Earlier this year the IRS announced proposed regulations extending ACA affordability to other tiers of employer-sponsored group medical coverage (employee + child/spouse, family, etc.). Today the IRS released final regulations.  

Previously, ACA affordability was based solely on the employee-only tier of coverage. If an employee was offered affordable, minimum-value coverage, the spouse and dependent children would not be eligible to purchase subsidized coverage on the exchange.

Under this new rule, if the family tier of coverage is not affordable, spouses and/or dependent children will now be eligible to purchase subsidized coverage on the exchange, provided they don’t have their own offer of affordable coverage.

Since its inception, the Affordable Care Act (“ACA”) has measured “affordability” based solely on the cost of employee-only coverage.  This so-called “family glitch” has meant that spouses and dependent children of employees who are offered affordable, minimum value coverage have not been eligible for federal tax credits (Premium Tax Credits; “PTCs”) to purchase coverage through the marketplace.  

As a result, even though such family members might not receive a penny of employer-subsidized health coverage, an employer’s satisfying mandate duties to the employee has always been “imputed” to children and spouses, thereby effectively blocking those family members from obtaining any federal money.

Recently the Internal Revenue Service (“IRS”) announced proposed regulations that would change this. This IRS change solely alters family access to federal marketplace coverage subsidy funding but does NOT expand the employer mandate to include family coverage.

Individual Coverage Health Reimbursement Arrangements (ICHRAs) are a new type of health reimbursement arrangement in which employers of any size can reimburse employees for some or all of the premiums that the employees pay for health insurance.

Employers can reimburse employees tax-free for individual health insurance, including coverage purchased on federal or state-sponsored health insurance exchanges, the individual markets, or Medicare.

And under federal rule changes in 2019, ICHRAs can be structured to fulfill the employer mandate under the ACA that requires most organizations to offer “affordable coverage" for employees.

The verdict is in – employer adoption of high-deductible health plans (HDHPs) as the sole medical option for employees is beginning to fade.

Brought on, in part, by the need to offer richer medical benefits in the face of a tightening labor market, a recent survey by the National Business Group on Health (NBGH) indicates that 23% of large employers who currently offer an HDHP as the sole medical option for employees are planning to introduce other medical options this year. 

This represents a drop from 39 percent to 30 percent of large employers who only offer an HDHP to their workforce. Similar surveys by the Kaiser Family Foundation (KFF) and Mercer support these findings. 

The intense competition for talent (who may be seeking richer plans) is only one reason for the decline in popularity of HDHPs as an employer’s sole medical plan option. Also contributing to this waning interest has been the ongoing postponement of the Affordable Care Act’s “Cadillac tax” on higher-value plans, which was initially a driving force for HDHP adoption by employers. 

The threat of the tax has abated to the point where it seems dubious if the tax will ever come to fruition. (The 40 percent tax on high-value health plans was originally set to take effect in 2018 but was then postponed to 2020 and then again to 2022.)

Author's note: This post is not intended to defend nor criticize the merits of the Affordable Care Act (a political lightening rod if ever there was one). Rather, this post is merely intended to dispel a few myths as it relates to the ACA's spill-over impact on the group insurance market. 

While its effects on the individual insurance market can be debated (though most agree the ACA did very little to contain healthcare costs but did a terrific job of making healthcare more accessible), it’s a common misconception that the Affordable Care Act (also known as the ACA, or Obamacare) is causing group health insurance rates to dramatically increase. This myth, along with others that play into it, have been perpetuated frequently since the law’s passage in 2010 — especially since the individual and small business health insurance marketplaces opened in 2014.

The truth is health insurance rates were increasing long before Barack Obama ever got close to the White House. According to data from the Kaiser Family Foundation, the average cost of premiums for individual coverage increased about 32.5 percent between 2010 and 2017. But compared to the 8-year period prior (when premiums increased about 56 percent) that amount seems low. For family coverage, the numbers are even worse, showing a 36 percent increase since 2010, compared to 67 percent in the 8 years prior. 

In addition, it would appear the ACA is actually helping to slow our national health expenditures (NHE) as a percentage of GDP. The Centers for Medicare and Medicaid Services (CMS) has been tracking this data since 1960. CMS defines NHE as “health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care.” In other words, NHE is what we collectively spend on healthcare each year between health insurance rates, out-of-pocket expenses, and any health programs we take part in.

Between 2010 and 2016 (the latest year for which data is available), NHE increased from 17.4 percent to 17.9 — a mere half a percent (although one could also argue this could be due in part to effects of the recession). By contrast, in the 7-year period beforehand, NHE increased nearly two percent, going from 15.4 percent of GDP to 17.3. 

In order to figure out how we could actually fix this system, we have to understand the differences between what’s really broken about it and the myths out there. Here are three myths we can easily bust.

Best-in-class employee benefits evolve with the times and our changing values. We saw marriage equality granted to all people in this country after Obergefell v. Hodges, opening employee benefits to many additional spouses and families. Now, we’re seeing more and more employers (including Fortune 100 and 500 companies) embrace transgender-inclusive health insurance plans as gender identity awareness improves. However, medical professionals have been stressing the importance of transgender health for years.

In 2008, the American Medical Association (AMA) first voiced its concerns for the discrimination of transgender individuals when it published a guidance supporting “public and private health insurance coverage for treatment of gender dysphoria as recommended by the patient's physician.” (This policy was updated in 2016).

In order to truly be an equal opportunity employer, you should have at least one transgender-inclusive health insurance plan in your employee benefits package. It’s not as complicated or expensive as it may sound. In fact, right here in our home state of Arizona, there are quite a few employers already offering such benefits.

Here are some practical issues you should consider when expanding your employee benefits to make sure they include transgender employees and how doing so could help you recruit and retain the workforce of the future — namely, millennials and generation Z, who see inclusivity as an important attribute of prospective employers.

One of the most common questions we receive as an employee benefits broker is how much the average employer contributes to their employees’ health insurance premiums. It’s a tough question because there are a lot of different factors involved, but luckily, there are some excellent resources available to help us source reliable answers.

In addition to our own proprietary client roster, one of our favorite resources is the annual Kaiser Family Foundation (KFF) Health Benefits Survey because it succinctly summarizes data from an accurate (and broad) representation of employers across the country and provides charts and graphs to make the information more easily digestible. This allows us to show our clients trends over long periods of time and perhaps help predict what they can expect for the upcoming year.

Here’s what the 2017 KFF Health Benefits Survey reported for employer contributions to health insurance and how the data compares to the previous benefits year.

Employers have been struggling to find the best way to provide affordable health benefits to their workers for many years now. One promising option, especially for those with smaller workforces, is to offer insurance through multiple employer welfare arrangements (MEWAs) and association health plans (AHPs).

The idea behind MEWAs is to bundle small groups into a larger community, thereby spreading risk over a larger and more diverse pool of covered individuals. It’s the same principle large employers benefit from by way of lower insurance premiums.  

If your small business is looking for cheaper healthcare options, MEWAs and association health plans may be good options for you to investigate.

What is a MEWA?

MEWA stands for multiple employer welfare arrangement, but is also sometimes referred to as a multiple employer trust (MET). MEWAs allow small employers to essentially team up to create a larger pool of employees to capitalize on the economies of scale that larger employers enjoy. This could mean as few as two employers in the group, or as many as deemed necessary to form a large enough employee pool.

Each employer gets a say in plan design, as well as plan offerings. If one employer has an older population who prefers more traditional plans, they can request such for their workforce. If another employer has a younger workforce for whom high deductible health plans would be more appealing, they could request more consumer-driven healthcare options for their employees. With these groups banded together, the premium costs should be lower than if each employer tried to get insurance on their own.

The American healthcare system functions pretty differently than healthcare in Europe — and most healthcare systems in other first world countries, for that matter. With the ongoing healthcare debate in America (from repealing and replacing the Affordable Care Act to Senator Sanders’ Medicare-For-All proposal), many people have begun to ask why we can’t have a system like Canada, the U.K., France, or most other European nations. In order to decide whether or not those types of systems would be suitable for America (a debate we will not delve into here), we first have to understand how healthcare in Europe works.

How Healthcare in Europe Works

Generally speaking, most European nations (in addition to others around the world) have some type of universal healthcare. According to the definition provided by the World Health Organization (WHO), this means that everyone has equal access to quality healthcare that improves the health of patients and that seeking such care would not cause financial harm to those receiving it.

While it’s easy for Americans to generalize European healthcare into one giant conglomerate of universal coverage, there are actually many different systems across the continent. Each country has figured out their own way of organizing their insurance companies, doctors, and hospital systems. But regardless of country, healthcare in Europe is designed with the same goal in mind: to make sure every person has access to basic health services.

Given that European nations have all been around far longer than America, they’ve tried almost every possible scenario and, for the most part, they’ve landed largely on three systems: single-payer, socialized, and privatized, but regulated. Of course, there’s quite a bit of variety between countries and no two systems are alike.

According to The Commonwealth Fund’s most recent study of 11 different countries’ healthcare systems, the United States comes in dead last. This study measures overall industry performance and each country is ranked by five factors that contribute to their score: care process (in which the U.S. placed 5th), access (11th), administrative efficiency (10th), equity (11th), and outcomes (11th).

For being one of the richest countries in the world, the U.S. just can’t seem to get a grip on their healthcare system. No matter the proposed solution over the past century, the system has slowly but surely become more and more expensive, which means it’s also becoming less and less accessible.

If you were to ask 10 people why America’s healthcare system is broken, you’re sure to get 10 different answers — and you might even get into a debate about what “broken” means, both of which could help explain why we haven’t been able to fix it yet. Experts have many opinions, but one thing is for sure: the problems with our healthcare system don’t point back to just one cause. There are multiple issues at hand and none of them are easy fixes. 

5 Major Ways Our Healthcare System is Broken

Lack of Cost Transparency

One of the most common complaints among consumers is the lack of cost transparency in our healthcare system. You’d be hard-pressed to find another industry where this is the case. Even in other insurance situations, such as a car repair after an accident, the driver can figure out a fairly accurate estimate before ever paying a dime. The same goes for a homeowners claim.