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2009 employer survey.

Employers are as worried about health care as anyone. And they share their employees' concerns, such as cutting costs, keeping HSAs and fighting mandates. In short, they want what you do.

Every year about this time--for about half a decade now--we check in with employers to find out where they are and how they're doing. Because there's nothing more crucial than knowing as much as you can about your clients--or prospects.

And has there ever been a more critical time in our business?

So, in light of that, this year, we decided to turn to couple of experts, who tackled this year's survey with an eye toward employer attitudes toward health care reform, whatever form it might take.>>


Between May 21 and June 30, 2009, the authors surveyed employers across the United States concerning various options for health reform under consideration by Congress. The authors contracted with TRL Consulting, a St. Paul, Minn. actuarial firm, to analyze results and recommend conclusions.

More than 1,200 employers responded, with more than 1,000 respondents completing the survey that also had consistent responses, for an 84 percent validation rate. The survey contained 42 questions, and was presented online using to administer and collect data. Respondents were allowed to add written comments on many of the questions.

Among the validated respondents, business owners represented the largest cohort--roughly 40 percent. When combined with CFOs, COOs, and CEOs, the senior leadership cohort equaled about 58 percent of survey respondents. More than 75 percent of the represented companies have been in business more than 10 years. The survey population represents about 210,000 employees in 41 states. These were primarily professional services, service businesses, and manufacturers.

Respondents learned of the survey when contacted via e-mail from several different sources. These included professional health insurance agents, providers, employer groups, or from blogs and magazine articles. This method of contacting potential respondents created a higher-than-average rate response from employers that offer health insurance when compared to the general population. Yet, using this method to contact respondents also served to increases the survey's value by testing the attitudes of those who have consistently invested in the health care benefit system.


To learn more about this survey, visit or for past employer surveys.


40% are business owners

58 % are senior leadership

75% represent companies that have been in business more than 10 years

210,000 employees represented in the survey population, covering 41 states

1. Dave Racer, MLitt, and Greg Dattilo, CEBS, are co-authors of three health reform books: Your Health Matters. FACTS: Not Fiction, and Why health care costs so much: The Solution--Consumers. They have authored several articles and papers, and regularly speak to groups across the country on health care reform. Email:; Phone: 651-340-1911 Website:

2. wTRL Consulting, LLC, provides actuarial, financial and Human Resources Consulting. Its Principal is Timothy R. Leier, a member of the American Academy of Actuaries and a Fellow of the Society of Actuaries. He certifies the application of standard statistical principles in the analysis of the data presented herein, and his conclusions are consistent with the questions asked and responses received.

Employers' primary concerns about health care

Almost 83 percent of respondents believed the most important reform needed is to reduce the cost of health care. Only 13 percent believe quality is the most important, while 8.3 percent saw reducing the uninsured rate as the GOP priority.
83% reduce cost
13% quality
8.3% reduce uninsured

Note: Table made from bar graph.

Employer-provided health benefits

More than 90 percent of respondents offer health insurance to full-time employees. Another 15 percent offer health benefits to part-time employees, but those that offer this benefit represent more than half of the total number of employees in the surveyed firms. Six respondents mentioned that when they provided a cash payment to employees in the hope that employees will use it to purchase health insurance, the employer does not consider it the same as providing a health benefit to that employee.

About 40 percent of respondents employ temporary and seasonal employees, but many of these employees are provided by temporary employment services, many of which offer their own health benefit. Although we did not measure this, experience has shown that a number of these temporary-seasonal workers receive their health benefit from a spouse that has full-time work elsewhere-they are not uninsured, they are insured under a spouse's coverage. We believe it would be of value to measure this question in a future survey.

The drop rate of insurance coverage remains very low. Of those that do not offer coverage but have offered sometime during the past five years, less than .8 percent per year had dropped coverage during each of the past five years. (This survey did not test this statistic for companies that have gone out of business during this time.)
offer insurance to
full-time employees 90%

offer health benefits to
part-time employees 15%

employ temporary and
sesonal employees 40%

Note: Table made from bar graph.

Health Savings Accounts are growing in perceived value

Roughly half of the respondents offer an HSA to employees. Yet, 60 percent believe that retaining or expanding the use of HSAs is very or extremely important.


Mandated coverage

Mandating coverage to achieve universal health insurance is an undesirable option for a large majority of respondents. About 70 percent oppose a specific or general mandate, with 75 percent of business owners in opposition.

Roughly 90 percent of respondents oppose allowing the government to design a mandatory health plan should Congress pass such a requirement. More than 95 percent of owners oppose a government-designed mandatory health plan.

More than 95 percent of respondents want to retain their ability to offer insurance options even if government mandates coverage.

Nearly 86 percent of owners object to allowing the government to set monthly premium rates, and more than 75 percent of owners oppose being responsible to report insurance enrollment statistics to the government. Moreover, 87 percent oppose being forced to pay premium on behalf of employees for plans designed and priced by the government.

A large majority--71 percent--would not want to withhold money from employees (garnish their wages) to pay mandatory health premiums; we found it instructive that 28 percent do agree with this idea. We speculate that this latter reflects the views of Human Resource and Payroll Managers, as opposed to owners, but the data does not clearly differentiate. We believe the difference in attitudes of owner/top managers and HR managers should be further tested and compared.
oppose specific or
general mandate 70%

business owners who oppose
specific or general mandate 75%

oppose allowing the government
to design a mandatory plan 90%

of owners oppose a
mandatory plan 95%

want to retain ability to
offer insurance options 95%

of owners object to government
set monthly premium rates 86%

of owners oppose having to
report enrollment statistics 75%

oppose being forced to
pay employee premiums
for government plans 87%

would not want to garnish wages
to pay mandatory premiums 71%

Note: Table made from bar graph.

When the mandate is tied to the idea of a Health Insurance Exchange, through which employers would be required to purchase insurance, nearly 91 percent oppose being required to purchase coverage through the Exchange.

Enforcement disconnect

If government chooses to mandate coverage, only 30 percent of respondents want the government to enforce the mandate. Though the survey did not specifically test the expectation of the rate of mandate compliance, it is instructive that nearly two-thirds of respondents expressed no desire to have the government actually enforce it. This may indicate that respondents have very little confidence that government can devise any effective, non-invasive enforcement procedures. This possible conclusion deserves further testing.

Expanding Medicare and providing coverage for low-income individuals

Nearly 88 percent of owners, and 80 percent of all respondents, oppose expanding Medicare (government health plan to compete with private health plans) as a reform option.

About 50 percent of respondents reject the idea of subsidizing their low-income employees' insurance premiums with government money. Yet other findings in this survey indicate that 70 percent to 90 percent of employers reject direct government involvement through mandates, premiums, and plan design. If there is a mandate, 50 percent are more willing to allow government to provide a premium subsidy.

About 75 percent of employers want nothing to do with helping to enroll low-income employees into government health plans for which they qualify, suggesting 25 percent would do it. The 25 percent who are willing, however, consists primarily of human resource and payroll management employees whose jobs are dependent on resolving these types of issues.
owners who oppose
expanding Medicare
as a reform option 88%

of all respondents
who oppose
expanding Medicare
as a reform option 80%

of respondents reject
the idea of subsidizing
low-income employees
insurance 50%

are willing to allow
a subsidy if there
is a mandate 50%

Note: Table made from bar graph.

Taxes to pay for reform


Nearly 65 percent of owners reject a tax increase of any type to pay for health system fixes, while about half of all survey respondents reject all tax increases. We suggest owners might better understand they will be the targets of those increased taxes, providing additional motivation to reject them. More than 14 percent of respondents indicated they could support a combination of types of taxes, while 7.2 percent would support a health care provider tax (taxes on health care as it is provided).


Premium rates and lifestyle choices

We asked whether lifestyle should be taken into account in setting insurance rates, more than 87 percent indicate that lifestyle choices should play a role in setting insurance premiums. We speculate that the 12.4 percent who believe that lifestyle should be ignored may be smokers or practice other risky behaviors, but we did not specifically test for this.

On the other side of this question, 81 percent believed that people who can demonstrate that they practice a healthy lifestyle should be allowed to pay a lower premium than those who life risky lifestyles.

A note on financial service providers

Although the cohort was not large enough from which to generalize to a broader population, those respondents who indicated wthey work in the financial service industry tended to support an insurance mandate at a higher rate than those in other types of businesses. Financial service providers, however also opposed increasing government's role in the design and distribution of health insurance. Compared to non-financial service employers, those in the financial service industry prefer to see more individuals and businesses purchase and maintain ownership of health insurance, even if it takes a government mandate to do so. But, they do not want government interference in pricing, benefit setting, or other direct involvement in their relationship with clients.


"When do I get my stimulus check, one sarcastic or maybe just frustrated employer asked.

This survey primarily tested the attitudes of employers that offer a health benefit to their employees (90 percent). They like this system, and do not want government to interfere with it. They want government to help find ways to reduce the cost of care, not change it or meddle with the provision or sale of health insurance. A statistically insignificant .8 percent of employers per year have dropped coverage during the past five years. This is a strong indication that correcting problems in the private insurance market will do more to keep people insured than to increase the role of government in the form of mandates, subsidies, government health plans, or government insurance purchasing organizations.


Employers recognize that compliance, withholding, enrollment, and other potential requirements that flow from government-directed health reform will cost money and complicate their businesses. They want relief, not more regulations and requirements.

Even when they recognize that an insurance mandate may become law, they have very little confidence that government can or will enforce it. Employers see no cost relief as a result of mandating coverage.

Employers, through their investment in HSA-compliant health plans, and their strong support for expanding them, imply a preference for market-based cost solutions, rather than central government planning.

Furthermore, employers suggest the government health reform is overreaching, and thus, threatens to damage the economy.

"A government mandate is a bad idea. It is too expensive, it will not be more efficient than the current system, and many, many jobs will be lost/eliminated if put into effect. U.S. citizens currently have choices and our citizens need to be allowed to make choices, whether to carry insurance or not, and if so, what type of plan works best for each individual. Health providers, insurance companies, and consumers need to work in concert to keep costs in check, determine services, and coverage," one employer commented.

"The government is not responsible for medical coverage. There are insurance companies that are in business to handle this commodity. [Government should] fix the roads--insure the safety of our borders and water. Leave the rest to us the citizens," another wrote.
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Author:Racer, Dave; Dattilo, Greg
Publication:Benefits Selling
Date:Sep 1, 2009
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