A Brief History of Employer-Sponsored Healthcare [From the 1930s to Now]

As Americans continue to debate the impact of the Affordable Care Act (ACA), perhaps a quick look at the historical timeline of employer-sponsored healthcare will provide context for the state of American healthcare as it exists today.

Small Beginnings

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.

At this point, everyone knows the Affordable Care Act (ACA) requires all employers with 50 or more full-time equivalent (FTE) employees to offer affordable coverage to their workforce. This requirement is called the employer mandate.

What’s less clear for some employers is to whom the coverage must be extended. Do employers have to offer family health insurance coverage? Dependent health insurance? What about coverage for spouses? The answer is pretty straightforward, so let’s dive right in and clear up all that confusion.  

ACA Requirements for Employers

The ACA requires that applicable large employers (ALEs) offer affordable coverage to their full-time employees and their dependents up to age 26. However, the law makes no requirement for spousal coverage, nor does it mandate that employers pay for any portion of the premium for dependents.

So in short — employers are not required to offer family health insurance. That being said, many employers choose to offer coverage for spouses and families, regardless of whether dependents are older or younger than 26 years of age. In addition, most choose to subsidize a portion of the premium as well.

One trend picking up steam in the past decade is to only offer spousal coverage if the spouse isn’t able to obtain health insurance through his or her own employer (or if the spouse doesn’t work).

Another common practice is for an employer to levy an additional surcharge for spouses who can obtain insurance through their own employers, but prefer to be on their spouses’ insurance instead. The reasons for doing so are often wide and varied. Nevertheless, the surcharge is often relatively minimal — perhaps around $100.

Even though the majority of the working population in America are parents, employers seem to be largely in the dark about how to cater benefits packages to people who are raising kids, especially working moms. Thanks to the openness of the internet and highly successful working moms (like Sheryl Sandberg of Facebook) talking about their experiences, a whole new avenue of conversation has started about making the workplace more family-friendly. The law provides a starting point, but there are little things (even free things) you can do to help make pregnancy and the return to work easier for working moms. 

First, a disclosure before I go on - I had a lot of help from my wife, a working mom of two children, when writing this particular article. She had a lot of thoughts about what she wished she would have had access to when our children were young and what employers could do now to make the return to work easier. With that out of the way, let's continue...

What’s Required of Employers by Law

Employers with 50 or more full-time equivalents are required to allow men and women to take up to 12 weeks of unpaid leave each year under the Family Medical Leave Act (FMLA). Most employers will allow their employees to use vacation or sick time during their leave so that part of the weeks are paid. Some even offer partially paid leave.

One of the provisions in the Affordable Care Act includes employer requirements for working moms who are still nursing. This stems from the scientific belief that breast milk, for the first year, is what’s best for babies, as well as the reality of breastfeeding — which is that it’s time consuming. Women are more likely to give up on breastfeeding if they don’t feel their employer is supportive of providing work breaks for pumping.

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.

The term “healthcare” gets thrown around quite a bit these days. As HR professionals, you may have seen “healthcare” used interchangeably with “health insurance,” although it’s the layman doing so, rather than industry professionals. Healthcare and health insurance are two completely different things. They have different definitions, even though we, as a country, have largely co-mingled the two.

This co-mingling has led the county to erroneously focus on health insurance as an equal target of wrath for the rising cost of medical care, when in truth, healthcare has been the driving force. This understanding is critical if we’re to wrestle the ever escalating cost of medical care in this country.

Healthcare vs. Health Insurance

Healthcare

Healthcare is defined as “the field concerned with the maintenance or restoration of the health of the body or mind.” This also pertains to any “procedures or methods” related to the care of a person’s physical or mental health.

The industry in which medical professionals work is often referred to as the “healthcare industry.” Healthcare is provided by doctors, nurses, dentists, therapists, hospital systems, and pharmaceutical companies. The price these providers set for their products and services is the primary driver of health insurance costs.

With healthcare costs continuing to rise, small employers that aren't obligated to offer health/medical insurance per the Affordable Care Act’s (ACA) “employer mandate” have been dropping group coverage. This is a trend that started in 2009 during the recent recession. Some larger employers have also considered doing the same (though, they must pay steep ACA penalties if they do). At first glance, it might seem like this would bolster the health and stability of the individual insurance market. Despite the numbers of insured rising, however, increased costs and fewer options have put a serious squeeze on what was once a very healthy marketplace.

Group Health Insurance and Individual Health Insurance by the Numbers

Occasionally, a news piece predicts major shifts in the health insurance landscape, including dire predictions about employers dropping group health plans due to their high costs. However, it’s important to look closely at these numbers, as well as the size of the companies cited in the statistics.