ntVery good 50 employeesGood 50 employeesFairFigure 3. How well coverage meets employee needsSmall employers were considerably more likely to rank the issue of noncovered costs as very serious or not serious at all for employees (Figure 4).SHOP Marketplaces may be able to improve the depth of insurance planofferings to small employers, particularly companies that may haveexperienced large swings in premiums when a single employee develops asevere illness. Large companies occupied the center of the spectrum with64% citing covered costs as a somewhat serious or serious problem.7
70%59%60%50%39%40%30%25%18%20%10%25%18%6%4%0%Very seriousSeriousSomewhatSerious 50 employeesNot serious 50 employeesFigure 4. Seriousness of non-covered costs for employeesCosts of employee health insurance coverage were an issue for virtually allsurvey participants. Large businesses were slightly more likely to be veryconcerned with the cost of coverage compared to small 1%0%6%Very concernedSomewhat concernedA little concerned 50 employees 50 employeesFigure 5. Concerns about cost of employee coverageHalf of large businesses and 41% of small businesses expected costs toincrease a lot as a result of the ACA (Figure 6). A further 24% of smallbusinesses expected costs to increase at least a little due to the ACA. Lessthan 20% of large or small businesses were expecting the ACA to lower costsor to have no impact on costs.
50%50%41%40%30%24%18%20%12%7%10%0%Increase a lotIncrease a littleStay the same 50 employees 50 employeesFigure 6. ACA impact on health insurance costsFigure 7 captures survey participant approaches to dealing with increases inemployee health insurance/health care costs over the previous 2 years.While approximately 70% of both small and large businesses increased thelevel of employee cost sharing as a result of cost increases, clear differencesemerge in other measures of attempted cost 11%10%0%WellnessprogramIncrease CostSharing 50 employeesCompensationChangesHiring/HoursChanges 50 employeesFigure 7. Responses to increases in health care costs (last 2 Years)Large businesses were much more likely to implement non-cost sharingoptions in response to increases in health care costs. For example, almosttwo-thirds were going to start or augment a wellness program. Although notfrequently mentioned as a potential feature of SHOP marketplaces, offering9
the administrative capacity to manage wellness programs could be valuableto small businesses. Changes in compensation such as foregoing wageincreases or altering retirement contributions were more likely amonglarger companies as was reducing hours or postponing hiring 0%12%10%0%WellnessprogramIncrease CostSharing 50 employeesCompensationChangesHiring/HoursChanges 50 employeesFigure 8. Responses to increases in health care costs (next 2 years)Regarding future plans, Figure 8 relays the results of asking businesses howthey were considering adjusting to potential health care cost increases inthe next two years. Increasing employee cost sharing was again the mostoften cited approach to managing cost increases. Overall, the plannedchanges over the next 2 years were of smaller magnitude than changes overthe previous 2 years, suggesting businesses were anticipating more mutedincreases in health care costs or had already made some of the necessarychanges to manage health care costs.Follow-up questions to the companies that had reported planned changesto insurance plans over the next 2 years indicated more evidence ofincreased cost sharing and a move toward high-deductible insurance plansfor almost 40% of the businesses planning changes. Almost 1 in 5 companiescurrently purchasing policies from a third-party carrier changed carriers inthe previous 2 years or are considering changing carriers in the next 2 years.SHOP Marketplaces may increase the opportunity for small businesses tochange insurance providers based on cost and/or quality compared to thecurrent small group market in Iowa.
Businesses Not Offering CoverageFor companies that did not currently offer health insurance coverage, weasked a series of questions to determine the reasons for not offeringcoverage and whether ACA policies might shift their likelihood of offeringcoverage in the future. Cost was cited most often as the reason for notoffering coverage. Businesses cited flexible work schedules and other fringebenefits as benefits offered in lieu of health insurance.Despite not currently offering coverage, a majority felt that offeringcoverage was important for employee recruitment and retention. Whilemost businesses did not feel the marketplaces would increase the likelihoodof their company would begin offering employee health insurance in thefuture, a clear majority felt that marketplaces would increase the likelihoodother companies would begin offering employee health insurance. A similarcontradiction emerges in evaluating the impact of tax credits available forsmall businesses purchasing employee health insurance. Businesses did notfeel the policy would change their likelihood of offering coverage but didfeel that other companies would take advantage of the policy.Such contradictions suggest that preconceived notions or inherentskepticism about the ACA may be a significant hurdle for designers of SHOPMarketplaces to overcome. The next section further gauges businessknowledge and sentiment toward the ACA generally and toward specificACA provisions.ACA Related QuestionsWe asked all businesses questions regarding their awareness, knowledge,and attitude toward the ACA. All businesses reported hearing some or a lotabout the ACA while 86% of large businesses and 78% of small businessesreported knowing a lot or some things about the ACA.Subsequent questions dug deeper into knowledge of specific components ofthe ACA and a contrast emerges between large and small businesses (Figure9). Large businesses were generally more knowledgeable about all the listedcomponents of the ACA than small businesses. Small businesses were muchless likely than large businesses to know about available tax credits and thecreation of marketplaces despite being the target of these ACA components.11
3%53%53%53%50%50%64%44%40%30%20% 50 employees 50 employeesFigure 9. Knowledgeable regarding ACA provisionAttitude toward ACA components featured a similar contrast by businesssize. With the exception of the individual mandate, a majority of largebusinesses supported all the component pieces of the ACA, even the largeemployer mandate that penalizes companies that do not provide affordablehealth insurance coverage to full-time employees. Our results suggest smallbusinesses are much more skeptical with regard to the ACA. Even the taxcredit policy barely exceeds 50% support among small %71%59%47%47%47%64%54%44%40%30%20% 50 employees 50 employeesFigure 10. Support/Strong support for ACA provision44% 43%38%
Health Benefits MarketplaceAll businesses answered questions about potentially using the marketplacefor obtaining employee health insurance. Of the SHOP-eligible businesses,1/3 reported that they were planning to use or were considering using themarketplace for employee health insurance. When asked who would handlemarketplace transactions, 80% cited company employees (humanresources, company owner, or other company personnel), while theremaining 20% cited insurance agents/brokers.Comfort levels with using an online system to purchase employee coveragevary by business size. Overall, more than 40% of businesses were “a little”or “not at all” comfortable using an online system to purchase employeehealth insurance. Small companies, however, reported being “verycomfortable” or “somewhat comfortable” at twice the rate of largecompanies (34% to 16%) albeit at levels that suggest a substantial learningcurve for all Marketplace participants.In parallel with results from a survey of Iowa consumers, significantnumbers of businesses feel they will need help in making decisions andnavigating the marketplace (61% of large businesses, 56% of smallbusinesses). Clear preferences for one-on-one assistance or live-personphone assistance emerge from business respondents as -OnePhone 50 employeesOnline 50 employeesFigure 11. Preferences for obtaining Marketplace help13
Marketplace ChoicesWe asked businesses to consider the number of health insurance planchoices available to them within the Marketplace. Only 25% indicated apreference for as many choices as possible. Nearly 60% preferred amoderate number of choices. Further corroborating the “more is not alwaysbetter” sentiment among businesses, 61% preferred the Marketplacewebsite guide them to a smaller number of insurance plan options using aseries of targeted questions.As previously discussed, employee choice was delayed as an option in SHOPMarketplaces run by the Federal government. Our results suggest employeechoice is a significant opportunity for SHOP Marketplaces to add value. Over90% of survey respondents indicated that employee choice was “important”or “very important” to them. Support for employee choice was equally highamong large companies and small, SHOP-eligible companies.Figure 12 highlights the important factors for businesses considering plansvia the Marketplace. In terms of relative importance, large and smallbusinesses put similar emphasis on factors related to insurance plans.Compared to small businesses, large businesses clearly assign moreimportance in general to factors relating to insurance plan 59%59%59%47%50%44%50%40%30%20% 50 employees 50 employeesFigure 12. Important/Very important factor in plan selectionIn contrast to the Iowa consumer survey results that indicated individualswould focus on costs of coverage, businesses expected that understandingcovered services and benefits would be the area employees would need themost help after plan purchases. More than 50% of small and largebusinesses cited information about covered services above networks,
premiums, and out-of-pocket costs as the most important post-purchaseneed for employees.Small businesses were much less likely than large businesses to reportconfidence in a broad range of sources of health insurance plan information(Figure 13). In particular, large businesses were highly confident in their HRpersonnel (82%) compared to small businesses (38%). No source ofinformation gained a 50% confidence rating among small businesses,suggesting that outreach will be a challenge for 10%0%82%71%57%38%34%54%50%34%19%50%34%22% 50 employees39%36%25%25%16%16%13% 14% 50 employeesFigure 13. Confident/Very Confident in marketplace information sourcesIntroducing the Marketplace to IowansThere have been many questioning the use of the word “exchange” todescribe the online health insurance marketplace. When asking businesseswhat the SHOP exchange should be called, the clear winner of the namingsweepstakes among business survey participants was the Iowa HealthInsurance Marketplace, (the current name) as 48% chose that name. Noother choice garnered more than 15%.Who will Iowa businesses trust with information about the Marketplace?Figure 14 shows that very few sources have broad-based support. Insuranceagents/brokers are one group that does have clear support from thebusiness community, as more than 50% of businesses would trustMarketplace information from agent/brokers. Paired with the fact that 78%of small businesses were most likely to hear about the Marketplace viainsurance agents/brokers, this evidence denotes the central roleagents/brokers play for small businesses in making decisions about15
employee health insurance. Public health agencies and trade associationswere other groups that had relatively high levels of trust among smallbusinesses. More widespread forms of disseminating information do notappear to have the trust of businesses, large or small. Television is trustedby less than 10% of small businesses and radio fared little better, trusted byonly 11% of small businesses.70% 50 employees56% 56%60% 54%50%42%44%40%30%23%20%10%39%19% 50 employees33% 33%31%23%17% 19% 19%12%11% 11% 11%8%6%4%0%Figure 14. Trusted source of information regarding MarketplacesConclusionsThis survey of Iowa businesses provides a snapshot of the likely challengesand opportunities facing SHOP Marketplaces. SHOP-eligible small businessesare less knowledgeable and more skeptical about the ACA in general andeven skeptical about parts of the ACA that are designed to assist smallbusinesses provide employee health insurance (exchanges, tax credits).Insurance agents/brokers play a key role in assisting small businesses makedecisions and purchase health insurance – 77% of small businesses reporthaving an agent/broker involved in purchasing policies. Insuranceagents/brokers are also the most trusted source of information regardingMarketplaces for small businesses. SHOP policies regarding insuranceagents/brokers will likely be a significant factor in participation rates.Businesses are not comfortable making decisions and purchasing coverageusing an online system. Only 40% of businesses were somewhat or verycomfortable with an online system. Nearly 60% felt they would needassistance and one-on-one help or live-person phone help was preferred bythe vast majority of survey participants. Considering these trends, SHOP
designers may need to encourage insurance agents/brokers to be thesource of help many businesses need given their level of trust in thatcommunity and close involvement in insurance decisions.Small businesses preferred a moderate number of choices and a guidedsystem to merely a list of available insurance plan choices. Finally, employeechoice is overwhelmingly supported by businesses, large and small. Thisfeature may be the clearest opportunity for SHOP Marketplaces to gain afoothold with eligible businesses.In summary:SHOP-eligible Small Businesses: Report being less knowledgeable about specific ACAprovisions compared to large businessesSupport for ACA provisions is much lower, even provisionsunambiguously positive for them (tax credits)Insurance agents/brokers most highly trusted informationsource and involved with 77% of plan purchasesPrefer moderate number of choices/guided online systemGeneral Findings: Strong support for a moderate number of insurance planchoices and a guided system based on a series of targetedquestionsVery strong support for employee choice as part of theMarketplaceLow levels of comfort with using an online system topurchase health insurance for employeesMost businesses indicate they would want help whenmaking Marketplace decisionsOne-on-One is the most preferred source of help17
Appendix BHealth Benefits Exchange Business Survey2013-05-17 Final DraftThe health care reform law, called the Affordable Care Act, was signed into law by PresidentObama in 2010 and will be starting later this year. This includes an option for people to buyprivate health insurance through an internet Health Insurance “Exchange” (also known as a“Marketplace”) that is run jointly by the state of Iowa and the federal government.There will also be an online health insurance “Marketplace” for small businesses that have lessthan 50 employees. The Small Business Health Options Program (SHOP) allows businesses tomake health insurance available to their employees and get a 35% tax credit for the first twoyears. Businesses will be able to choose the level of coverage they offer and decide how muchthey will pay toward employees’ coverage. Businesses with 50 or more full-time or full-timeequivalent employees must offer affordable coverage to full-time employees and theirdependents or be subject to penalties.In both the individual and small business “Marketplace” people will be able to compare the costand level of coverage of available health insurance options and know that the plan(s) they choosemeets state and federal standards.This survey asks questions about what you know about the Affordable Care Act, and the types ofinformation your company might need if you were to buy employee insurance through the“Marketplace”. This information will be used by the state of Iowa to help improve how the“Marketplace” is set up and how people are informed about it.
The following questions are about how much you know about the health care reform lawcalled the Affordable Care Act1. How much have you heard about the Affordable Care Act?01 Not much Some03 A lot88 Not sure99 Prefer not to answer022. How have you learned about the Affordable Care Act? (Please choose all that apply)01 Family and/or friends Health insurance agents/brokers03 TV04 Radio05 Newspaper06 Internet sites07 Direct mail08 Informational meetings through the local hospital09 Brochures at your doctor’s office10 Public forums at places like libraries, senior centers, etc.11 Social media such as Facebook12 Public health agencies13 Other (please specify):023. In general, how much do you think you know about this new health care program?01 I know a lot about the new program. I know some things about the new program.03 I’ve heard about it, but don’t know much about what it means04 I don’t know anything about the new program.88 I’m not sure99 I don’t want to answer02
The following items are parts of the Affordable Care Act.4. How much do you think you know about each of these new policies?a. Insurance companies can nolonger deny health coveragebecause of a person’s medicalhistory or health condition.b. Tax credits will be given to smallbusinesses that offer healthcoverage to their employees.c. Large employers with 50 or moreemployees will incur taxpenalties if the insurance offeredis not considered affordable toemployees.d. States can expand their existingMedicaid program to cover lowincome, uninsured adults even ifthey don’t have children or arenot disabled.e. Children and young adults canstay on their parents’ insuranceplan until age 26.f. The creation of an insurance“exchange” or “marketplace” tomake it easier for people to buyinsurance.g. By 2014, most people must havehealth insurance or pay a penalty(known as the ‘individualmandate’).h. People with lower to middle classincomes, will get money from thegovernment to help pay for thecost of insurance bought throughthe Marketplace.i. Insurance companies must covercertain preventive services withno out of pocket cost to you.I know a lotI know somethingsI have heardabout itI don’t knowanythingI’mnotsureI 91234889912348899123488991234889912348899
5. What do you think about each of these parts of the Affordable Care inionPrefer notto answer1234889912348899123488991234889912348899f. The creation of an insurance“exchange” or “marketplace” to makeit easier for people to buy insurance.12348899g. By 2014, most people must havehealth insurance or pay a penalty(known as the ‘individual mandate’).123488991234889912348899a. Insurance companies can no longerdeny health coverage because of aperson’s medical history or healthcondition.b. Tax credits will be given to smallbusinesses that offer health coverageto their employees.c. Large employers with 50 or moreemployees will incur tax penalties ifthe insurance offered is not consideredaffordable to employees.d. States can expand their existingMedicaid program to cover lowincome, uninsured adults even if theydon’t have children or are notdisabled.e. Children and young adults can stay ontheir parents’ insurance plan until age26.h. People with lower to middle classincomes, will get money from thegovernment to help pay for the cost ofinsurance bought through theMarketplace.i. Insurance companies must covercertain preventive services with no outof pocket cost to you.
The next questions ask about the health insurance currently offered to your employees6. Does your company currently offer health insurance or health plan coverage to any of youremployees?01 Yes No – skip to Q-7z88 Not sure – skip to Q-2199 Prefer not to answer – skip to Q-21026a. {If Answer to Q-6 is Yes} Is your company self-insured?01 Yes -- skip to Q-7x No88 Not sure99 Prefer not to answer026b. {If Answer to Q-6a is not Yes} Is your company considering self-insuring?01 Yes No88 Not sure99 Prefer not to answer02(skip to Q-7y)For companies answering 6 and 6a: Yes and Self-Insured7x. Which employees are covered by company insurance?01 All employees Full time employees only03 Full time and some part-time employees03 Other ( please specify)88 Not sure99 Prefer not to answer028x. Which company is the third-party administrator (TPA) of your health care plan?01 Wellmark (Blue Cross Blue Shield of Iowa) United Healthcare03 Coventry04 Other (please specify)05 None88 Not sure99 Prefer not to answer02
9x. What type of health care coverage does your company offer to employees? (Check all thatapply)01 Health Maintenance Organization (HMO) Poi
Marketplace in Iowa: The business perspective . Background . In addition to the individual Health Insurance Marketplace (HIM) established by the Affordable Care Act (ACA), the law established Marketplaces to assist small businesses in providing health insurance to employees. The Small-Business Health Options Program (SHOP) exchanges
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