oversight

Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage

Published by the Government Accountability Office on 2012-07-13.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to the Ranking Member,
                             Committee on Health, Education,
                             Labor, and Pensions, U.S. Senate


July 2012
                             PATIENT
                             PROTECTION AND
                             AFFORDABLE CARE
                             ACT
                             Estimates of the
                             Effect on the
                             Prevalence of
                             Employer-Sponsored
                             Health Coverage

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GAO-12-768
                                              July 2012

                                              PATIENT PROTECTION AND AFFORDABLE
                                              CARE ACT
                                              Estimates of the Effect on the Prevalence of
Highlights of GAO-12-768, a report to the
                                              Employer-Sponsored Health Coverage
Ranking Member, Committee on Health,
Education, Labor, and Pensions, U.S. Senate




Why GAO Did This Study                        What GAO Found
The share of employers offering health        The five studies GAO reviewed that used microsimulation models to estimate the
coverage has generally declined in the        effects of the Patient Protection and Affordable Care Act (PPACA) on employer-
last decade. Researchers believe that         sponsored coverage generally predicted little change in prevalence in the near
certain provisions of PPACA could             term, while results of employer surveys varied more widely. The five
affect employers’ future willingness to       microsimulation study estimates ranged from a net decrease of 2.5 percent to a
offer health coverage, such as the            net increase of 2.7 percent in the total number of individuals with employer-
availability of subsidized coverage           sponsored coverage within the first 2 years of implementation of key PPACA
through new health insurance                  provisions, affecting up to about 4 million individuals. Two of these studies also
marketplaces called “exchanges” and
                                              indicated that the majority of individuals losing employer-sponsored coverage
an “individual mandate,” which will
                                              would transition to other sources of coverage. In contrast to the microsimulation
require most people to obtain health
coverage or pay a tax penalty. Certain
                                              studies, which estimate the net effect on individuals, most employer surveys
PPACA provisions are scheduled to             measure the percentage of employers that may drop coverage in response to
take effect in 2014. Researchers have         PPACA. Among the 19 surveys, 16 reported estimates of employers dropping
provided various estimates of the effect      coverage for all employee types. Among these 16, 11 indicated that 10 percent
PPACA may have on employer-                   or fewer employers were likely to drop coverage in the near term, but estimates
sponsored coverage.                           ranged from 2 to 20 percent. Most surveys were of employers currently offering
                                              coverage and therefore did not also address whether other employers may begin
GAO was asked to review the research          to offer coverage in response to PPACA; however, 3 that did found that between
on this topic. GAO examined                   1 and 28 percent would begin offering coverage as a result of PPACA. Longer-
(1) estimates of the effect of PPACA
                                              term predictions of prevalence of employer-sponsored coverage were fewer and
on the extent of employer-sponsored
                                              more uncertain, and four microsimulation studies estimated that from about
coverage; (2) factors that may
contribute to the variation in estimates;     2 million to 6 million fewer individuals would have employer-sponsored coverage
and (3) how estimates of coverage             in the absence of the individual mandate compared to with the mandate.
vary by the types of employers and            Differences in key assumptions and consideration of PPACA provisions likely
employees that may be affected, as            contributed to some variation among estimates from the five microsimulation
well as other changes employers may           studies and the 16 employer surveys. Variation among the microsimulation
be considering to the health benefits         studies may have stemmed from differences in assumptions about employer and
they offer. GAO reviewed studies
                                              employee decision making, the time frames of the estimates, and assessments
published from January 1, 2009,
                                              of potential compliance with the individual mandate. Variation among the
through March 30, 2012 containing an
original numerical estimate of the            employer surveys may be related to differences in survey sampling techniques,
prevalence of employer-sponsored              the number and types of employer respondents, and the framing of survey
coverage at the national level. These         questions. For example, some surveys used a random sampling methodology,
included 5 microsimulation models and         allowing their results to be generalized across all employers, while others did not.
19 employer surveys. Microsimulation          Also, some referred to specific PPACA provisions or provided specific
models can systematically estimate the        information about provisions to respondents, while others did not.
combined effects of multiple PPACA            Some of the 19 employer surveys indicated that PPACA may have a larger effect
provisions in terms of both gains and
                                              on small employers and certain populations and may prompt some employers to
losses of coverage; their results are
                                              change benefit designs. For example, 4 surveys found that smaller employers
based on multiple data sets and
assumptions. Surveys reflect employer         were more likely than other employers to stop offering health coverage in
perspectives; they have limits as a           response to PPACA, and 5 found that employers in general were more likely to
predictive tool in part based on varied       drop coverage for retirees than for all employees. Nine surveys also indicated
survey methodologies and respondent           that employers are considering key changes to benefit design, some of which
knowledge of PPACA.                           may result in greater employee cost for health coverage.
View GAO-12-768. For more information,        GAO provided a draft of this report to two researchers with expertise in employee
contact John E.Dicken at (202) 512-7114 or    health benefits issues. The experts agreed with GAO’s report and provided
dickenj@gao.gov.
                                              technical comments, which were incorporated as appropriate.
                                                                                       United States Government Accountability Office
Contents


Letter                                                                                   1
              Background                                                                 5
              Microsimulation Models Predicted Little Near-Term Change in
                Employer-Sponsored Coverage, but Other Studies and Employer
                Surveys Varied More Widely                                             10
              Differences in Key Assumptions and Consideration of PPACA
                Provisions Likely Contributed to Variation in Estimates among
                Studies Using Similar Techniques                                       18
              Employer Surveys Suggest That PPACA May Have a Larger Effect
                on Small Employers and Certain Employee Populations and
                Prompt Some Employers to Change Benefit Designs                        25
              External Comments                                                        28

Appendix I    Studies Reviewed by GAO                                                   30



Appendix II   GAO Contact and Staff Acknowledgments                                     36



Table
              Table 1: Employer Survey Results regarding Percentage of
                       Employers Likely to Drop Coverage for Employees in the
                       Near Term                                                       14


Figures
              Figure 1: Microsimulation Model Predictions of Near-Term
                       Changes in Employer-Sponsored Coverage as a Result of
                       PPACA                                                           11
              Figure 2: Effect of PPACA on Employer-Sponsored Coverage with
                       and without the Individual Mandate                              17




              Page i                     GAO-12-768 Employer-Sponsored Coverage under PPACA
Abbreviations

CBO               Congressional Budget Office
CDHP              Consumer-Directed Health Plan
CMS               Centers for Medicare & Medicaid Services
CPS               Current Population Survey
EBRI              Employee Benefit Research Institute
EPI               Employment Policies Institute
HCERA             Health Care and Education Reconciliation Act of 2010
HDHP              High Deductible Health Plan
HRET              Health Research & Educational Trust
IFEBP             International Foundation of Employee Benefit Plans
MBGH              Midwest Business Group on Health
MEPS              Medical Expenditure Panel Survey
NFIB              National Federation of Independent Business
PPACA             Patient Protection and Affordable Care Act
RWJF              Robert Wood Johnson Foundation
SHOP              Small Business Health Options Program
SIPP              Survey of Income and Program Participation




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Page ii                           GAO-12-768 Employer-Sponsored Coverage under PPACA
United States Government Accountability Office
Washington, DC 20548




                                   July 13, 2012

                                   The Honorable Michael B. Enzi
                                   Ranking Member
                                   Committee on Health, Education, Labor, and Pensions
                                   United States Senate

                                   Dear Senator Enzi:

                                   Employer-sponsored health coverage is the leading source of health
                                   coverage in the United States and was provided to more than 156 million
                                   Americans under age 65 (about 59 percent) in 2010. 1 Nearly all large
                                   employers and more than half of small employers offer health coverage to
                                   their employees, in part as a means of recruiting and retaining
                                   employees. 2 Most employees participate in employer-sponsored
                                   coverage when it is available, 3 in part because employers typically
                                   subsidize a large share of employees’ premiums, these premium
                                   contributions are generally excluded from taxable income, and employees
                                   may lack other affordable health coverage options. 4 The proportion of
                                   employers offering health coverage has declined in the last decade—from




                                   1
                                    See Paul Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured:
                                   Analysis of the March 2011 Current Population Survey,” Employee Benefit Research
                                   Institute Issue Brief, no. 362 (2011).
                                   2
                                    See Kaiser Family Foundation and Health Research & Education Trust (HRET),
                                   Employer Health Benefits 2011 Annual Survey (Menlo Park, Calif., and Chicago, Ill.:
                                   September 2011). In this report, large employers are defined as those with 200 or more
                                   employees, while small employers are those with 3 to 199 employees.
                                   3
                                    M. W. Stanton and M. K. Rutherford, Employer-Sponsored Health Insurance: Trends in
                                   Cost and Access, a report prepared for the Agency for Healthcare Research and Quality,
                                   Research in Action Issue 17, AHRQ Pub. No. 04-0085 (Rockville, Md.: 2004).
                                   4
                                    Individual health coverage purchased directly through an insurer in the individual market
                                   is typically more expensive than comparable employer-sponsored coverage. For example,
                                   the average individual premium for single coverage in 2010 was $2,580 compared to the
                                   average employee contribution for employer-sponsored single coverage of about $900.
                                   Further, unlike employer-sponsored coverage, insurers in the individual markets of most
                                   states may also restrict eligibility for individual coverage based on a person’s health status
                                   or pre-existing heath conditions.




                                   Page 1                             GAO-12-768 Employer-Sponsored Coverage under PPACA
68 percent of all employers in 2001 to 60 percent in 2011, with most of
the decline occurring by 2005. 5

The Patient Protection and Affordable Care Act (PPACA), enacted in
March 2010, 6 contains a number of provisions that some researchers of
employer-sponsored health coverage indicate may affect employers’
willingness to offer health coverage to their employees. 7 Researchers
believe some provisions—such as financial penalties that certain
employers with at least 50 full-time equivalent employees may face if they
do not offer health coverage or if they offer coverage that does not meet
certain minimum requirements, and an “individual mandate,” which will
require most people to obtain health coverage or pay a tax penalty—may
encourage employers to continue offering or newly offer health coverage.
However, some researchers believe certain PPACA provisions that result
in coverage from other sources—such as an expanded Medicaid program
and subsidized coverage for certain individuals who purchase coverage
through new health insurance marketplaces called “exchanges”—may
discourage employers from offering coverage. Recent studies have
predicted employers’ responses to PPACA in terms of offering coverage
once key PPACA provisions are in effect. You requested that we review
existing research on the potential effect of PPACA on the prevalence of
employer-sponsored coverage. Based on this request, we examined

    1. estimates of the effect of PPACA on the prevalence of employer-
       sponsored health coverage, including the number of individuals
       with employer-sponsored coverage and the proportion of
       employers that would offer coverage to their employees;

    2. the factors that may contribute to varying estimates; and

    3. how estimates vary by the types of employers and employees that
       may be affected, as well as other changes employers may be
       considering to the health benefits they offer.




5
See Kaiser Family Foundation and HRET, 2011 Annual Survey.
6
 Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and
Education Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 1029. For
purposes of this report, references to PPACA include the amendments made by HCERA.
7
Certain PPACA provisions are scheduled to take effect in 2014.




Page 2                          GAO-12-768 Employer-Sponsored Coverage under PPACA
To conduct this work, we identified and reviewed 27 studies, published
from January 1, 2009, through March 30, 2012, 8 which fell into three
broad study types—5 based on microsimulation models, 9 3 based on
other analytic approaches, and 19 based on employer surveys. 10 We
included in our report only those studies from our review that provided an
original numerical estimate at the national level of the likely prevalence of,
or changes to, rates of employer-sponsored health coverage as a result
of PPACA. To identify these studies, we conducted a review of research
databases using relevant search terms. We also identified studies
available online from research organizations, consulting firms, and other
relevant websites. In addition, we included studies that met our criteria
from a June 2011 report by Avalere Health, a health care consulting firm.
This report provided a comprehensive review of studies published by that
time, comparing estimates of the effect of PPACA on employer-
sponsored health coverage. 11 We also reviewed the bibliographies of the
selected studies for additional studies that met our criteria. (See app. I for
a complete list of these studies.)



8
 We included studies published during or subsequent to 2009 because key elements of
PPACA were being considered by Congress at this time.
9
 Microsimulation models are statistical models that have been used since the 1950s to
predict behavioral responses to changes in economic and social policies. They are
commonly used by government agencies such as the Department of Labor and the
Congressional Budget Office to model the effects of policies, programs, and proposed
legislation. The studies we reviewed used models that attempted to predict the behavior of
employees and employers in response to changes in health policy brought about by
PPACA. To simulate likely responses, these models rely on a variety of elements,
including economic theory, national survey data, and existing empirical evidence from
related or smaller-scale policy changes, such as prior changes in Medicaid eligibility and
state insurance reform efforts.
10
  Where authors published more recent studies containing updated estimates from those
in their prior studies, we primarily cited the most recent estimates. Multiple microsimulation
studies conducted by the same organization were counted as one study for our purposes
because they used the same proprietary microsimulation model (despite changing certain
modeling assumptions and, in some cases, using updated data in more recent studies).
Similarly, employer surveys conducted by the same firm in multiple years were counted as
one study because the newer surveys generally updated findings from the previous
survey. However, we reviewed each of the surveys and microsimulation models for the
report, and where appropriate, we cite results of older studies that were not updated in
newer studies.
11
  See Avalere Health LLC, The Affordable Care Act’s Impact on Employer-Sponsored
Insurance: A Look At the Microsimulation Models and Other Analyses (Washington, D.C.:
2011).




Page 3                             GAO-12-768 Employer-Sponsored Coverage under PPACA
To examine estimates of the effect of PPACA on the prevalence of
employer-sponsored health coverage, we summarized information from
our review of studies. From the microsimulation studies and studies using
other analytic approaches, we summarized estimates of net changes in
the number of individuals who may be affected by employers dropping, as
well as newly offering, coverage as a result of PPACA. We did not
summarize other changes employers may make to employee
compensation packages to remain competitive in the labor force, such as
providing compensation for lost coverage to enable employees to
purchase coverage elsewhere. From employer surveys, we summarized
the percentage of surveyed employers likely to drop employer-sponsored
coverage as a result of PPACA. 12 To examine the factors that could
account for varying estimates, we reviewed the key assumptions and
methods used in the studies we identified. In particular, to evaluate the
studies based on microsimulation models and other analytic approaches,
we examined underlying key assumptions that the studies used when
modeling employer and employee behavior in making decisions about
health coverage, as well as assumptions about the effectiveness of
relevant PPACA provisions and how the provisions might be
implemented. We examined the authors’ own assessments of their study
methods as well as publicly available assessments by other researchers.
To evaluate the employer surveys, we used publicly available information
about the survey instrument, methodology, sample size, and the
response rate. Information on employer response rates—which can be an
important measure of the ability to generalize survey results beyond the
employers surveyed—was not publicly available for most surveys. We did
not interview the study authors. To examine how estimates varied by the
types of employers and employees that may be affected, we summarized
information from the employer surveys that provided estimates by the
type of employer and employees. We also summarized other predicted
changes in employer-sponsored coverage, such as changes in benefit
design. 13




12
  Most employer surveys did not examine the extent to which employers may newly offer
coverage as a result of PPACA.
13
  Most microsimulation studies and studies using other analytic approaches that we
reviewed did not provide estimates of the prevalence of employer-sponsored coverage by
type of employer or employee, or estimates of other changes in benefit design.




Page 4                          GAO-12-768 Employer-Sponsored Coverage under PPACA
             We conducted this performance audit from February 2012 through July
             2012 in accordance with generally accepted government auditing
             standards. Those standards require that we plan and perform the audit to
             obtain sufficient, appropriate evidence to provide a reasonable basis for
             our findings and conclusions based on our audit objectives. We believe
             that the evidence obtained provides a reasonable basis for our findings
             and conclusions based on our audit objectives.


             Employer-sponsored health coverage is the leading source of health
Background   coverage in the United States. In 2010, 59 percent of Americans under
             age 65 received health coverage through employer-sponsored group
             health plans, and an additional 7 percent received coverage through
             health coverage purchased directly from health insurers in the individual
             market. 14 Employers may provide coverage either by purchasing
             coverage from a health insurer (fully insured plans) or by funding their
             own health coverage (self-insured plans). Small employers typically offer
             fully insured plans, while large employers are more likely to be self-
             insured. 15 Small employers are also less likely to offer their employees
             health coverage compared to large employers, citing the cost of coverage
             as a key reason. 16 Additionally, firms with more high-wage workers are
             more likely to offer coverage to their employees than those with more low-
             wage workers. Rates of employer-sponsored health coverage have
             declined in the last decade—from 68 percent in 2001 to 60 percent in
             2011. Most of this decline occurred by 2005 and was driven primarily by a


             14
               Another 22 percent of Americans under age 65 received coverage through public
             programs such as Medicare and Medicaid, and an additional 19 percent were uninsured.
             Percentages do not sum to 100 because estimates of coverage types are not mutually
             exclusive and individuals can have more than one type of coverage during the year. See
             Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured.”
             15
               Self-insured employee health benefit plans are not subject to state insurance regulations
             or to certain requirements in PPACA that apply to fully insured plans—for example,
             required coverage of certain “essential” health benefits. See 29 U.S.C. § 1144 (certain
             employee benefit plans not subject to state laws); 42 U.S.C. §§ 18021, 18022 (as added
             by Pub. L. No. 111-148, §§ 1301, 1302, 124 Stat. 162,163) (certain employee benefit
             plans excluded from definition of “health plan” and requirement to provide essential health
             benefits under PPACA).
             16
               In 2011, almost all (99 percent) of large employers (those with 200 or more workers)
             offered health coverage, compared to 59 percent of small employers (those with 3 to
             199 workers). In the small employer category, 48 percent of the smallest employers (those
             with 3 to 9 workers) offered health coverage. See Kaiser Family Foundation and HRET,
             2011 Annual Survey.




             Page 5                            GAO-12-768 Employer-Sponsored Coverage under PPACA
decline in the number of very small employers with three to nine
employees offering health coverage. In addition, employee participation in
employer-sponsored coverage has also decreased—from 70 percent in
2001 to 65 percent in 2011, in part because of a decline in employee
eligibility for the coverage. 17 Further, employees’ share of the cost of
coverage is increasing faster than employers’ share—the employee
contribution to the average annual premium for family coverage increased
131 percent from 2001 to 2011 compared to a 108 percent increase in the
employer contribution for the same time period. 18

PPACA contains a number of provisions that may affect whether
employers offer health coverage. These provisions include

•     an “individual mandate,” or the requirement that individuals—subject
      to certain exceptions—obtain minimum essential health coverage or
      pay a tax penalty starting in 2014;

•     the establishment of health insurance exchanges in 2014—
      essentially, health insurance marketplaces in which individuals and
      small businesses can compare, select, and purchase health coverage
      from among participating carriers;

•     health insurance market reforms including a requirement that prevents
      health plans and insurers in the individual and small group markets
      from denying coverage or charging higher premiums because of pre-
      existing conditions or medical history, and that limits the extent to
      which premiums may vary; 19




17
  Employees may not be eligible for employer-sponsored coverage because they work on
a part-time or temporary basis, or have not completed a required waiting period. Eligible
employees may choose not to participate for several reasons, including the non-
affordability of the coverage, or because they have coverage through other sources.
See Paul Fronstin, “Employment-Based Health Benefits: Trends in Access and Coverage
1997–2010,” Employee Benefit Research Institute Issue Brief, no. 370 (2012).
18
    See Kaiser Family Foundation and HRET, 2011 Annual Survey.
19
  For example, insurers may vary premiums based on factors such as age, but not on
health status, and the premiums may vary by no more than a 3 to 1 ratio for adults,
meaning that the rate for the oldest person would be no more than three times higher than
for the youngest person.




Page 6                           GAO-12-768 Employer-Sponsored Coverage under PPACA
•    premium subsidies—which provide sliding scale tax credits starting in
     2014 to limit premium costs for individuals and families with incomes
     up to 400 percent of the federal poverty level—for purchasing
     individual coverage through an exchange;

•    penalties for certain large employers that do not offer qualified health
     coverage and have at least one full-time employee receiving a
     subsidy (in the form of a premium tax credit or cost-sharing reduction)
     in a plan offered through an exchange starting in 2014, or for certain
     large employers that provide access to coverage but do not meet
     certain requirements for affordability; 20

•    tax credits for certain small businesses toward a share of their
     employee health coverage beginning in 2010;

•    a 40 percent excise tax on certain employer-sponsored health plans
     whose costs exceed a certain threshold in 2018; 21 and

•    a state Medicaid expansion effective in 2014 for individuals who are
     under 65 years old, have incomes at or below 133 percent of the
     federal poverty level, and meet other specified criteria. 22

Researchers have used various types of studies to predict the effect of
PPACA on employer-sponsored health insurance, including
microsimulation models, other analytic approaches, and employer
surveys. Microsimulation models—commonly used statistical models—
generally use published survey data to construct a base data set of


20
  IRS has proposed establishing a future safe harbor in this context such that the
threshold would be established at 9.5 percent of an employee’s household income.
Request for Comments on Health Coverage Affordability Safe Harbor for Employers,
Treasury Notice 2011-73.
21
  Threshold amounts in 2018 are $10,200 for single coverage and $27,500 for nonsingle
coverage. These amounts will be indexed for inflation in subsequent years. See 26 U.S.C.
§ 4980I, as added by Pub. L. No. 111-148, §§ 9001, 10901, 124 Stat. 847, 1015 and Pub.
L. No. 111-152, § 1401, 124 Stat. 1059.
22
  The U.S. Supreme Court has ruled that states may choose not to expand Medicaid
coverage to this group of individuals and forgo only the federal matching funds associated
with such expanded coverage. See National Federation of Independent Business, et al.,
vs. Sebelius, Sec. of Health and Human Services, et al., No. 11-393 (U.S. June 28, 2012).
Estimates of Medicaid enrollment used in studies cited in this report were made prior to
the Supreme Court decision and are therefore likely to assume expanded Medicaid
participation under PPACA by all states.




Page 7                            GAO-12-768 Employer-Sponsored Coverage under PPACA
individuals, families, and employers, and then attempt to predict
responses to public policy changes by drawing from the best available
evidence in health economics literature and, in some cases, existing
empirical evidence from related or smaller-scale policy changes (such as
prior changes in Medicaid eligibility and state insurance reform efforts).
The models systematically estimate the combined effect of multiple
provisions in legislation, such as PPACA, based on this previous research
and empirical data. For example, with respect to PPACA, models can
provide an estimate of employer-sponsored coverage that considers both
the number of employers that may discontinue offering coverage and the
number that may begin to offer coverage. Models can also incorporate
into their analyses estimates of the number of employees who may take
up or refuse offers of such coverage. Model limitations include their
dependence upon multiple types of data from multiple sources of varying
quality and that they must rely on many assumptions. 23 The impact of
past policy changes also may not necessarily be predictive of the impact
of future changes, and there is little information available with which to
assess the validity of their projections. 24 Studies we reviewed using other
analytic approaches to model behavior in response to policy changes




23
  Researchers may include analyses that test the sensitivity of their results to changes in
various assumptions.
24
  Some researchers have noted that predictions of employer responses to PPACA in the
microsimulation studies are generally consistent with employer responses to health care
reform in Massachusetts that contained certain provisions similar to PPACA, including an
individual mandate, exchanges, employer penalties, and subsidies for low-income
individuals. Others suggest that the experience in Massachusetts cannot be generalized
nationally because of differences between health reform provisions in that state and
PPACA. For example, employer penalties do not apply to self-insured employers in
Massachusetts, but they do apply under PPACA. Further, one researcher noted that the
imposition of employer penalties in Massachusetts (under which employers not offering
coverage would pay a share of uncompensated care costs for their employees) might
provide a greater incentive for employers to offer coverage than the employer penalty
under PPACA. The researcher also noted that because Massachusetts had one of the
highest rates of insurance coverage in the country prior to the implementation of state
health reform, its resulting response to health reform may differ from those of other states.




Page 8                             GAO-12-768 Employer-Sponsored Coverage under PPACA
varied in their methods, ranging from a cost-benefit comparison to an
analysis that used survey data and economic theory to predict behavior. 25

Employer surveys have also been cited to illustrate the potential impact of
PPACA on employer health benefits. Unlike microsimulation models,
surveys have the advantage of reflecting the actual, current perspectives
of employers, and they can also assess how employers’ behavior may be
affected by the actions of other employers of similar size and industry.
However, they have limitations as a predictive tool. For example, most
surveys relating to PPACA asked respondents about employers’
likelihood of dropping coverage, rather than the likelihood of newly
offering coverage as a result of PPACA or the number of employees that
may take up or refuse such coverage. Thus, they may not illustrate the
net effect of PPACA on employer-sponsored coverage. Further, the
validity of their results may be limited by the knowledge of survey
respondents. Experts have noted that employer surveys tend to be
answered by human resource officials with varying levels of knowledge
about PPACA. In addition, researchers note that survey responses do not
require careful analysis or extensive deliberation and have no
consequences for the responders. Therefore, surveys are more limited in
their ability to systematically assess the combined effect of multiple
PPACA provisions—that is, they cannot ensure that respondents consider
(or have the ability to consider) all of the relevant provisions when
deciding how to respond. Moreover, the results of the sample of
employers surveyed may not always be generalizable to all employers,
depending on the number of respondents and other aspects of the survey
methodology.




25
  The analysis that used survey data and economic theory to predict behavior was similar
in some respects to a microsimulation model. However, its purpose was not to estimate
the effects of PPACA on employer-sponsored coverage per se, but rather to illustrate how
these estimates could change under varying assumptions about the cost of health
insurance. Unlike the microsimulation models, it focused on a subset of the working
population and did not consider all of PPACA’s provisions.




Page 9                           GAO-12-768 Employer-Sponsored Coverage under PPACA
                            Microsimulation studies generally predicted little change in employer-
Microsimulation             sponsored health coverage in the near term, but results of studies using
Models Predicted            other analytic approaches and employer surveys varied more widely. Few
                            studies provided longer-term predictions of the prevalence of employer-
Little Near-Term            sponsored coverage, and those that did so expressed uncertainty about
Change in Employer-         their estimates. Microsimulation studies that examined the effect of the
Sponsored Coverage,         individual mandate estimated that more people would have employer-
                            sponsored coverage with the mandate in place compared to without the
but Other Studies and       mandate.
Employer Surveys
Varied More Widely
Microsimulation Studies     Among the five microsimulation studies we reviewed, estimates of
Predicted Small Near-Term   PPACA’s net effect on changes in the rates of employer-sponsored
Changes to Employer-        coverage ranged in the near term from a decrease of 2.5 percent to an
                            increase of 2.7 percent in the number of individuals with coverage. 26 In
Sponsored Coverage
                            particular, three projected an increase in the number of individuals with
                            coverage. The Centers for Medicare & Medicaid (CMS) estimated a net
                            increase of about 0.1 percent (200,000 individuals), and the studies by
                            the RAND Corporation (RAND) and the Urban Institute/Robert Wood
                            Johnson Foundation (RWJF) each projected a net increase of 2.7 percent
                            affecting about 4 million individuals. The remaining two studies projected
                            a decrease: the Congressional Budget Office (CBO) projected a
                            2.5 percent net decrease affecting about 4 million individuals, while The
                            Lewin Group projected a net decrease of 1.6 percent affecting about
                            2 million individuals. (See fig. 1.)




                            26
                              We consider effects likely to take place within 2 years of the implementation of a
                            provision of PPACA to be in the “near term” and those likely to take place over a longer
                            period to be “long term.” Some studies assessed the effects of PPACA as if key provisions
                            were implemented in or by a certain year, such as 2011. We consider these studies to be
                            examining the near-term effects of PPACA. Other studies assessed the effects of PPACA
                            over a range of years, incorporating provision phase-in dates established in the legislation;
                            for these studies, we consider the estimates up to 2016 to be near term because key
                            provisions are scheduled to take effect in 2014. In each study, predicted changes are
                            estimated as compared to a baseline level of coverage in a given year without
                            implementation of PPACA.




                            Page 10                            GAO-12-768 Employer-Sponsored Coverage under PPACA
Figure 1: Microsimulation Model Predictions of Near-Term Changes in Employer-
Sponsored Coverage as a Result of PPACA




Notes: For full citations of studies, see app. I.
Predicted changes are estimated as compared to predicted baseline coverage in a given year without
PPACA. The estimates are for different time frames: the CBO, CMS, and RAND estimates are for
2016, and The Lewin Group and Urban Institute/RWJF estimates are for 2011 (assuming
implementation of key PPACA provisions). Since baseline estimates of coverage without PPACA may
differ between models, the number of individuals with employer-sponsored coverage after
implementation of PPACA may vary despite similar percentage changes.


Two of the studies also indicated that the majority of individuals who lose
employer-sponsored coverage would transition to other sources of
coverage. For example, the RAND study indicated that out of the
6.5 million individuals it projected to lose employer-sponsored coverage
after implementation of PPACA, 1.9 million would enroll in individual




Page 11                                  GAO-12-768 Employer-Sponsored Coverage under PPACA
                         coverage through an exchange and 3.5 million would enroll in Medicaid.
                         The remaining 1.1 million individuals would become uninsured. 27


Estimates from Studies   Estimates from the three studies we reviewed that used other analytic
Using Other Analytic     approaches varied more widely than those from the microsimulation
Approaches Varied More   models. Two of the three studies predicted small near-term changes in
                         the number of individuals with employer-sponsored coverage. One of the
Widely                   studies, published by the Employment Policies Institute (EPI), used a
                         modeling approach that predicted behavioral responses of all workers
                         in a nationally representative sample to three main provisions of PPACA.
                         This study projected a net increase of about 6 percent, or 4 million, in the
                         number of individuals with employer-sponsored coverage. 28 Another
                         study by Booz & Company Inc. that used a combination of surveys,
                         interviews, focus groups, and modeling projected a net decrease of 2 to 3
                         percent, or from 3 million to 4 million individuals. 29 The third study,
                         conducted by the American Action Forum, used a decision-making model
                         based on cost-benefit comparisons to project a larger decrease of up to
                         35 million in the number of people with employer-sponsored coverage. 30
                         However, this study did not consider whether employers may newly offer
                         coverage or estimate the number of individuals that would be newly
                         covered as a result.




                         27
                           Although this study indicated that 6.5 million individuals would lose employer-sponsored
                         coverage after implementation of PPACA, it also found that 10.7 million individuals would
                         be newly covered, resulting in a net gain of 4.2 million individuals with employer-
                         sponsored coverage.
                         28
                           This estimate was for 2008, assuming that three key PPACA provisions were
                         implemented in that year. See R. V. Burkhauser, S. Lyons, and K. Simon, An Offer You
                         Can’t Refuse: Estimating the Coverage Effects of the 2010 Affordable Care Act,
                         (Washington, D.C.: Employment Policies Institute, July 2011).
                         29
                          This estimate was for 2016 compared to coverage without PPACA in 2009. See G. D.
                         Ahlquist, P. F. Borromeo, and S. B. Saxena, The Future of Health Insurance: Demise of
                         Employer-Sponsored Coverage Greatly Exaggerated, Booz & Company Inc. (2011).
                         30
                          This estimate was for 2014. See D. Holtz-Eakin and C. Smith, Labor Markets and Health
                         Care Reform: New Results, American Action Forum (2010).




                         Page 12                           GAO-12-768 Employer-Sponsored Coverage under PPACA
Employer Surveys Varied     Employer surveys varied widely in their estimates of employers’
Widely in Their Estimates   responses to PPACA. Sixteen of the 19 surveys we reviewed reported
of PPACA’s Effect on        estimates of employers dropping coverage for employees in general
                            (rather than only for certain types of employees). 31 Among these
Employer-Sponsored
                            16 surveys, 11 indicated that 10 percent or fewer of employers were likely
Coverage                    to drop coverage in the near term, and 5 indicated that from 11 to
                            20 percent were likely to drop coverage in the near term. 32 The estimates
                            ranged from 2 to 20 percent across these 16 surveys. (See table 1.)
                            Because these surveys were typically of employers currently offering
                            coverage, most did not reflect the number of employers that may be likely
                            to begin offering coverage under PPACA.




                            31
                              We excluded 3 of the 19 total surveys from this analysis. One survey did not include an
                            estimate of employers dropping coverage but only provided an estimate of small
                            employers newly offering coverage as a result of PPACA. See Kaiser Family Foundation
                            and HRET, 2011 Annual Survey. The remaining 2 surveys included estimates only for
                            retired, but not all, employees. See Aon Hewitt, Employer Reaction to Health Care
                            Reform: Retiree Strategy Survey, 2011 (Lincolnshire, Ill.: 2011), and National Business
                            Group on Health, Large Employers’ 2011 Health Plan Design Changes (Washington,
                            D.C.: 2010).
                            32
                               “Likely” responses include employers that stated they were “likely,” “definitely likely,” or
                            “very likely” to drop coverage, or were “seriously considering” dropping coverage. For two
                            surveys (Benfield Research and International Foundation of Employee Benefit Plans),
                            “likely” responses included those “considering” dropping coverage because there was no
                            other affirmative response available. Surveys generally specified only near-term time
                            frames. One survey did not separate out “likely” from “somewhat likely” responses.




                            Page 13                             GAO-12-768 Employer-Sponsored Coverage under PPACA
Table 1: Employer Survey Results regarding Percentage of Employers Likely to Drop Coverage for Employees in the Near
Term

                                                                                                                 Percentage of employers
                                                                                                                   likely to drop coverage
Organization                             Size of employers surveyed                                                        in the near term
National Federation of Independent       Small (50 or fewer employees)                                                                        2
Business
Towers Watson                            Midsize and large: from 2,000 to 10,000+ employees                                                   2
International Foundation of Employee     Small and large employers from IFEBP membership:                                                     3
Benefit Plans (IFEBP)                    employers with annual revenues ranging from less than
                                         $1 million to over $1 billion
Benfield Research                        Jumbo (5,000+) employees only                                                                        4
Mercer                                   All sizes: 10+ employees                                                                             5
Willis                                   All sizes. Fewer than 500 employees, 25 percent; 500 to                                              5
                                         4,999 employees, 43 percent; and 5,000+ employees,
                                         33 percent
HR Policy Association                    Large employers (not defined) drawn from the                                                         6
                                         organization’s membership
Midwest Business Group on Health         58 percent were employers with 500+ employees;                                                       6
                                         25 percent had 50 to 500 employees
PricewaterhouseCoopers                   All employers                                                                                        7
Market Strategies International          All sizes from at least 2 employees                                                                  9
McKinsey & Co.                           All sizes from <20 employees to >10,000 employees                                                    9
GfK Custom Research North America        N/A                                                                                                 12
Ceridian                                 N/A                                                                                                 19
Lockton Companies                        N/A                                                                                                 19
Fidelity Investments                     N/A                                                                                                 20
HighRoads                                N/A                                                                                                 20
                                        Source: GAO analysis of employer surveys.

                                        Notes: “Likely” responses include employers that stated they were “likely,” “definitely likely,” or “very
                                        likely” to drop coverage, or were “seriously considering” dropping coverage. For two surveys (Benfield
                                        Research and IFEBP), “likely” responses included those “considering” dropping coverage because
                                        there was no other affirmative response available. Near term is defined as generally within 2 years of
                                        implementation of key PPACA provisions. Surveys are for different time periods.


                                        A higher proportion of employers indicated that they were “somewhat
                                        likely” to drop coverage, among the 6 surveys that also provided this
                                        response option. 33 Among these surveys, 2 (the National Federation of


                                        33
                                          The Mercer survey provided a choice of “very likely” and “likely” responses. We included
                                        the “very likely” response in the count of the 16 surveys in fig. 1, and the “likely” response
                                        in this count of 6 surveys with “somewhat likely” responses.




                                        Page 14                                     GAO-12-768 Employer-Sponsored Coverage under PPACA
                           Independent Businesses (NFIB) and Towers Watson) indicated that
                           10 percent or fewer of employers were “somewhat likely” to drop
                           coverage, 2 surveys (Willis and Mercer) indicated that 11 to 20 percent of
                           employers had such plans, and the remaining 2 surveys (McKinsey & Co.
                           (McKinsey) and PricewaterhouseCoopers) indicated that over 20 percent
                           had such plans. In addition, two surveys asked respondents how their
                           decisions to drop or offer coverage may be affected by other employers’
                           actions. In one survey 78 percent of employers indicated that they were
                           planning to follow the lead of other employers. In the other survey
                           25 percent of employers indicated that it would have a “major impact” on
                           their decision if “one or a few large, bellwether employers” or one of their
                           major competitors dropped coverage for a majority or all of their
                           employees.

                           Three of the 16 surveys that also examined employer plans to newly offer
                           coverage as a result of PPACA indicated that from 1 and 28 percent of
                           employers were likely to do so. The NFIB survey indicated that about
                           1 percent of the employers surveyed were likely to begin offering
                           coverage as a result of PPACA; the McKinsey survey indicated that
                           13 percent of employers with 2 to 49 employees, and 14 percent of
                           employers with 50 to 499 employees, were likely to begin offering
                           coverage. In addition, the Kaiser Family Foundation/Health Research &
                           Educational Trust survey that examined employer plans to only newly
                           offer (but not drop) coverage indicated that 15 percent of small employers
                           (fewer than 50 employees) that did not offer health coverage and were
                           aware of the small business tax credit were planning to add coverage as
                           a result of it; 34 and the Market Strategies International survey indicated
                           that 28 percent of employers not offering health coverage would begin to
                           do so.


Estimates of Longer-Term   Among the studies we reviewed, only two microsimulation studies
Effects of PPACA on        examined the longer-term effects of PPACA on employer-sponsored
Employer-Sponsored         coverage. CMS projected that the number of individuals with employer-
                           sponsored coverage would decrease by approximately 1 percent relative
Coverage Were Fewer and    to estimates without PPACA in each year from 2017 through 2019, and
Less Certain               that this annual gap would accelerate after that as a result of the high-


                           34
                            GAO recently reported on the use of the small business tax credit under PPACA. See
                           GAO, Small Employer Health Tax Credit: Factors Contributing to Low Use and
                           Complexity, GAO-12-549 (Washington, D.C.: May 14, 2012).




                           Page 15                         GAO-12-768 Employer-Sponsored Coverage under PPACA
                           cost plan excise tax. CBO projected a drop of about 3 percent, slightly
                           larger than its near-term estimate, in employer-sponsored coverage in
                           each year from 2017 through 2019, relative to estimates without PPACA
                           in each year, and projected that this annual gap would decrease
                           thereafter. The studies also noted that there is a large amount of
                           uncertainty regarding how employers and employees will respond to
                           policy changes as sweeping and complex as those included in PPACA,
                           and some researchers indicated that long-term predictions of the effects
                           of PPACA are particularly uncertain.


Studies Predicted Larger   Four of the five microsimulation studies examined the effect of the
Decreases in Employer-     individual mandate and predicted that fewer individuals would have
Sponsored Coverage         employer-sponsored coverage without the mandate as compared to with
                           the mandate. These studies separately estimated the effect of PPACA
without the Individual     both with and without the individual mandate. The estimates ranged from
Mandate                    about 2 million to 6 million fewer people covered without the mandate
                           compared to with the mandate. (See fig. 2.)




                           Page 16                    GAO-12-768 Employer-Sponsored Coverage under PPACA
Figure 2: Effect of PPACA on Employer-Sponsored Coverage with and without the
Individual Mandate




Notes: The CBO estimate of the effect of PPACA with the mandate noted here (-3 million) differs from
the estimate noted in fig. 1 (-4 million) because CBO’s analysis of the effect of eliminating the
individual mandate used the agency’s 2010, rather than its 2012, projections, and predicted PPACA’s
effect in 2021, rather than 2016. In each study, predicted changes are estimated as compared to a
baseline level of coverage in a given year without implementation of PPACA. The estimates
presented in this figure are for different time frames: the CBO estimate is for 2021, the RAND
estimates are for 2016, and The Lewin Group and Urban Institute/RWJF estimates are for 2011
(assuming implementation of key PPACA provisions).




Page 17                              GAO-12-768 Employer-Sponsored Coverage under PPACA
                            Certain differences in key assumptions may have contributed to some
Differences in Key          variation in the estimates from the microsimulation studies we reviewed.
Assumptions and             Variation in estimates from the studies that used other analytic
                            approaches was likely caused in part by differences in their
Consideration of            methodologies and the extent of their incorporation of PPACA provisions
PPACA Provisions            into their analyses. Variation in estimates from the employer surveys was
Likely Contributed to       likely due in part to differences in survey methods, respondents, and the
                            manner in which PPACA provisions were referenced throughout the
Variation in Estimates      survey.
among Studies Using
Similar Techniques
Differences in              Certain differences in factors, such as underlying assumptions about
Assumptions, Time Frames    employer and employee decision making, may have contributed to some
of Projections, and         variation in the estimates, although the five microsimulation studies we
                            reviewed shared methodological similarities and therefore generated
Assessment of the           relatively similar estimates of changes to employer-sponsored coverage.
Individual Mandate Likely   The studies generally used similar modeling techniques and many of the
Contributed to Small        same data sets to calculate their estimates. Specifically, to construct
Variation in Estimates      baseline distributions of coverage in the United States and “synthetic”
from Microsimulation        firms intended to reflect the demographics of employees in actual firms,
Studies                     the studies relied on data sets such as the Medical Expenditure Panel
                            Survey (MEPS), the Current Population Survey (CPS), and the Survey of
                            Income and Program Participation (SIPP). 35 The studies also made
                            certain common assumptions. For instance, most assumed, as illustrated
                            by evidence in the literature, that employers electing to drop coverage for
                            their employees would increase wages in order to compensate for the
                            loss of health benefits, and certain studies noted that the increased
                            wages would factor in the tax exclusion of health benefits. 36 However,


                            35
                              The MEPS, sponsored by the Agency for Healthcare Research and Quality within the
                            U.S. Department of Health and Human Services, is a set of large-scale surveys of families
                            and individuals, their medical providers, and their employers across the United States.
                            The surveys collect data on the cost and use of health care and health coverage. The
                            CPS is sponsored jointly by the U.S. Census Bureau and the U.S. Bureau of Labor
                            Statistics and collects data on labor force statistics for the population of the United States,
                            including data on employment and earnings. The SIPP is sponsored by the U.S. Census
                            Bureau and also collects information about the labor force, including the source and
                            amount of income and other demographic data.
                            36
                              Experts have noted that if employers choose to stop offering health coverage to their
                            employees, they will generally increase employees’ wages to help compensate for the
                            loss of benefits and to continue to attract a competitive workforce.




                            Page 18                            GAO-12-768 Employer-Sponsored Coverage under PPACA
another researcher has noted that employers’ decisions to increase
employees’ wages in lieu of offering health coverage will depend on a
number of factors—most important the strength of the economy and the
labor market. Further, most studies assumed that employers generally
make decisions about health coverage based on their entire workforce
and would not offer health benefits to some, but not all, employees. For
example, CBO noted that there are legal and economic obstacles to
offering health benefits to only certain employees, including a prohibition
on discrimination in favor of highly compensated individuals. 37 Such
similar assumptions likely contributed to the consistency of the studies’
estimates, which suggested that PPACA would result in relatively small
changes to employer-sponsored coverage in the near term.

However, differences in underlying assumptions about employer and
employee responses to PPACA, the time frames of projections, and
assessment of the effectiveness of PPACA’s individual mandate likely
contributed to some variation in the estimates.

•    Modeling employer and employee responses to PPACA: The
     studies generally used one of two different approaches to model
     employer and employee responses to PPACA. The CBO study drew
     from available evidence in health economics literature about historical
     responses to premium changes in order to model the future decisions
     of employers and employees in response to PPACA. 38 The RAND
     and Urban Institute/RWJF studies assumed that employers and
     employees would make optimal choices by weighing the financial
     costs and benefits of available options, taking into account factors
     such as the PPACA-imposed individual and employer penalties for not




37
  Congressional Budget Office, CBO and JCT’s Estimates of the Effects of the Affordable
Care Act on the Number of People Obtaining Employment-Based Health Insurance
(March 2012), 18 (citing 26 U.S.C. § 105(h) and 42 U.S.C. § 300gg-16 (as added by Pub.
L. No. 111-148, §1001, 124 Stat. 130)).
38
  Researchers have referred to this method as an elasticity-based approach. Price
elasticity is a commonly used economic tool that measures consumers’ sensitivity to price
changes.




Page 19                          GAO-12-768 Employer-Sponsored Coverage under PPACA
      obtaining or offering coverage. 39 The Lewin Group study used a
      combination of the two approaches. 40

•     Time frames of the estimates: While each microsimulation model
      estimated the effects of PPACA in a certain year as compared to
      coverage without PPACA in a given year, the models varied in their
      time frame of focus. The Lewin Group and Urban Institute/RWJF
      studies we reviewed simulated the effects of PPACA in 2011
      (assuming implementation of key PPACA provisions). However, the
      RAND study simulated the effects of PPACA in 2016, and the CBO
      and CMS studies simulated the effects of PPACA over a range of
      years (2012 through 2022 and 2010 through 2019, respectively). 41

•     Compliance with the individual mandate: Models varied in their
      assessment of the degree of compliance with PPACA’s individual
      mandate. The CMS and Urban Institute/RWJF studies assumed
      compliance would be driven by both the financial incentive of a
      penalty as well as the desire to obey a statutory mandate. Similarly,
      the CBO study assumed that compliance with the mandate would be
      high, even among individuals exempt from penalties, because of a
      natural preference for complying with the law. CBO also assumed that
      the penalties for noncompliance may be imperfectly enforced.
      However, the RAND study assumed that penalties for noncompliance
      would be perfectly enforced, but did not assume that the mandate


39
    This method was referred to as a utility maximization approach.
40
  Study authors conducted sensitivity analyses to determine how estimates would differ
under alternate assumptions. For example, CBO’s estimates of the number of people with
employer-sponsored coverage ranged from a decrease of 20 million to an increase of
3 million compared to coverage without PPACA under varying assumptions about
employers’ sensitivity to the cost of health insurance and the effect of the individual
mandate. CBO indicated that these alternative assumptions about employer behavior
were unlikely or inconsistent with previous research. Other studies projected smaller
variations in estimates because of different assumptions. Specifically, the Urban
Institute/RWJF estimate ranged from a decrease of 0.81 million to a decrease of
2.1 million because of varying assumptions about the success of the exchanges, and
RAND found that employer coverage was relatively insensitive to the assumptions it
tested, including an employer preference for maintaining the status quo (in other words, a
preference for continuing to offer coverage directly rather than through the exchanges,
despite financial incentives to make this change).
41
  Because data were generally adjusted to statistically correspond to studies’ years of
focus—for example, data in the RAND study were “aged” to reflect projected 2016
prices—resulting estimates of coverage may differ from studies that focused on other
years.




Page 20                            GAO-12-768 Employer-Sponsored Coverage under PPACA
                                would increase compliance among individuals exempt from penalties.
                                Similarly The Lewin Group also assumed a lower compliance with the
                                individual mandate than CBO, in part because there are no legal
                                consequences to going without coverage beyond the penalty.


Differences in Study       Estimates from the three studies that used other analytic approaches
Methodologies and          varied more widely likely in part because of differences in the studies’
Consideration of PPACA     methodologies as well as their consideration of PPACA provisions. For
                           example, the EPI study, which predicted a net increase of 4 million in the
Provisions Likely Led to   number of individuals with employer-sponsored coverage, incorporated
Wider Variation in         some of the statistical modeling techniques and underlying theory of
Estimates from Studies     employer and employee behavior used by the microsimulation models,
Using Other Analytic       and was therefore able to more systematically examine the combined
Approaches                 effects of PPACA’s provisions. 42 The American Action Forum study,
                           which predicted that up to 35 million individuals may lose employer-
                           sponsored coverage, used a cost-benefit comparison, examining
                           individual employers’ financial trade-offs between offering coverage and
                           dropping coverage for employees of different income levels and paying
                           the employer penalties and increasing employees’ wages to compensate.
                           The study suggested that PPACA provides strong financial incentives for
                           employers to drop coverage for many of their low-income employees, but
                           that there are few incentives to drop coverage for higher-income
                           employees. Certain researchers have noted key limitations of the study,
                           including that it did not take into account the impact of PPACA’s individual
                           mandate, the nonfederal tax advantage of employer-sponsored coverage,
                           the cost of single health coverage plans, and the nondiscrimination rules
                           that may prevent employers from dropping coverage for some, but not all,
                           employees. 43 Additionally, unlike the other two studies, this study did not
                           measure the net effect of PPACA on employer health coverage, thus



                           42
                              The purpose of this study was not to estimate the effects of PPACA per se, but rather to
                           illustrate how these estimates might change under different assumptions about the
                           definition of affordability of coverage and the extent of premium cost sharing between
                           employers and employees. The study concluded that PPACA would further decrease the
                           number of people with employer-sponsored coverage if the definition of affordability of
                           coverage (which is currently based on single coverage) was changed to single or family
                           coverage as applicable, and if employees were responsible for paying the entire share of
                           premium costs.
                           43
                             See G. Bowen and M. Buettgens, Employer-Sponsored Insurance Under Health
                           Reform: Reports of Its Demise Are Premature, Urban Institute/RWJF (Washington, D.C.:
                           2011).




                           Page 21                           GAO-12-768 Employer-Sponsored Coverage under PPACA
                          addressing only those that may drop coverage but not those that may
                          newly offer it. Finally, the Booz and Company Inc. study, which predicted
                          a net decrease of 3 to 4 million in the number of individuals with
                          employer-sponsored coverage, used a combination of interviews, focus
                          groups, surveys, and statistical modeling to derive its estimates. 44 The
                          study estimated the change in employer-sponsored coverage between
                          2 years—2009 and 2016—but did not separate the effects of PPACA
                          from any changes to employer-sponsored coverage that may occur
                          between these years because of factors unrelated to PPACA, such as a
                          continuation of the overall declining rates of employer-sponsored
                          coverage since the last decade. 45


Variation in Estimates    Varying estimates from the 16 employer surveys of the extent to which
from Employer Surveys     employers were likely to drop health coverage may have stemmed from
Was Likely Due to         differences in sampling techniques, the response rates and number of
                          respondents, the types of employers surveyed, the framing of survey
Differences in Survey     questions, and the manner in which PPACA provisions were referenced
Methods and Assumptions   throughout the survey. 46
about Respondent
Knowledge of PPACA        •    Sampling techniques and number of respondents: Surveys varied
Provisions                     in the methodology used to draw their sample of respondents. Some,
                               such as the Mercer survey, sampled randomly within the national
                               employer population, which helped ensure that results were
                               generalizable to all nonsurveyed employers with similar
                               characteristics. Others, such as the International Foundation of
                               Employee Benefit Plans (IFEBP) survey, used nonrandom sampling
                               techniques, which limited the generalizability of their results. In
                               addition, the number of survey respondents ranged widely, from 104
                               in the Benfield Research survey to about 2,840 in the Mercer survey,




                          44
                            We could not fully assess the methodology of this study since detailed information was
                          not publicly available.
                          45
                            The EPI study modeled the effects of PPACA as if key provisions were implemented in
                          2008. The American Action Forum study simulated employer decisions in 2014, but it was
                          unclear whether it drew from predicted coverage levels without PPACA in 2014 or current
                          coverage levels at the time of publication to calculate its estimate.
                          46
                            These differences may prevent estimates from being fully comparable. Additionally,
                          because of a lack of publicly available information on the survey instrument and
                          methodology for many surveys, we cannot comment on their limitations in more detail.




                          Page 22                          GAO-12-768 Employer-Sponsored Coverage under PPACA
     which also could have implications for the generalizability of results. 47
     The surveys generally did not publicly disclose their response rates.

•    Employer respondent type: Surveys varied in the type of employers
     surveyed. Some, such as those conducted by trade groups, were
     limited to members of the surveying organization. Others were limited
     to only small or only large employers, or employers within a particular
     industry, or included a broader mix of small, midsize, and large
     employers across all types of industries. For example, the NFIB
     survey included only small employers with 50 or fewer employees,
     while the majority of respondents to the HighRoads survey were from
     hospitals and other health care systems. The Mercer and Willis
     surveys included a wider range of employer sizes and industries.
     Some surveys, such as the Benfield Research survey, included only
     self-insured employers, and others, such as the McKinsey survey,
     included only private sector employers.

•    Framing of the survey questions: Surveys varied in the manner in
     which they asked whether employers were planning to drop health
     coverage in response to PPACA. For example, the Fidelity
     Investments (Fidelity) survey reported whether respondents were
     “seriously thinking about no longer offering health care coverage,” the
     HR Policy Association survey asked if respondents were giving
     “serious consideration to discontinuing providing health benefits,” and
     the NFIB survey asked if employers were “not at all likely” or “not too
     likely” to “have an employee insurance plan 12 months from now.” In
     addition, some surveys reported specifically about active employee
     health plans, while others did not distinguish between active
     employees and retirees. For example, the Towers Watson survey
     reported whether respondents planned to “replace health care plans
     for active employees working 30+ hours per week with a financial
     subsidy” while the GfK Custom Research North America survey
     reported whether employers were “very or somewhat likely to drop
     coverage” without specifying whether this was for active employees or
     retirees. 48




47
  Surveys with a greater number of respondents are generally considered to be more
generalizable than surveys with fewer respondents.
48
 Although we considered these questions similar for the purposes of our analysis, they
may elicit different responses even if presented to the same respondents.




Page 23                          GAO-12-768 Employer-Sponsored Coverage under PPACA
•    Referencing of PPACA provisions: Surveys varied in their
     assumptions of respondent knowledge of PPACA provisions. For
     example, 11 surveys assumed a certain level of respondent
     awareness of key PPACA provisions and did not specifically refer to
     the provisions in the phrasing of their questions about plans to drop
     coverage. However, other surveys phrased their questions in the
     context of specific PPACA provisions or explicitly asked respondents
     about their knowledge of the provisions. For example, the
     PricewaterhouseCoopers survey asked how likely respondents were
     to “cover employees through state-run health insurance exchange
     pools,” and the Willis survey asked how likely respondents were to
     “drop coverage to trigger migration of employees to state-based
     exchanges.” The McKinsey survey also phrased its questions about
     discontinuing health coverage in the context of select PPACA
     provisions and provided additional information to respondents to
     inform them about the provisions. 49




49
   The McKinsey survey included three questions relating to employer plans for dropping
or retaining coverage in light of the enhanced availability of coverage through the small
business and individual market insurance exchanges. The first question, directed at
respondents with 1 to 99 employees, noted the availability of Small Business Health
Options Programs (SHOPs)— exchanges where small businesses may purchase health
care for their employees. The respondent was then asked about the likelihood of the
employer’s continuing to offer or newly offering coverage assuming that “SHOPs become
an easy, affordable way for small businesses to obtain coverage for their employees.” The
other two questions provided information about the availability of coverage through the
individual exchanges, and respondents were asked: “Assume exchanges become an easy
and affordable way for individuals to obtain health insurance. Given this information, how
likely do you think your company would be to discontinue employee health coverage?”
One researcher pointed out that these were “significant assumptions,” and others have
pointed out methodological flaws in McKinsey’s survey design. McKinsey noted that its
survey captured employer attitudes and was not intended to be a predictive economic
analysis of the effect of PPACA.




Page 24                          GAO-12-768 Employer-Sponsored Coverage under PPACA
                          PPACA may affect certain types of employers or employers with certain
Employer Surveys          employee populations more than all employers or employees. Some
Suggest That PPACA        employers were considering benefit design changes.
May Have a Larger
Effect on Small
Employers and
Certain Employee
Populations and
Prompt Some
Employers to Change
Benefit Designs
PPACA May Affect Small    Four of five surveys that examined changes in the prevalence of
Employers and Certain     employer-sponsored coverage by employer size indicated that a greater
Types of Employees More   share of small employers (from 5 to 22 percent) were considering
                          dropping coverage compared to large employers (from 2 to 14 percent) in
Than Others               these surveys. 50, 51 These surveys included Fidelity (22 percent and
                          14 percent for small and large employers, respectively), McKinsey
                          (9 percent and 5 percent for small and large employers, respectively), and
                          Mercer (5 percent and 2 percent for small and large employers,
                          respectively). One survey (Willis) did not indicate any differences between
                          small and large employers. 52, 53




                          50
                            Two of the microsimulation studies noted that small employers and those with
                          predominantly low-wage workers would be more likely to drop employer-sponsored
                          coverage than large employers; however, no numerical estimates were published.
                          51
                            The definitions of “small” and “large” employers varied or were not clearly provided in
                          these surveys.
                          52
                            Other surveys may have included this question; however, the information was not
                          publicly available.
                          53
                            One survey that examined changes in coverage by employer size—McKinsey—also
                          estimated that about 13 percent of small employers would begin, or continue, to offer
                          coverage through the exchanges.




                          Page 25                           GAO-12-768 Employer-Sponsored Coverage under PPACA
Surveys that examined changes in the prevalence of employer-sponsored
coverage for certain types of beneficiaries indicated that these individuals
could be more affected than others. Five of the nine surveys that
considered the effect on retirees indicated that a higher proportion of
employers were considering dropping coverage for retirees compared to
all employees in these surveys—between 9 and 20 percent compared to
4 percent and 9 percent, respectively. 54, 55, 56 For example, Mercer
indicated that 17 percent and 5 percent of employers were considering
dropping coverage for new retirees and all employees, respectively, and
Willis indicated that 9 percent and 5 percent of employers were
considering dropping coverage for retirees and all employees,
respectively. Two of the four remaining surveys
(PricewaterhouseCoopers and IFEBP) indicated no differences between
rates of employers dropping coverage for retirees and for all employees,
and the remaining two only examined the effect of PPACA on subsets of
employees, but not all employees. In addition, two surveys that examined
the effect of PPACA on spouses and dependents indicated that between
12 and 15 percent of employers were considering dropping health
coverage for spouses and dependents compared to a lower proportion for
all employees. For example, McKinsey indicated that 15 percent and
9 percent of employers were definitely considering dropping coverage for
spouses/dependents and all employees, respectively.




54
  The proportion of employers considering dropping coverage was slightly lower for pre-65
retirees compared to post-65 retirees in two surveys and somewhat higher for future
retirees compared to current retirees in one survey.
55
  Of the remaining four surveys, two showed virtually no difference in rates of employers
dropping coverage for retirees and other types of employees, and the remaining two
examined rates for retirees but not all employees.
56
  The microsimulation studies focused on active employees and their dependents, and did
not examine the effect of PPACA on retirees.




Page 26                           GAO-12-768 Employer-Sponsored Coverage under PPACA
PPACA May Also Prompt        Several of the 19 employer surveys that we reviewed also indicated that
Employers to Change          PPACA may prompt employers to consider key changes to benefit
Health Plan Benefit Design   designs that will generally result in greater employee cost for health
                             insurance. 57

                             •    Increased employee cost sharing: The 9 surveys that examined
                                  benefit design changes indicated that from 16 to 73 percent of
                                  employers were considering increasing employees’ share of the cost
                                  of coverage, for example, through increased premiums, deductibles,
                                  or co-payments. For example, the IFEBP survey indicated that about
                                  40 percent of employers had increased or were planning to increase
                                  employee premium sharing, and about 29 percent had increased or
                                  planned on increasing in-network deductibles. Similarly, the
                                  PricewaterhouseCoopers survey indicated that 61 percent planned to
                                  increase employee premium sharing, and 57 percent planned to
                                  increase employee cost sharing through other benefit design
                                  changes.

                                  In addition, the 7 surveys that examined employer responses to the
                                  high-cost excise tax effective under PPACA in 2018 indicated that
                                  from 11 to 88 percent of employers had plans to take steps to avoid
                                  paying the tax; in 5 of these surveys, employers planned to redesign
                                  benefits and in 2 surveys employers had not identified specific
                                  strategies but planned to take steps. For example, the Aon-Hewitt
                                  survey indicated that 25 percent of employers anticipated changing
                                  their benefits to reduce plan cost, while the Willis survey indicated that
                                  22 percent planned to increase deductibles or co-payments to avoid
                                  the tax.

                             •    Use of account-based plans: The 9 surveys that examined employer
                                  plans to offer account based plans, such as high-deductible health
                                  plans (HDHP), consumer-directed health plans (CDHP), or health
                                  savings accounts indicated that from 17 to 73 percent of employers
                                  either had plans to offer such plans or saw the plans as attractive
                                  options for providing health coverage. For example, the Benfield
                                  Research survey indicated that about two-thirds of employers planned



                             57
                               Several trends in employer-sponsored coverage predate PPACA, including increases in
                             the employee share of health plan premiums and cost sharing and increases in the
                             prevalence of account-based health plans. See Kaiser Family Foundation and HRET,
                             2011 Annual Survey.




                             Page 27                         GAO-12-768 Employer-Sponsored Coverage under PPACA
                         to offer a CDHP by 2015, and the Towers Watson survey indicated
                         that 17 percent planned to start offering HDHPs in 2013 or 2014,
                         bringing the total share of employers with HDHPs up to 74 percent.

                    •    Move to self-insurance: Two of the 3 surveys that examined
                         employers potentially becoming self-insured in response to PPACA
                         indicated that from 12 to 52 percent were considering doing so, and
                         the remaining survey indicated that 13 percent of employers reported
                         increasing their consideration of such a move in response to
                         PPACA. 58 For example, the IFEBP survey indicated that about
                         52 percent of employers were considering such a move, compared to
                         only about 6 percent in a prior year’s survey.

                    We provided a draft of this report to two researchers with expertise in
External Comments   employee health benefits issues. They agreed with our report and
                    provided suggestions and technical comments, which we incorporated as
                    appropriate.


                    As agreed with your office, unless you publicly announce the contents of
                    this report earlier, we plan no further distribution until 30 days from the
                    report date. At that time, we will send a copy to the Secretary of Health
                    and Human Services. In addition, the report will be available at no charge
                    on the GAO website at http://www.gao.gov.




                    58
                      Self-insured employee health benefit plans are not subject to state insurance regulations
                    or to certain requirements in PPACA that apply to fully insured plans—for example,
                    required coverage of certain “essential” health benefits. See 29 U.S.C. § 1144 (certain
                    employee benefit plans not subject to state laws); 42 U.S.C. §§ 18021, 18022 (as added
                    by Pub. L. No. 111-148, §§ 1301, 1302, 124 Stat. 162,163) (certain employee benefit
                    plans excluded from definition of “health plan” and requirement to provide essential health
                    benefits under PPACA). Some researchers have raised concerns that employers with
                    healthier employees are more likely to become self-insured, thereby leaving the
                    exchanges—particularly for the small group market—with relatively sicker enrollees, and
                    thereby driving up premiums in the exchanges.




                    Page 28                           GAO-12-768 Employer-Sponsored Coverage under PPACA
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made key contributions to this report
are listed in appendix II.

Sincerely yours,




John E. Dicken
Director, Health Care




Page 29                    GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix I: Studies Reviewed by GAO
                  Appendix I: Studies Reviewed by GAO




                  We reviewed the 27 studies listed below that contained original numerical
                  estimates of the effect of the Patient Protection and Affordable Care Act
                  (PPACA) on the prevalence of employer-sponsored coverage 1—5 based
                  on microsimulation models, 2 3 based on other analytic approaches, and
                  19 based on employer surveys. 3


                  1. Centers for Medicare & Medicaid Services.
Microsimulation
Models                Foster, R. S., Centers for Medicare & Medicaid Services Office of the
                      Actuary. Estimated Financial Effects of the “Patient Protection and
                      Affordable Care Act,” as Amended. Baltimore, Md.: April 2010.

                  2. Congressional Budget Office (CBO).

                      CBO and JCT’s Estimates of the Effects of the Affordable Care Act on
                      the Number of People Obtaining Employment-Based Health
                      Insurance. Washington, D.C.: March 2012.

                      Updated Estimates for the Insurance Coverage Provisions of the
                      Affordable Care Act. Washington, D.C.: March 2012.

                      Banthin, J. Effects of Eliminating the Individual Mandate to Obtain
                      Health Insurance. Presentation at Bloomberg Government/Rand
                      Corporation event. Washington, D.C.: March 2012.

                      Elmendorf, D. W. CBO’s Analysis of the Major Health Care Legislation
                      Enacted in March 2010. Testimony before the Subcommittee on
                      Health, Committee on Energy and Commerce, House of
                      Representatives. Washington, D.C.: March 2011.


                  1
                   We reviewed studies published from January 1, 2009, through March 30, 2012, that
                  provided an original numerical estimate at the national level of the prevalence of, or
                  changes to, rates of employer-sponsored coverage.
                  2
                   Multiple microsimulation studies conducted by the same organization were counted as
                  one study for our purposes because they used the same proprietary microsimulation
                  model.
                  3
                   Employer surveys conducted by the same firm in multiple years were counted as one
                  study for our purposes because the newer surveys generally updated relevant findings
                  from the previous surveys. The full text of certain surveys was not publicly available; in
                  these cases, we cite the press releases we reviewed that contained the surveys’ findings.




                  Page 30                           GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix I: Studies Reviewed by GAO




    H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation).
    Washington, D.C.: March 2010.

3. The Lewin Group.

    Sheils, J. F. and R. Haught. “Without the Individual Mandate, the
    Affordable Care Act Would Still Cover 23 Million; Premiums Would
    Rise Less Than Predicted.” Health Affairs, vol. 30, no. 11 (2011). 4

    Patient Protection and Affordable Care Act (PPACA): Long Term
    Costs for Governments, Employers, Families and Providers. Staff
    Working Paper # 11. Falls Church, Va.: 2010.

4. RAND Corporation.

    Eibner, C. and C. C. Price. The Effect of the Affordable Care Act on
    Enrollment and Premiums, With and Without the Individual Mandate.
    Santa Monica, Calif.: 2012.

    Eibner, C. et al. Establishing State Health Insurance Exchanges:
    Implications for Health Insurance Enrollment, Spending, and Small
    Business. Santa Monica, Calif.: 2010.

5. The Urban Institute/Robert Wood Johnson Foundation.

    Buettgens, M. and C. Carroll. Eliminating the Individual Mandate:
    Effects on Premiums Coverage, and Uncompensated Care.
    Washington, D.C., and Princeton, N.J.: January 2012.

    Garrett, B. and M. Buettgens. Employer-Sponsored Insurance under
    Health Reform: Reports of Its Demise Are Premature. Washington,
    D.C., and Princeton, N.J.: January 2011.




4
 The authors of this study are staff members of The Lewin Group, and the study was
conducted using The Lewin Group’s proprietary microsimulation model. We therefore
consider it to be a study by The Lewin Group for our purposes.




Page 31                         GAO-12-768 Employer-Sponsored Coverage under PPACA
                   Appendix I: Studies Reviewed by GAO




                   6. Ahlquist, G. D., P. F. Borromeo, and S. B. Saxena. The Future of
Other Analytic        Health Insurance: Demise of Employer-Sponsored Coverage Greatly
Approaches            Exaggerated. Booz & Company Inc. 2011.

                   7. Burkhauser, R. V., S. Lyons, and K. Simon. An Offer You Can’t
                      Refuse: Estimating the Coverage Efffects of the 2010 Affordable Care
                      Act. Washington, D.C.: Employment Policies Institute, July 2011.

                       Burkhauser, R. V., S. Lyons, and K. Simon. The Importance of the
                       Meaning and Measurement of “Affordable” in the Affordable Care Act.
                       Working Paper # 17279, National Bureau of Economic Research.
                       Cambridge, Mass.: August 2011.

                   8. Holtz-Eakin, D. and C. Smith. Labor Markets and Health Care Reform:
                      New Results. American Action Forum. Washington, D.C.: May 2010.


                   9. Aon Hewitt. Employer Reaction to Health Care Reform: Retiree
Employer Surveys      Strategy Survey. Lincolnshire, Ill.: 2011.

                   10. Benfield Research. Special Report: Employer Market Healthcare
                       Reform Research Summary. St. Louis, Mo.: 2011.

                   11. Ceridian Health Care Compass. “Health Care Reform Presents New
                       Challenges, Choices to U.S. Employers.” Issue 21. Cites findings from
                       Ceridian’s Health Care Compass reader poll, July 2011. Accessed
                       February 1, 2012.
                       http://www.ceridian.com/employee_benefits_article/1,6266,15766-
                       79463,00.html.

                   12. Fidelity Investments. Fidelity Investments Survey Finds Majority of
                       Employers Rethinking Health Care Strategy Post Health Care Reform.
                       Boston, Mass.: July 2010. Accessed March 6, 2012.
                       http://www.fidelity.com/inside-fidelity/employer-services/fidelity-
                       survey-finds-majority-of-employers-rethinking-health-care-strategy-
                       post-health-care-reform.

                   13. GfK Custom Research North America. Employers Skeptical of Health
                       Reform, But Few Project Dropping Health Insurance Coverage.” New
                       York, N.Y.: December 2011. Accessed March 29, 2012.
                       http://www.gfkamerica.com/newsroom/press_releases/single_sites/00
                       9103/index.en.html.



                   Page 32                         GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix I: Studies Reviewed by GAO




14. HighRoads. “HighRoads Study Shows Employers Will Not Eliminate
    Benefits Coverage Due to Health Care Reform.” December 2011.
    Accessed February 1, 2012. http://newsroom.highroads.com/hr-
    compliance-connection/highroads-study-shows-employers-will-not-
    eliminate-benefits-coverage-due-to-health-care-reform.

15. HR Policy Association.

    2011 Annual Chief Human Resource Officer Survey. Washington,
    D.C.

    2010 Summer Chief Human Resource Officer Survey: Questions on
    the New Health Care Law. Washington, D.C.

16. International Foundation of Employee Benefit Plans.

    Health Care Reform: Employer Actions One Year Later; Survey
    Results: May 2011. Brookfield, Wis.: 2011.

    Health Care Reform: What Employers Are Considering; Survey
    Results: May 2010. Brookfield, Wis.: 2010.

17. Kaiser Family Foundation and Health Research & Education Trust.
    Employer Health Benefits 2011 Annual Survey. Menlo Park, Calif.,
    and Chicago, Ill.: September 2011.

18. Lockton Companies, LLC. Employer Health Reform Survey Results,
    June 2011. Kansas City, Mo.: 2011.

19. Market Strategies International. Many Companies Intend to Drop
    Employer Coverage in 2014 as Health Care Reform Takes Full Effect.
    Livonia, Mich.: January 2011. Accessed May 1, 2012.
    http://www.marketstrategies.com/news/1902/1/Many-Companies-
    Intend-to-Drop-Employee-Coverage-in-2014-as-Health-Care-Reform-
    Takes-Full-Effect.aspx.

20. McKinsey & Company. How US Health Care Reform Will Affect
    Employee Benefits. 2011.




Page 33                         GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix I: Studies Reviewed by GAO




21. Mercer, LLC.

    National Survey of Employer-Sponsored Health Plans: 2011 Survey
    Report. New York, N.Y.: 2012.

    National Survey of Employer-Sponsored Health Plans: 2010 Survey
    Report. New York, N.Y.: 2011.

22. Midwest Business Group on Health. Financial Impact of Health
    Reform on Employer Benefits Not as Significant as Anticipated.
    Chicago, Ill.: March 2012. Accessed March 29, 2012.
    http://www.mbgh.org/mbgh/news/2012pressreleases/go.aspx?navigati
    onkey=a4956928-cca2-495a-94fc-ed56ce991fcd.

23. National Business Group on Health.

    Large Employers’ 2011 Health Plan Design Changes. Washington,
    D.C.: 2010.

    Majority of Employers Revamping Health Benefit Programs for 2012,
    National Business Group on Health Survey Finds. Washington, D.C.:
    August 2011. Accessed January 1, 2012.
    http://www.wbgh.org/pressrelease.cfm?ID=179.

24. National Federation of Independent Business. Small Business and
    Health Insurance: One Year After Enactment of PPACA. Washington,
    D.C.: 2011.

25. PricewaterhouseCoopers LLP. Health and Well-Being Touchstone
    Survey Results, May 2011. New York, N.Y.: May 2011.

26. Towers Watson.

    Health Care Changes Ahead: Survey Report. New York, N.Y.:
    October 2011.

    Health Care Reform: Looming Fears Mask Unprecedented Employer
    Opportunities To Mitigate Costs, Risk, and Reset Total Rewards. New
    York, N.Y.: May 2010.




Page 34                         GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix I: Studies Reviewed by GAO




27. Willis Group Holdings plc.

    Willis. The Health Care Reform Survey, 2011-2012. New York, N.Y.:
    2011-2012.

    Diamond Management Technology Consultants and Willis North
    America. The Health Care Reform Survey, 2010. New York, N.Y.:
    2010.




Page 35                         GAO-12-768 Employer-Sponsored Coverage under PPACA
Appendix II: GAO Contact and Staff
                  Appendix II: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  John E. Dicken, (202) 512-7114 or dickenj@gao.gov
GAO Contact
                  In addition to the contact named above, Randy DiRosa (Assistant
Staff             Director), Iola D’Souza, Yesook Merrill, Laurie Pachter, and Priyanka
Acknowledgments   Sethi made key contributions to this report.




(291020)
                  Page 36                              GAO-12-768 Employer-Sponsored Coverage under PPACA
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