Prepared by Vishaal Pegany December 22, 2015
Advancing the Triple Aim
for Employer-Based Health
Insurance
Introduction
Through expanding Medi-Cal and subsidizing private insurance through Covered California for 1.3 million Californians, the Affordable Care Act (ACA) launched the triple aim of better access, improved care, and reduced costs. As the ACA enters its third year of implementation, California faces key ACA implementation challenges in 2016 and beyond: employer mandate for midsize em-ployers, evolving market rules and aligning incen-tives in the small group, mid-sized and individual markets, affordability of employment based cover-age for employees, and effective implementation of Covered California’s SHOP. Thus, California will need to look beyond coverage expansion and eval-uate strategies and policies that advance the triple aim framework for employment based health in-surance. California’s policymakers and the em-ployer community will need to work together to address needs and challenges that include:
1) Improving coverage and affordability with-in the different employer markets (small, midsize, and large)
2) Implementing payment and delivery sys-tem reforms that reward value
3) Preparing for the impacts of the Cadillac tax; and
4) Consider the merits of insurance market mergers.
This report provides background history and key findings from the literature and the latest available survey data on employer health benefits, describes the California context, and outlines issues for poli-cymakers and employers to consider in advancing the triple aim for employer-based health insur-ance.
Part 1: Improving Coverage and
Affordability
A Brief History of Pre-ACA Insurance Market Reforms affecting Small Group Employers
Small businesses have historically experienced disadvantages in the health insurance market be-cause of their size. When small businesses do offer coverage, they generally offer a single plan and often incur higher administrative costs, premiums, and cost-sharing.1 Historically, employees in small businesses could voluntarily enroll and small busi-nesses generally had lower employer premium contributions for dependents than larger employ-ers. The voluntary nature of enrollment and in-creased employee responsibility for premiums re-sulted in enrollments that skewed towards employ-ees with greater health care needs.
Small businesses are also generally aware of the health care needs of their employees, which might influence their choices about the plan type and coverage level. This made insurers wary of adverse selection, which is the disproportionate enrollment of sick people into plan. This led plans to turn away small groups with less favorable risk, the exclusion of specific employees from coverage, and excessive premiums that effectively priced these employers out of the market. Similar to the indi-vidual market, the small group market was not as favorable to distribute financial risk as insurers serving large groups. From an economic point of view, the small group market experienced market failures because many small businesses lacked op-tions for affordable coverage. The misaligned in-centives encouraged market competition based on risk avoidance rather than true competition based on price, quality, and service.
In 1992, California policymakers enacted Assem-bly Bill (AB) 1672, which balanced the competing needs of reliable access to health insurance for small businesses and the adverse selection con-cerns of insurers. AB 1672 required insurers to
proactively market and sell insurance plans to small groups with less than 50 employees on a guaranteed issue and renewal basis. Though not completely eliminating medical underwriting, AB 1672 specified that pre-existing condition exclu-sions of employees could only occur once for a six-month period and would not recur when an em-ployee switches insurance carriers or moves to a new employer so long as the employee maintained continuous coverage. AB 1672 placed some con-straints on medical underwriting by requiring that premiums could only vary by plus or minus 10% of the standard rate every insurer charges. The standard rate that every insurer developed was based on the following rating factors: age, family size, and geographic location; there were no rate bands on age rating.2
To guard against adverse selection and maximize enrollment, insurers were able to include require-ments for minimum employee participation (gen-erally at least 70% of eligible employees) and em-ployer premium contributions (at least 50% of the premium for employee only coverage). These re-quirements also ensured that the pool of enrolled individuals was better balanced with healthier in-dividuals who had greater incentives to enroll in coverage. While AB 1672 did make the small group insurance market fairer, more transparent and more predictable for small businesses, the law did not directly address the underlying issue of whether the rates in the small group market were affordable enough to encourage more small nesses to offer coverage. To this day, small busi-nesses continue to have high rates of uninsured employees with only 39.6% of very small business-es voluntarily offering coverage to their employebusiness-es – a figure that steadily increases with employer size.3
Between the years of 1993-2006, California oper-ated an insurance exchange, the Health Insurance Plan of California (HIPC), which intended for small businesses to have the purchasing power advantages enjoyed by larger businesses. HIPC consistently struggled with enrollment, and even at its highest point of 150,000 enrollees, it represent-ed a very small share of the small group market.4
Though HIPC ultimately was not a viable insur-ance exchange model, it provided many relevant lessons that were incorporated into the ACA and directly applied by California and other states as they implemented their exchanges.
There are four intertwining reasons for HIPC’s failure.5 First, because not all health plans partici-pated, HIPC was limited in its ability to capture a significant market share. Second, HIPC did not reach a sufficient economy of scale to achieve ad-ministrative savings that could lower premiums. Third, HIPC did not have the purchasing leverage to negotiate lower prices because insurers were less invested in HIPC. Insurers were concerned about profits and losses when sicker enrollees could churn to other plans within HIPC. Lastly, because there were different insurance market rules for plans inside and outside of HIPC, HIPC eventual-ly succumbed to adverse selection.
To elaborate on this last point, plans sold in HIPC did not experience rate but outside plans contin-ued to do so under the terms of AB 1672 which permitted a rate band of plus or minus 10% for health status or claims experience rating. This resulted in insurers steering high risk customers to HIPC and even insurers within HIPC channeling customers to other plans within HIPC. When plans no longer had well-balanced risk pools, they were forced to raise premiums to cover their costs. This produced a repeating, vicious cycle whereby healthier individuals found more affordable op-tions outside HIPC, leaving behind an even sicker risk pool within HIPC.
While the HIPC had its shares of problems that ultimately led to its closure, the concept of an in-surance exchange that allows for consumers to easily comparison shop remained popular among employers, policy makers and some health plans. When Congress incorporated insurance exchanges into the ACA, it put in place requirements that likely drew from California’s experience with HIPC. For example, the requirement that subsi-dies could only be accessed through the exchanges guaranteed a fairly large and stable customer base. Health plans could only tap into these consumers by participating in the exchange. More
compre-hensively, the ACA minimized adverse selection concerns through the individual mandate. And California required that plans in the individual and small group markets inside and outside of the exchange play by the same insurance market rules and offer the same prices for the same products.
Challenges in Maximizing Enrollment in Covered California for Small Business
Through improved marketplace rules, the ACA represents a second chance for California to im-prove coverage for small businesses. The ACA established a dedicated small group insurance marketplace for employers (with less than 50 em-ployees) known as Covered California for Small Business (CCSB) (previously referred to as the Small Business Health Options Program or SHOP). To be a sustainable marketplace for small businesses, CCSB depends on the optimal partici-pation of employers to ensure a larger and more balanced risk pool and to achieve an economy of scale.6 Equally important, a high participation of small businesses would position Covered Califor-nia to capture sufficient market share to drive down costs, offer more choices for plan selection, and increase overall competition in the market-place.7
While Covered California exceeded its individual market targets by enrolling over 1.4 million Cali-fornians in 2014, it remains challenged with achieving similar levels of success with CCSB. As of August 2015, CCSB has enrolled 2,865 small groups covering a total of 19,465 members with an average group size of 6.8.8 Based on 2010 data, an estimated 456,500 California small business with 25 or fewer employees are eligible for refundable tax credits under the CCSB, representing approx-imately 80% of California businesses.9 Of this group, an estimated 135,900 are eligible for the maximum tax credit of up to 50% of premium costs.10 There are several explanations for the lim-ited success of CCSB, an important one of which could be a one-year delay for small group employ-ers to purchase ACA-compliant plans.
In July 2014, the Legislature and Administration enacted Senate Bill (SB) 1446, which delayed the
requirement of small businesses from purchasing ACA compliant plans until 2016. There were mixed opinions regarding the delay, with some in the business community appreciative of the addi-tional time for compliance.11 On the other hand, advocacy groups believed it was confusing to have different sets of rules for the market inside and outside of the exchange. They believed the delay limited CCSB’s ability to create a large and well-balanced risk pool.12 As 2015 draws to a near close, CCSB has observed an uptick in new small businesses transitioning to ACA compliant plans. Under a medium uptake scenario, CCSB projects that it will enroll the following: 37,859 for Fiscal Year (FY) 2015-16, 58,830 for FY 2016-17, and 83,834 for FY 2018.13
The ACA includes tax credits that defray the cost of the employer premium contribution for certain small businesses, but uptake has been very low in California. To qualify, the small business must have less than 25 full-time employees and have an average annual salary of less than $50,000 a year. Some small business can receive the maximum credit of 50% of the employer’s contribution to-wards the premium if they have less than 10 em-ployees and have an average annual salary of less than $25,000; tax-exempt small businesses also qualify but receive a lower tax credit.14 Despite the high number of California small businesses esti-mated as eligible for the tax credit (described above), there was a very low uptake rate.
Mixed perceptions about the tax credit inducing purchasing decisions and a host of other factors may have contributed to the low uptake of the ACA tax credits for small businesses. A recent publication commissioned by the Commonwealth Fund reported that California insurers and poli-cymakers believed that the low uptake was at-tributed to unawareness of the tax credit among small businesses.15 When these small businesses were interviewed, they indicated they were aware of the tax credit but they were not the deciding factor for enrolling with CCSB.16 Other factors that may have contributed to lower than expected uptake include: complicated rules, the limited two year duration for the credits, the higher average
wages in California that limit the number of quali-fying businesses, and uncertainty about the added value in purchasing through CCSB versus the out-side small group market (including the private exchange known as California Choice).
Beyond the tax credits, the Commonwealth Fund report also described other challenges and poten-tial improvements that could better position CCSB to improve its enrollment. Because CCSB experi-enced technical glitches that resulted in the sus-pension of the online portal, CCSB contracted with another vendor that better understood the nuances of the small group insurance market. CCSB initially did not prioritize brokers as an important sales channel, but has since improved its relationship with brokers. In the first quarter of 2015, only 13% of CCSB sales were directly from small businesses.17 Although there might be somewhat less reliance on brokers in the future, brokers play a vital role in advising small business-es who seek more information on health insurance than is available online. Stakeholders interested in the success of CCSB also indicated support for alternative benefit designs in plans, options to con-tract with Medicaid plans for low-income workers, and increased availability of ancillary or supple-mental benefits such as wellness plans.
The Intersection of Large Group Employers and ACA Mandates
The vast majority of Americans today rely on em-ployer-based health insurance, which some have described as a sheer accident in history. The ori-gins of employer-based health insurance can be traced back to price control policies during WWII that limited employers from offering higher wages to employees. To compete for employees, some employers offered fringe benefits that paid for health care services. Federal tax policy evolved to exempt employers from paying taxes on the health benefits they provided to their employees, which encouraged employers to continue offering health insurance to stay competitive in attracting talent. Nationally, employer-based health insurance co-vers 149 million people as of 2014.18 The tax
ad-vantages are highly regressive, giving the greatest tax benefits to the highest paid workforces. 19,20 As the cost of health care soared prior to the ACA, employers analyzed the tradeoffs of offering health insurance, which led some to adjust cost-sharing, modify the actuarial value of their plans, or drop coverage all together. To ensure that Americans receive coverage that is meaningful and affordable, the ACA puts in place a combination of reforms that support Americans in continuing to receive health insurance through the workplace.
The ACA’s employer mandate includes standards for affordability, minimum value, and definitions for full-time equivalent employees that create “play or pay” incentives for employers to offer health insurance. The employer mandate in 2016 will apply to employers with at least 50 full-time equivalent employees. The employer mandate requires that health insurance provided to em-ployees meets standards for affordability and impos-es financial penaltiimpos-es for noncompliance. Afforda-bility is defined as the employee’s contribution towards employee only premiums not exceeding 9.5% of the employee’s annual household income. If the employee share of the premium exceeds 9.5% of annual household income, then the em-ployee is permitted to shop in the exchange and qualify for subsidies depending on income. For large employers that do not offer health insurance coverage, the employer mandate would impose financial penalties if at least one full time employee received premium tax credits through the ex-change.
The employer mandate requires that coverage meet standards for minimum value, defined as the plan covering at least 60% of the costs (actuarial value) of lowest cost bronze plan. As acknowl-edged by the federal government in its implement-ing regulations for minimum value, virtually all large employer groups provide coverage that meets minimum value. The minimum value means that the employee would pay a maximum of 40% of the total allowed costs of plan benefits, i.e., their out-of-pocket costs (deductibles, co-payments, coinsurance, and other out of pocket payments) cannot exceed 40% of the total allowed
costs for plan benefits. The employer must pay at least 60% of the cost of a minimum value plan for the employee and dependent children, but is not required to contribute for spousal coverage. Taken together, the employee could be at risk for 40% of medical costs of the plan, could be expected to pay 40% of the premium for the employee and chil-dren, and could be expected to pay 100% of the costs of spousal coverage.
Like many other aspects of the ACA, the employer mandate has been embroiled in implementation delays that vary by group size and remains op-posed by some in the employer community. Be-cause of administrative barriers, the employer mandate was delayed in 2014 to allow employers and the federal government additional time for planning and setting up the necessary reporting mechanisms. To provide transitional relief, the mandate will be phased in to apply to large em-ployers with at least 100 employees in 2015 and mid-sized employers with between 50 employees and 100 employees in 2016.
Different Impacts of Insurance Market Reforms for Large Employers
There are a few differences in the way the ACA’s insurance market reforms differ across the individ-ual and small group markets and the large group market. First, insurers serving employers in the large group market are less concerned about ad-verse selection. Large employers generally have high participation from employees, which results in a risk pool that is large and well-balanced.21 Second, Congress was more concerned about em-ployers dropping coverage and increasing out-of-pocket costs in large group plans than with the specific benefit levels. Congress was concerned with rising trends in cost-sharing and changes in actuarial value of coverage provided to employees in large group plans. Thus, similar to the individu-al and smindividu-all group markets, large group plans must also cap their employees out-of-pocket cost exposure (e.g., $6,850 for individuals and $13,700 for families in 2016).22
Congress focused most of their reforms on the individual and small group market, one of which
was the essential health benefits (EHB) require-ment that standardized benefit offerings in plans. The EHB requirement allows for more meaningful comparisons of benefits by enabling an apples-to-apples comparison on health coverage. Large group plans cover most categories of EHBs, but may not cover all of them (e.g., pediatric dental or rehabilitative services). For this reason, large group plans are not required to meet the EHB require-ment and instead have to demonstrate they meet minimum value (which virtually all do). The ACA prevents large group plans from imposing lifetime or annual dollar limits on any benefits they pro-vide that would be considered an EHB (e.g., phy-sician services).
Congress believed large group plans provide rela-tively comprehensive coverage and sought to min-imize burdens on large group plans that collective-ly cover 149 million Americans. Congress was far more concerned that large employers continue to offer coverage than in regulating the coverage they already offered. Therefore, Congress sought to reduce the crowd-out risk of mid-size and large employers opting to pay the fine, dropping cover-age and sending their employees to get subsidized coverage in the exchange.
The Current State of Employer-Based Health Coverage: Increasing Premiums & Cost-Sharing
Large employers have traditionally benefitted from using their group size to distribute financial risk and negotiate better coverage and premiums, but rising health care costs challenge group purchas-ing. Based on data from the 2014 California Em-ployer Health Benefits Survey, this section reports key findings from the California HealthCare Foundation (CHFC) report aptly titled, California
Employer Health Benefits: Rising Costs, Shrinking Cover-age.23 Notably, the CHCF report finds that the rate of offering coverage has declined significantly over the past 14 years, from 69% of employers offering health coverage in 2000 to only 58% in 2014. As the employer mandate is enforced and expanded, this offer rate will be an interesting statistic to monitor. Generally, medium, large and very large
employers all have very high rates of offering cov-erage.
When looking at family coverage, the annual pre-mium growth for all employers in 2014 was 6%, far outpacing the California inflation rate of 2.2% in 2014. But for those employers and employees who shopped around (i.e., changed plans), their rates of premium growth was less than 2%.24 Trends in cumulative premium growth across 2002-2014 show an alarming chasm between the growth in health care premiums and overall pric-es. During this period, health insurance premiums grew by 202.2% while California’s inflation rate only grew by 36.1%, an over five-fold difference.25 When health insurance premiums outpace the growth in prices, health insurance becomes less affordable and consumes a greater share of em-ployer, individual and family budgets. Similarly, when premium growth outpaces wage growth, employers and employees may pay more or drop coverage because it is unaffordable. Employers have reacted to these trends by shifting rising health care costs onto employees, restructuring plan benefits, dropping coverage, or absorbing costs.
In California, cost-shifting to employees has oc-curred through increases in premium contribu-tions and deductibles. In 2014, Californians re-ceiving employer based coverage contributed on average 17% of the total premium for single cov-erage and 26% for family covcov-erage.26 Except for a one time unexplained spike in 2013, employee contributions to the total premium have been fair-ly consistent across 2009-2014.27 For small group employers defined as having 3-199 workers, the share of employees with deductibles greater than $1,000 has grown significantly, from 21% in 2009 to nearly one-third (32%) in 2014.28 In compari-son, large employers defined as having 200+ workers, have experienced slower growth in the share of employees with large deductibles, from 6% in 2009 to 14% in 2014.29 Overall, half of Cal-ifornians enrolled in all plan types (HMO, PPO, Point-of-Service, and High Deductible Health Plans) have a deductible larger than $1,000.30
Notably, two thirds of Californians enrolled in a high deductible health plan for single coverage have a deductible larger than $2,000.31 Within the past eight years, there has been a two-fold increase in the share of employees with deductibles larger than $1,000 for single PPO coverage, from 10% in 2006 to 20% in 2014.32 When examining family deductibles for all plan types, 60% of covered em-ployees had a deductible greater than $2,000.33 When examining out-of-pocket limits, nearly one-fifth of workers in family coverage could bear costs up to $6,000.34
When drilling down into national employer survey data on changes already made or planned by ployers, it shows high rates of change among em-ployers. When looking at all employers in 2013, there was a high level of plan changes in which a quarter (24%) of all employers either reduced the scope of benefits or increased employee cost-sharing35. For 2014, a tenth (9%) of all employers reported making such changes.36 The percentage of small employers (3 to 199 workers) making changes were nearly the same as all employers (24% in 2013 and 8% in 2014). In 2013, a third (36%) of large employers with 1,000 or more em-ployees reduced benefits or increased cost-sharing; in 2014, over a quarter of large employers made such changes. When employers were asked about plan changes for the following year, over half of large employers (57%) stated they are “very likely or somewhat likely to increase the amount that employees pay for health insurance premiums” while two-fifths (40%) of small employers report similar plans.
Employer-based coverage is the largest source of coverage for Californians and the alarming trends pose legitimate questions regarding whether it is maintaining value for consumers. Notably, the data shows that the growth in health care costs is impacting even the largest employers. When bene-fits are reduced at the same time premiums and cost-sharing increase, consumers are paying more and getting less.
Third Party Supplemental Premium Assistance
Despite the ACA’s coverage expansions, a subset of individuals and families eligible for Covered California have not yet enrolled due to affordabil-ity barriers. Monthly premiums remain unafford-able for this group despite their eligibility for fed-eral tax credits. One solution to this problem is providing supplemental premium assistance that furthers defray premium costs and out-of-pocket expenses. While safety net providers ranging from county governments to private nonprofit clinic are most interested in this policy option, supplemental premium assistance could also be a viable option for employers of low wage workers. Particularly, non-traditional workers, such as part-time and seasonal workers, face affordability challenges and could use supplemental premium assistance to purchase through Covered California.
Under Section 17000, California counties are re-sponsible for providing care to the medically indi-gent population. With the expansion of the Medi-Cal program, the remaining uninsured in Medi- Califor-nia counties primarily comprise undocumented residents and those eligible for Covered California but not yet enrolled. While those eligible for Cov-ered California may be above the income eligibil-ity for enrollment in county indigent programs, they will likely depend on emergency departments and community clinics for care. To address the remaining uninsured population, there is increas-ing interest among stakeholders to use county in-digent funds to provide supplemental premium assistance for those experiencing affordability bar-riers for Covered California.
The Healthy San Francisco Model for Supplemental Premium Assistance
As part of its effort to align with its pioneering Healthy San Francisco (HSF) Program with the ACA, San Francisco County is leading an effort to implement supplemental premium assistance. Since 2007, San Francisco has had a local city ordinance that requires employers to contribute to the cost of coverage through one of the following options: 1) directly cover their employees in em-ployer-sponsored plans; or 2) through the city
op-tion, contribute to either a health reimbursement account or towards HSF. Participants that enroll in HSF are assigned to a medical home that coor-dinates their care and have access to San Francis-co General Health as part of their provider net-work. In July 2015, San Francisco announced a new “Bridge to Care” program that works in par-allel with HSF to ensure that residents in the “city option” are either enrolled in Healthy San Fran-cisco or covered through the ACA. Like HSF, the Bridge to Care program serves individuals up to 500% of the federal poverty level (FPL) who are not eligible for any public programs and either cannot afford the Covered California premiums or are exempt from the individual mandate.
The Bridge to Care program supplements the ACA’s premium tax credits for employees who are enrolled in the city option. For example, the total premium for a 40-year old San Franciscan en-rolled in the second lowest cost silver plan in 2015 is $6,978. Under Bridge to Care, a 40-year old at 250% FPL would be covered through the follow-ing sources: federal subsidies (34% or $2,376), Bridge to Coverage (31% or $2,190), and consum-er responsibility (35% or $2,412). In tconsum-erms of monthly premiums, the 40-year old San Francis-can would pay $201 per month with the Bridge to Care program vs. $384 per month without the program. This represents a striking 48% savings in premiums for this particular consumer in San Francisco. There could be further individual and societal benefits because individuals remain con-tinuously insured.
Emerging Models for Premium Assistance in the Employer Market
While the ACA reforms the individual insurance market to be fairer to consumers and subsidizes health insurance for eligible individuals, a category of workers known as the “flex workforce” experi-ence affordability challenges that may require ad-ditional financial assistance. The “flex workforce” is a broad umbrella term encompassing the self-employed, temporary, seasonal, and part-time workers, micro-businesses, and contract workers that generally have high uninsured rates. The flex
workforce has a unique set of challenges because they are not always covered by employer-based coverage and because they have unsteady income they struggle to pay for health insurance. From employers to county governments, various groups have an interest in supporting additional financial assistance to the flex workforce and further max-imize California’s enrollment under the ACA.37 One subset of the flex workforce are part-time and/or seasonal workers that work for large em-ployers, but have low rates of employer-based cov-erage. Even though large employers generally have high rates of offering coverage to their em-ployees, part-time workers may not always receive an offer; those that do receive an offer may not participate because the cost for employer-based coverage is too high. Before the ACA, these part-time workers had the option to purchase insurance in the individual market but they were subject to underwriting reforms. These workers also experi-enced difficulty in continuously paying premiums due to the fluctuating nature of their work.
The ACA does not require employers to offer cov-erage to part-time workers working less than 30 hours. When employers voluntarily offer health insurance coverage to these part-time workers, the premiums may be too expensive. Under the ACA, two large employers, Target and Trader Joe’s de-cided to discontinue offering coverage to part-time employees and instead offered $500 to purchase a plan through the exchange or a family member’s plan.38 These employers performed a cost-benefit analysis and found their employees eligible for federal tax credits and cost-sharing subsidies would benefit from more affordable, comprehensive cov-erage through the exchange. Because the part-time workforce plays an important role in our economy, employer-provided premium assistance could be a viable and cost-effective option in max-imizing coverage.
References
1http://www.slu.edu/Documents/law/SLUJHP/Hall_Article.pdf 2 These rating factors are similar to what is included in the
ACA’s adjusted community rating, but does not in-clude the age band ratio of 3:1.
3 Covered California for Small Business. 2015. Small Business
Advisory Group Meeting: April 30,
2015.http://hbex.coveredca.com/stakeholders/SHOP/PDFs/Covered %20CA%20for%20Small%20Business%204%2030%2015%20 %20FINAL.pdf. The California Employer Health Benefits Survey of 2014 (at www.chcf.org) reports that 48% of very small (3-9) California employers offer coverage and 71% of small (10to 49 employees) employers offer coverage.
4http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/ PDF%20B/PDF%20BuildingANationalInsuranceExchange.pdf 5 Ibid. 6http://www.slu.edu/Documents/law/SLUJHP/Hall_Article.pdf 7 Ibid. 8http://board.coveredca.com/meetings/2015/10-08/PPT%20-%20 Executive%20Director's%20Report%20October%208,%202015.pdf
9 Families USA and Small Business Majority, A Helping
Hand for Small Businesses: Health Insurance Tax Credits, July 2010, available at
http://www.familiesusa.org/assets/pdfs/health-reform/CA-Helping-Small-Businesses.pdf. See more at:
http://itup.org/author/itup_admin/page/3/#_ftn13. 10 Ibid. 11 http://www.benefitnews.com/news/ebn_hc_health_reform/california-delays-aca-for-small-employers-2742608-1.html 12 Ibid. 13 http://hbex.coveredca.com/stakeholders/SHOP/PDFs/CCSB-Advisory-PPTV4-w-KW-edits-final.pdf 14http://www.coveredca.com/small-business/faqs/tax-credits/#3 15 http://www.commonwealthfund.org/~/media/files/publications/fund-report/2015/aug/1833_haase_lessons_shop_calif_colo.pdf 16Ibid. 17 Ibid.
18 Kaiser Family Foundation. 2014. 2014 Employer Health
Benefits Survey. http://kff.org/report-section/ehbs-2014-summary-of-findings/
19
http://www.taxpolicycenter.org/UploadedPDF/2000482-The-ACAs- Cadillac-Tax-Versus-a-Cap-on-the-Tax-Exclusion-of-Employer-Based-Health-Benefits.pdf
20 Sheils, J., & Haught, R. (2004). The cost of tax-exempt
AFFAIRS-MILLWOOD VA THEN BETHESDA MA-,23(2),
291-291.
21 Additionally, California state law requires that employers
offering coverage have at least 70% of employees par-ticipating and employers comply by requiring that em-ployees enroll or waive coverage by demonstrating proof of other coverage (e.g., dependent coverage through a spouse).
22 Herman, Bob. September 2015. “CMS moves forward
with rule on out-of-pocket limits.”
http://www.modernhealthcare.com/article/20150915/NEWS/150 919927
23 California HealthCare Foundation. 2015. California
Em-ployer Health Benefits: Rising Costs, Shrinking Cover-age. http://www.chcf.org/publications/2015/04/ employer-health-benefits#ixzz3rXrjPFit 24 Ibid. 25 Ibid. 26 Ibid. 27 Ibid. 28 Ibid. 29 Ibid. 30 Ibid. 31 Ibid. 32 Ibid. 33 Ibid. 34 Ibid. 35 Ibid. 36 Ibid.
37 See more at: Coleman, Carolina. 2014. Assistance With
Premium Payments and Cost-Sharing: The Non-Federal Share.
http://itup.org/wp-content/uploads/2014/05/Premium-Asisstance-DRAFT.pdf
38https://www.washingtonpost.com/news/wonk/wp/
2014/01/22/target-is-dropping-insurance-for-some-because-of-obamacare-that-could-be-good-news-for-workers/
