National Academies Press: OpenBook
« Previous: GLOSSARY AND ACRONYMS
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Index

A

Access, 7, 334

public subsidies to improve, 18-19

risk selection affecting, 182-183

vs. coverage, 7, 234

Accountability, 237

Actuarial techniques

early development of, 56

fairness issues in, 179-182

Administration of health benefit plans

administrative services only agreements, 113, 334

in Canadian system, 110

case studies in, 128-145

complexity of, in U.S., 11-12, 149-152, 232, 240-241

cooperatives for, 127

cost of, 108-110, 151-152, 206, 240

early cost containment strategies, 73-77

employer functions in, 5-6, 11, 121-127, 149-152, 232-233

ERISA on, 303-304

legal issues in, 152-153

risk selection through practices in, 174-175

size of employer and, 121-122, 124-126

state regulation of, 296, 298-299

third-parties for, 113, 126, 152-153, 344

Admission review, 334

Adverse selection, 46, 169, 334,

see also Risk selection

Age

coverage for elderly, 77, 90

discrimination, protection against, 316

of health plan, related to enrollment age, 178

of individual, vs. group, enrollees, 168 n.1

premiums related to, 173

of uninsured workers, 93

Agency for Health Care Policy and Research, 226

Ambulatory care, definition of, 334

American Association for Labor Legislation, 58-59

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

American College of Surgeons, 63

American Medical Association

opposition to group health plans by, 70

opposition to social insurance proposals by, 59-60, 63, 65

American Risk and Insurance Association, 41 n.6

Americans with Disabilities Act of 1990, 117-118, 148, 316-317

application to risk selection, 185-187

confidentiality provisions of, 246

legal uncertainties in, 186

medical records management in, 17

medical underwriting in, 182

B

Benefit, definition of, 43, 335

Benefit design, 114-115

basic benefits, 19-20, 193, 249, 258

cost management in, 74-75

cost sharing in, 74, 103-106

diversity in, 10, 122-126, 237-238, 242

employee assistance programs in, 118-119

employee concerns about, 136-137, 145-149

ERISA on, 84, 302

evolution of, 101-102

flexible, 119, 218, 337

in health maintenance organizations, 102

health promotion programs in, 116-119

influence on risk selection of, 171-172, 173-174

innovation in, 10, 71-72, 238-239, 242

insurable events in, 44-45, 338

Medicare, 78-79

mental health care in, 104-106

planning, in case study, 130-133, 137-139

regulating, 19-20, 193-194, 249, 258

risk selection affecting, 184-185

in sample request for proposal, 156-158, 162-165

in social insurance, 41-42, 56-57

state-mandated, 101, 249, 298

in workers' compensation programs, 115-116

Biased risk selection, see Risk selection

Blue Cross plans

costs of, 219

HMO sponsorship by, 126

origins of, 66-69, 71-72, 295

Blue Shield plans

HMO sponsorship by, 126

in Medicare program, 78-79

origins of, 54 n.3, 68-69, 295

Bureau of the Census, Current Population Survey, 88, 93, 96

C

Cafeteria plan, 335

California, 37, 108, 250

Canada, 22, 32, 33, 110, 151, 252

Capital expenditures, regulation of, 208-209

Capitation, 335

Carve-outs, for retirees, 94-95 n.6

Case management, 335

Case study

contrasting cases, 142-145

employee advisory group in, 135-137

evaluating benefit plans in, 131-133

evaluating proposals in, 137-140

financial management in, 133

goal setting in, 130

implementing new benefit plan in, 140-142

legal issues in, 134

request for proposals in, 137, 155-166

small business concerns in, 143

Catastrophic expense protection, 335

Certificates of need, 209

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) , 335

Claims management

definition of ''claim," 335

in ERISA, 83

in sample request for proposal, 160-161

COBRA, see Consolidated Omnibus Budget Reconciliation Act of 1985

Coinsurance, 104, 335

Commercial insurance, 55-56, 71-72

Committee on the Costs of Medical Care (1927), 60-64, 66-67

Community rating, 257

definition of, 336

in early insurance plans, 67

experience rating vs., 47

in social insurance, 42

theoretical basis of, 181

Competition

ability of, to regulate health care, 207, 220-223, 240

among purchasing cooperatives, 18

effect of risk selection on, 169

managed, 37, 38, 81, 190-194

risk selection as basis for, 183

Complexity of U.S. health care system, 11-12, 149-152, 240-241

Compulsory coverage in social insurance, 41-42, 56-57

recommendations, 251-254

Confidentiality in Americans with Disabilities Act, 185-186, 246

recommendations for, 16-17, 246

worker concerns about, 148

Consolidated Omnibus Budget Reconciliation Act of 1985, 85, 313-314

Consultants, in planning health benefits, 124-126

Continuity of care

problems with, 10-11, 146, 239

research on, 259

Continuity of coverage, 10-11, 239, 259

under COBRA, 85, 313-314

termination benefits, ERISA on, 84

Cooperatives

health-plan purchasing, 18, 127, 214-215, 247-248, 342

regulating competition through, 191-192

Coordination of benefits, 94-95 n.6, 336

Copayment, 336

Cost management

benefit designs for, 74-75

cost sharing strategies in, 217

early efforts in, 73-77

early federal initiatives, 82

flexible benefits and, 218

growth of government role in, 207-211

health planning in, 75-76, 208-209

health promotion programs in, 218

issues in, 202-204

market-based strategies for, 220-223, 240

in Medicare program, 208-209

in network plans, 217-218

obstacles to, 11, 239-240

private sector strategies for, 212-220

prospective payment system for, 211

rate-setting programs for, 208-210

risk pool management for, 74

role of, in health care reform, 20, 250-251

self-insurance and, 218

see also Costs of health care;

Utilization management

Cost sharing, 74, 103-106

definition of, 336

effect on cost of care, 217

income-adjusted, 181 n.7

Cost shifting

definition of, 336

employer concerns about, 232

government role in. 211-212

recommendations for controlling, 248

uncompensated care and, 21, 184, 252

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Costs of health care

administrative expenses in, 108-110, 151, 206, 240

caps on enrollee spending, 104

concept of value in, 203-204, 223-227

consumer concerns about, 202

consumer spending on, 4, 204

distribution of spending on, 3, 4, 5, 27-28, 167

in early insurance plans, 67-68

economic effects of, 202-203

employer spending on, 4, 27-28, 71 n.17, 207

factors in rise of, 4, 7, 202-204, 221

growth of, 4, 28-29, 61, 78, 108, 204-207

individual's health status affecting, 178-179

inflation as factor in, 204

inpatient vs. outpatient services in, 204

international comparisons of, 4-5, 29-30

market forces in, 220-223

medical care component of, 204-205

medical technology in, 203, 204-206, 224

as obstacle to small group benefit plans, 94

population growth as factor in, 204

premium costs in, 106-108

public program spending on, 5, 207, 274

public subsidy of, 18-19, 248

reform and, 20, 248, 250-251

risk selection and, 183-184

size of group and, 183

tax expenditures in, 110

trends in, 204-206

uncompensated care in, 184, 252

in workers' compensation programs, 115

see also Cost management

Council of Smaller Enterprises, 127

Coverage

continuity of, 10-11, 85, 239, 259, 313-314

direct employer, 90, 337

indirect employer, 90, 338

issues in legislative reform, 256

mandated continuity of, 313-314

state-mandated, 298

state regulation of, 296-297, 298

vs. access, 7, 234

see also Benefit design

D

Deductibles, 103-104, 336

Demographic risk adjustment, 196-197

Dental benefits, 102

Department of Health and Human Services, 88, 89

Department of Labor, Bureau of Labor Statistics, 88-89

Diagnosis-related groups, 197, 211, 336

Disability insurance, 43 n.8

in origins of medical insurance, 51-54

Discrimination

age, protection against, 316

health related, 117-118, 148, 185-187, 236-237

in workplace health promotion programs, 118-119

E

Economic Stabilization Program, 208

Elderly

employment-based insurance for, 90

private insurance for, 77

Eligibility

defining family members for, 89-90 n.5

state-mandated, 101

workplace rules, 93-94

Employee advisory groups, in case study, 135-137

Employee assistance programs, 24, 118-119, 258-259, 337

Employee Benefit Research Institute, 31, 88

survey, 148-149, 287-292

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Employee Retirement Income Security Act of 1974 (ERISA), 82-85, 231-232, 293, 300-313

deemer clause of, 310

definitions in, 302, 304

employer liability for managed care and, 152-153

federal legal supplements to, 315-317

fiduciary standards in, 304-306

government regulation before, 82

multiple employer welfare arrangements and, 315

preemption of state law by, 306-311

recommendations for amending, 16, 19, 249-250

regulation of self-funded plans under, 310-313

reporting requirements of, 303-304

savings clause of, 307-310

underwriting in, 182

vesting in, 302-303

Employment-based health coverage

case study of, 128-145

costs of, 106-111

defining, 40-41, 44

development of, 3, 27, 49-56, 65-71, 67-71

employee responsibilities in, 145-149

in health care reform, 23-24, 26-27, 36, 207, 230-231, 242-243, 260-261

management activities in, 5-6, 121-127, 149-152, 232

mandated, 21-23, 251-254

participation in, 5-6, 8-9, 26, 27-28, 89-98, 232-233

private initiatives to control costs in, 212-220

types of, 98-106, 114-119

Employment practices

discontinuity in benefit coverage, 10-11, 239

effect of Americans with Disabilities Act on, 185-187

encouraging enrollment in spouse's benefit plan, 92

hiring of smokers, 117-118 n.16, 186

medical screening in hiring, 9, 117-118

ERISA. See Employee Retirement Income Security Act of 1974

European experience, see International comparisons

Experience rating, 47, 112-113, 133, 197, 337

F

Families

deductibles in coverage for, 103

of insured workers, benefits for, 89-92

of uninsured workers, 92-94

Federal Employees Health Benefits Program

features of, 170, 175

origins of, 73

risk selection in, 175-177

Federal regulation

in development of employment-based health plans, 70-71

early social insurance proposals, 60-65

encouraging HMOs, 210

before ERISA, 82, 300

of mental health benefits, 106 n.11

need for, 19, 245-246, 248-250, 251-254

of pre-employment medical screening, 9

see also Employee Retirement Income Security Act of 1974 (ERISA);

State regulation

Fee-for-service plans

definition of, 337

modified, in network plans, 100

Fiduciary

definition of, 337

standards in ERISA, 304-306

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Financial Accounting Standards Board, 95

Financial management

ERISA requirements, 84

evaluating benefit options, in case study, 133

retiree benefits as corporate liabilities, 95, 113-114

tax expenditures in health benefits, 110-111

Flexible benefits, 119, 218, 337

Foundations for medical care, 76

France, health care spending in, 30, 32

Fraud, 116

G

Gatekeeper physician, 100, 338

Gender, premiums related to, 173

Geographic variations in coverage, 98, 101

Germany, 36-37 n.3

development of medical insurance in, 53

health care spending in, 30, 32t

premium costs in, 106

risk segmentation in, 46 n.9, 168 n.2

role of employers in, 217 n.5

sickness funds of, 46 n.9, 56, 57

social insurance in, 41 n.6, 42, 57

Group Health Association, 69

Group practice

origins of, 66, 69

prepaid, 341

H

Hawaii, 37, 83, 108, 219, 307

Health Care Financing Administration, 88, 89

Health Insurance Association of America, 88, 89, 188 n.13

Health Maintenance Organization Act of 1973, 82

Health maintenance organizations

benefit coverage in, 102

definition of, 338

evaluating, in case study, 130, 132-135

evidence of cost savings in, 218

government encouragement of, 210

group model, 338

growth of, 100

Medicare-contracted, 197

numbers of, 126

open-ended, 340

relative restrictiveness of, 98

risk selection in, 174, 177-178, 179

staff model, 344

state regulation of, 298-299

Health planning, 75-76, 208-209

Health Planning and Resources Development Act of 1974, 209

Healthy People 2000, 116

Heritage Foundation, 37

High-risk individuals, 117-118, 171-172, 199-200

Historical developments, 3, 27

Blue Cross plan, 66-69

in cost management, 73-77

early social insurance proposals, 57-65

government efforts to control health care costs, 207-212

growth of cost of care, 78

key dates of, 52

origins of employment-based health plans, 69, 70-72

origins of medical insurance, 51-56

private insurance initiatives, 65-71

in regulation of insurance, 293-295

in social insurance, 56-57

in utilization review, 76-77

Hospice care, 102

Hospitals

administrative expenses in, 110

cost of uncompensated care in, 184, 252

cost shifting in, 211-212

development of, 53

government cost control programs in, 208-210

prospective payment system in, 211

resource management of, 75-76

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

I

Indemnity insurance, 98-99, 338

evaluating, in case study, 132-133

Independent practice associations, 126, 338

employee concerns about, in case study, 135-136

evaluating, in case study, 130, 132

evidence of cost savings in, 218

origins of, 75

relative restrictiveness of, 98

risk selection in, 174

Information management under Americans with Disabilities Act, 185-186

analyzing health care data, 88

in establishing health status measures, 198-199, 225

evaluating benefit plans, case study of, 131-133

in risk-adjustment methodologies, 18, 197-198

see also Confidentiality

Innovation

in benefit plan design, 10, 24, 238-239

by commercial insurers, 71-72

in health research, 238

in medical technology, 10, 31, 50

in state regulatory efforts, 249-250

Insurable event, 44-45, 338

Insurance

actuarial fairness in, 180

administrative costs of, 109-110

administrative practices, regulation of, 296

basis for state regulation of, 293-295

definition of, 43, 338

disability, defining, 43 n.8

ERISA preemption and state regulation of, 308-310

growth of, 71-72

indemnity, 98-99

insurable event in, 44-45, 338

language of, 40-47

moral hazard in, 45-47

origins of, 51-56

prepayment, definition of, 44

private, enrollment in, 90

rate regulation of, 296-297

social, 41-42, 56-57, 58-60, 60-65, 181, 344

unfair practices in, 297-298

Insured workers, 89-92

concerns of, in benefit plan, 145-149

employee advisory group, in case study, 135-137

full-year, full-time, 92-93, 337

full-year, part-time, 337-338

health care spending by, 106

International comparisons

defining employment-based systems in, 36

early medical insurance in, 51-56

in health care reform, 36-37

in health care spending, 4-5, 29-34, 239-240

universal coverage, 56-57, 236

see also specific country

J

Japan, health care spending in, 30, 33

Job "lock," 32, 239

K

Kaiser plan

origins of, 69

underwriting in, 127 n.2, 219

L

Labor Management Relations Act of 1947, 300

Legal issues

in authority of ERISA, 301

employer liability for managed care, 152-153

federal preemption of state laws by ERISA, 306-311

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

fiduciary standards in ERISA, 304-306

foundations of state insurance regulation, 294-295

in multiple employer welfare arrangements, 314-315

in review of benefit plan options, in case study, 134

unfair insurance practices, state regulation of, 297-298

Lifestyle factors, 180, 186-187

Loading factor, 339

Louisiana, 108

Low-wage workers

extent of coverage for, 92-93

subsidized coverage, 248, 251

tax deductions for health care for, 111

M

Managed care, 100, 339

Managed competition, 190-194

Managed coverage, see Compulsory coverage in social insurance

Marketing practices, risk selection through, 175

Maryland, 209

Massachusetts, 108

McCarran-Ferguson Act, 82, 295, 309

Medicaid, 2, 42, 79-80, 339

administrative expenses, 108, 110

cost shifting and, 212

Oregon plan for restructuring, 193

Medical organizations

early opposition to health plans by, 69-70

see also American Medical Association

Medical records, see Information management

Medical services

in cost of care, 204-206, 223-226

regulation of, 75-77, 208-211

Medical technology

assessing value of, 225-226

cost of care and, 203, 205-206, 218, 224

development of, 51-53

innovation in benefit design and, 10, 31, 50

Medicare prospective payments and, 211

risk assessment methodologies and, 195-196

role in cost of health care, 205-206

Medicare, 2, 12, 78-79, 208-209, 339

administrative expenses, 108, 110

enrollment history, 79

HMOs in, 20

integrating retiree employment-related coverage with, 94-95 n.6

pharmacy benefits in, 102

prospective payment system in, 211, 212

risk assessment in, 195-196

secondary payers in, 316

use of utilization measures in, 197

Mental health care

cost of, as percentage of health expenditures, 104-106

coverage limits on, 104-106

employee assistance programs for, 118-119

Mississippi, 108

Moral hazard, 45-47, 339

Multiemployer plans, 85, 339

Multiple employer welfare associations, 84, 314-315, 339

N

National Association of Insurance Commissioners, 82, 188 n.13, 295

National Conference on Medical Costs, 212

National Labor Relations Board, 70-71

National Medical (Care) Expenditures Survey, 92

Netherlands, 106, 145-146

Network health plans

coinsurance in, 103-104

definition of, 340

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

effect on cost of care by, 217-218

risk selection in, 174

state regulation of, 298-299

types of, 100-101

Norway, health care spending in, 30

O

Oregon, 19, 193 n.15

P

Part-time workers, 90, 337-338

Peer review, 76

Peer review organizations, 210-211

Pepper Commission, 37

Pharmacy benefits, 102, 147 n.4

Physician(s)

early opposition to health insurance, 55

as gatekeepers, 100

impact of employment-based benefits on, 149-152

importance of, in consumer choice, 170

in Medicare program, 78-79

payment, 211

primary care, 341

risk selection in restricted network of, 174

role of, 53

types of, in state-mandated benefits, 101

Point-of-service plans

definition of, 341

features of, 191

growth of, 100

relative restrictiveness of, 98

Preadmission review, 341

Preferred provider organizations, 218, 341

coinsurance in, 104

relative restrictiveness of, 98

risk selection in, 174

state regulation of, 298-299

Premiums

age related to, 173

considerations in regulating, 255

cost of, 106-108

definition of, 341

effect of risk selection on, 175-176

evaluating benefit plan options, in case study, 133

gender related to, 173

risk rating of individuals and cost of, 117

for self-insured groups, 112, 113

workers' compensation, 115

Private insurance, enrollment in, 90

Professional standards review organizations, 210

Prospective Payment Assessment Commission, 212

Prospective payment system

cost shifting and, 211-212

definition of, 342

effect of, 211

origins of, 211

Public opinion

on administration of health care system, 232

compulsory employment-related coverage in, 31

cost concerns in, 202

delivery of health care in, 1-2, 22-23, 31

Employee Benefit Research Institute

survey on, 148-149, 287-292

of health benefits system, 12-13

Public spending

early social insurance proposals, 57-65, 60-65

financing through reform, 20, 248

international comparisons, 4-5, 32-33, 56-57

for Medicaid, 80

need for, 18-19, 248

public understanding of, 202

in risk-adjusted payment plans, 17-18

statistics, 4, 27

Purchasing cooperatives, see Cooperatives

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Q

Quality assurance, 342

Quality of care, 342

definition of, 184

effect of risk selection on, 184-185

health care spending and, 33 n.2

for the uninsured, 21, 252

R

Redlining, 97-98

Reform of health care system

administrative issues in, 151-152

alternatives proposed for, 37-38

amending ERISA in, 16, 19, 248-250

American Medical Association stance on, 59 n.8

basic benefit design in, 19-20, 193, 249, 258

confidentiality issues in, 16-17

continuity of care in, 259

cooperatives in, 18, 247-248

cost of, 250-251

employee assistance programs in, 258-259

employer size and, 219-220

high risk individuals in, 199-200

impact of private cost control strategies, 216-220

issues in, 1-3, 35-40, 48, 50, 254-256

managing competition in, 190-194

mandated universal coverage in, 21-23, 251-254

market-oriented approaches to, 7, 22, 207, 220-223, 240

mental health care in, 106 n.11

need for, 1, 14, 17, 47-48, 260

pace of, 227-228

proposals in other countries, 36-37

public subsidy of, 18-19, 248

to reduce risk selection, 14-17, 175-176, 187, 242

research needs for, 256-259

risk-adjusted payments in, 17-18, 194-196, 247, 257

risk sharing and, 261

role of employer in, 14, 22, 23-24, 31, 36, 216-220, 230-231, 242-243, 260-261

role of private sector in, 227-228, 229-230, 260-261

state experimentation in, 249-250

underwriting practices in, 16, 47, 187-190, 245-246, 257

within voluntary system, 243

workers' compensation system in, 115-116

Reimbursement systems

cost shifting and, 211-212

development of, 75

evaluation of, in case study, 133

in Medicare program, 79

in network plans, 100

physician, 211

prospective payment, 211

resource-based relative value scale, 211

Reinsurance, 199-200, 342

Request for proposals, in case study, 137-139, 155-166

Research needs

basic benefit design, 19-20, 258

on continuity of care, 259

employee assistance programs, effects of, 258-259

for health care reform, 23, 256-259

methodologies for risk adjusting, 18, 257

technology assessment, 226-227

underwriting reforms, consequences of, 257

Resource-based relative value scale, 68, 211

Responsible National Health Insurance plan, 37

Retirees, 94-95

benefits for, as corporate liability, 95, 113-114

Retrospective payment, 342

Risk, definition of, 43, 343

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Risk-adjusted payments, 17-18, 194-196, 247, 343

demographic approach to, 196-197

health status measures in, 198-199

methodologies for, 196-199, 257

prior use data for, 197-198

Risk pools, see Risk sharing

Risk rating, 47, 117, 343

Risk segmentation

arguments for, 13, 242

causes of, 47, 168

definition of, 46-47, 343

strategies for reducing, 187, 245-246

Risk selection, 167-169, 200-201

benefit design affecting, 171-174

biased, 46, 167, 335

causes of, 170-175, 178-179

definition of, 46, 168

discrimination and, 9, 236-237

in early insurance plans, 67, 69

effect of Americans with Disabilities Act, 185-187

effect on access, 182-183

effect on costs of care, 183-184

effect on premiums, 175-176

effect on quality of care, 184-185

employer factors contributing to, 170-172

equity issues in, 179-182

evidence of, 177-179

in Federal Employees Health Benefits Program, 175-177

high risk individuals and, 199-200

moral hazard and, 46

in network plans, 174

regulating competition to discourage, 190-194

risk-adjusted payments to reduce, 17-18, 194-196

size of group and, 168

strategies for reducing, 14-16, 187, 245

through administrative practices, 174-175

through individual medical records, 16-17

through marketing practices, 175

underwriting practices and, 173, 187-190, 245-246

universal coverage and, 22, 252

Risk sharing

definition of, 343

importance of, 26

risk pools for, 43, 74-76, 199-200, 343

Rochester, New York, 113, 127, 181 n.8, 218-219

S

Second opinion, 76, 343

Self-insured groups, 343

advantages of, 111-112

in case study, 133

cost savings by, 218

ERISA regulation of, 83-85, 310-313

funding mechanisms for, 111

liability for managed care in, 153

medical underwriting within, 16

premiums for, 112, 113

related to employer size, 111

risk segmentation and, 47, 168

risk-sharing arrangements for, 112-113

state regulation of, 101, 250, 310-313

stop-loss insurance for, 113

taxing of, 248

trends in, 189

types of, 44

Size of employer

administration of health plan and, 110, 121-122, 124-126

benefit design and, 5-6, 9-10, 99

cost containment strategies related to, 214

costs of health care and, 106, 183, 237

coverage availability related to, 5, 96-97, 232-233

employee assistance programs, 118

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

employer-financed coverage for retirees and, 95

evaluating benefit plans and, in case studies, 142-145

flexible benefit plans and, 119

health care reform and, 16, 219-220

health promotion programs and, 5-6, 117

risk selection and, 16, 168

self-insurance practices and, 16, 111

underwriting and, 16, 245-246

Small businesses

cooperative efforts by, 18, 127, 214-215, 247-248

definition of, 5, 42-43

HMO offerings by, 99, 214

limiting underwriting practices in, 187-190

reasons for not offering health benefits in, 94

see also Size of employer

Smokers, hiring of, 117-118 n.16, 186

Social insurance

definition of, 41-42, 344

development of, 56-57

early proposals for, 58-65

in Germany, 41 n.6, 42, 59

theoretical basis of, 181

Social Security Act, 64, 78, 80

Amendments of 1972, 208-209

Societe Francaise de Bienfaisance Mutuelle, 53

State regulation

benefits mandated by, 19-20, 101, 249, 298

ERISA and, 82-85, 249-250, 306-313

experimentation in, 249-250

extent of, 293

of insurance company management, 296

of insurance rates, 296-297

limiting risk selection through, 181-182

of managed care organizations, 298-299

of Medicare, 79-80

of multiple employer welfare arrangements, 315

origins of, in health care, 293-295

of self-insured groups, 310-313

social insurance initiatives, 58-60

of unfair insurance practices, 297-298

Statistics

administrative expenses, 108-110

benefit design, 102

coinsurance arrangements, 104

in Committee on the Costs of Health Care report (1928-1932), 60-61

consumer concerns about cost of care, 202

cost of mental health care, 104-106

coverage related to size of company, 96, 99

data sources for, 88-89

deductibles, 103

employment-based plans, enrollment in, 1, 27, 71, 236

flexible benefit plans, 119

health care in Rochester, New York, 219

health care spending, 3, 4, 27-28, 78, 204-206, 207

HMO enrollment, 210

industry type as variable in coverage availability, 97

insured populations, 3, 26, 27, 28, 236

insured workers, 89-92

Medicaid, 80

Medicare, 79, 236

network plan enrollments, 100

premium costs, 106-108

publicly funded health coverage, 4, 27

regional variation in coverage availability, 98, 99

retirees, 94-95

self-insured groups, 111

taxation of health benefit expenditures, 110-111

types of plans offered, 99

uninsured populations, 1, 4, 27, 236

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

uninsured workers, 92-94

worker attitudes toward benefit plans, 148-149, 287-292

workers' compensation benefits, 115

Steelman Commission, 37

Stop-loss coverage

definition of, 113, 344

extent of, in self-insured groups, 111

for self-insured groups, 113

types of, 113

Switzerland, 42

T

Taft-Hartley Act of 1947, 70

Tax Equity and Fiscal Responsibility Act of 1982, 85

Taxes, 110-111

deductibility of contributions to health plans, 71, 110-111

flexible benefit packages and, 119

legal supplements to ERISA, 315

in market-based reforms, 222

retiree health benefits as corporate liabilities, 95, 113-114

for self-insured groups, 248

Technology. See Medical technology

Terminating benefits, ERISA provisions on, 84

Third-party administrators, 113, 126, 152-153, 344

Traveler's Insurance Company, 55 n.4

Triple-option plan, 344

Trusts, for self-insurers, 113, 344

U

U.S. Chamber of Commerce, 37

U.S. Public Health Service, origins of, 57

Uncompensated care, 21, 184, 252, 344

Underwriting

in Americans with Disabilities Act, 185, 186

in cooperative plans, 127 n.2

by Council of Smaller Enterprises, 127

definition of, 344

risk selection and, 173, 182, 187-190, 245-246

role of, 47

in small-group market, 16

strategies for limiting, 16, 181-182, 187-190, 245-246, 251-252, 255, 257

Uninsured populations

age of, 93

health care for, 21, 234, 252

health of, 183

statistics, 1, 4, 27, 236

workers as, 8-9, 87, 92-94

working, vs. nonworking, in generating uncompensated care, 184 n.9

Unions

in development of employment-based health plans, 70-71

in development of medical insurance, 54, 55, 76

United Kingdom

health care spending in, 30, 33

origins of medical insurance in, 51, 55-56

Universal coverage, 236

employment-based, 21-23, 251-254

lack of, 22-23, 254

need for, 21, 251-252

Utilization management

definition of, 344

effect of, on cost of care, 217

employer liability for managed care and, 152-153

extent of, in employer benefit plans, 213-214

as measure in risk-adjusting, 197-198

in Medicare, 208

origins of, 76-77

retrospective, 342

V

Voluntary employee beneficiary association, 113

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×

Voluntary system of coverage, 1, 8, 26, 235, 237

early history, 51-56

improving, 243-251

limitations of, 21, 251-252

marketplace effects of, 9-10

replacing, 251-254

W

Welfare capitalism, 54

Well baby care, 102

Wellness programs, 116-119, 218

Workers' compensation, 114, 115-116, 345

Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 347
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 348
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 349
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 350
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 351
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 352
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 353
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 354
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 355
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 356
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 357
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 358
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 359
Suggested Citation:"INDEX." Institute of Medicine. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: The National Academies Press. doi: 10.17226/2044.
×
Page 360
Employment and Health Benefits: A Connection at Risk Get This Book
×
Buy Hardback | $70.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

The United States is unique among economically advanced nations in its reliance on employers to provide health benefits voluntarily for workers and their families. Although it is well known that this system fails to reach millions of these individuals as well as others who have no connection to the work place, the system has other weaknesses. It also has many advantages.

Because most proposals for health care reform assume some continued role for employers, this book makes an important contribution by describing the strength and limitations of the current system of employment-based health benefits. It provides the data and analysis needed to understand the historical, social, and economic dynamics that have shaped present-day arrangements and outlines what might be done to overcome some of the access, value, and equity problems associated with current employer, insurer, and government policies and practices.

Health insurance terminology is often perplexing, and this volume defines essential concepts clearly and carefully. Using an array of primary sources, it provides a store of information on who is covered for what services at what costs, on how programs vary by employer size and industry, and on what governments do—and do not do—to oversee employment-based health programs.

A case study adapted from real organizations' experiences illustrates some of the practical challenges in designing, managing, and revising benefit programs. The sometimes unintended and unwanted consequences of employer practices for workers and health care providers are explored.

Understanding the concepts of risk, biased risk selection, and risk segmentation is fundamental to sound health care reform. This volume thoroughly examines these key concepts and how they complicate efforts to achieve efficiency and equity in health coverage and health care.

With health care reform at the forefront of public attention, this volume will be important to policymakers and regulators, employee benefit managers and other executives, trade associations, and decisionmakers in the health insurance industry, as well as analysts, researchers, and students of health policy.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!