No thank you.
According to a new study, that's the response employers are hearing more often when they offer health insurance coverage to their workers. Those findings would seem to undermine key assumptions of healthcare reform efforts.
President Clinton's reform plan seeking universal insurance coverage for working Americans and their families was the dominant story in healthcare five years ago. More recently, insurance portability legislation that addressed the needs of workers as they changed jobs-both the legislation's benefits and now its glaring faults-has been a primary issue. Everyone believed scores of people would leave the ranks of the uninsured if only coverage were offered to them.
But a study by Barbara Schone and Philip Cooper of the Agency for Health Care Policy and Research in Rockville, Md., suggests a lot of people aren't taking their employers up on their offers. The number of people rejecting healthcare coverage-apparently dictated in part by disparities in wages-has risen dramatically in the past decade.
According to the study, out of a U.S. work force of 100 million in 1996, 75.4% were offered benefits, but only 60.4% had coverage. That translates to an acceptance rate of 80.1%. But in 1987, out of a work force of 86.8 million, 72.4% were offered coverage, and 63.9% accepted-an acceptance rate of 88.3%.
That means the percentage of workers holding employer-sponsored health insurance dropped 3.5 percentage points in a decade, even though the work force grew by 13.2 million, or more than 15%. All told, the number of workers declining healthcare coverage offered to them has more than doubled, to 15.1 million in 1996, from 7.4 million in 1987, according to the study.
"There is no causality in our study; we're not able to say these patterns are due to X, Y or Z," Schone says. "We're going to have to do more research." However, she did venture an educated guess. She believes the more than 90% increase in health insurance premiums during the time of the study was nearly quadruple the rise in wages and salaries, meaning out-of-pocket costs were becoming unmanageable for some employees.
Moreover, some recent data suggest employers have been shifting more out-of-pocket costs to their employees. According to last year's KPMG Peat Marwick survey of employer-sponsored health plans, the average employee contribution for single coverage increased almost 20% between 1993 and 1997, to $31 from $26. Family coverage increased 6.5%, to $116 from $109. While the numbers cited by KPMG had risen and then declined during the course of the study, making a clear correlation difficult, experts backed up the trend.
"There's been a large increase in the inflation-adjusted dollars workers have to pay for premiums," says Thomas Rice, professor at the University of California Los Angeles School of Public Health and chairman of its health services department.
"The contributions required have increased sharply (over) the past 10 years, so it's not surprising many employees are forgoing coverage," says Richard Johnson, assistant research professor at Rutgers University's Institute for Health.
The consequences of declining coverage are obvious: There's a much higher risk for incurring catastrophic costs, Rice says.
Adds Johnson: "These people are getting less preventive care and less routine health services, so when they get sick they tend to be sicker than the rest of the population."
What type of employee is the most likely to decline coverage? The study suggests workers under the age of 25 in low-paying jobs are the most likely to take a pass on health benefits. Of those under 25, only 70% accepted healthcare coverage, compared with 80% among those ages 25 to 34.
Pay appears to be an even stronger determinant, with only 63% of those earning $7 per hour or less taking coverage (only 43% of those in that wage bracket were offered benefits in 1996 and 1987), compared with an 86% acceptance rate among those earning more than $15 per hour (of whom 93% were offered benefits in 1996, compared with 87% in 1987).
African-Americans and Latinos also are more likely to decline coverage than whites and other groups: 79.5% of African-Americans and 77.5% of Latinos accepted coverage offered, compared with 80% for whites and others. Most strikingly, only 61% of Latino workers were offered insurance, compared with 74.5% of African-Americans and 77% of whites and other groups. The percentage of Latinos offered insurance in 1996 dropped 1.5 percentage points compared with 1987, while the percentage of African-Americans and other groups increased 3.1 percentage points and 3.9 percentage points, respectively.
Schone is concerned about the implications of the data for Latinos: "It makes me wonder what types of jobs they hold now vs. 10 years ago," she says.
While the insurance effort by employers may be sagging, the healthcare safety net still appears to be strong. Rutgers' Johnson noted that when most uninsured workers need healthcare, a third party still pays for it, be it either Medicaid or charity care.