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Backgrounder #2312 on Health Care

August 28, 2009

Economics of Play-or-Pay Mandates in Health Care Reform Bills

By and

The two main health care reform bills that Con­gress is currently debating each include some form of "play-or-pay" employer mandate: America's Afford­able Health Choices Act of 2009 (H.R. 3200)[1] and the Affordable Health Choices Act.[2] The House "Blue-Dog compromise," a version of H.R. 3200, also includes a play-or-pay employer mandate.[3]

The play-or-pay mandates in these bills, which require employers to offer health insurance to their employees or pay a tax to the federal government, will affect between 95 million and 105 million work­ers, and 509,000 to 1.4 million employers, including up to 1 million small businesses.[4] The mandates will cost businesses at least $49 billion per year and put 5.2 million low-wage workers at risk of unemploy­ment or reduced working hours. The prospect of fewer job opportunities in the future will put another 10.2 million workers at risk of slower wage growth and cuts in other benefits.[5] Up to 382,000 low-wage unskilled workers are likely to lose their jobs.[6] Fur­ther, some of the cost of the mandates will be passed on to American consumers in higher prices for goods and services--an indirect tax on savers and those with fixed incomes.

Although the employer mandate in H.R. 3200 will result in a net increase of 3 million workers with employment-based health insurance (1.7 percent), according to the Congressional Budget Office (CBO), the mandate will cause 9 million mostly low-wage and part-time workers to lose their employment-based health insurance.[7]

Economic research also shows that mandating employee health insurance will discourage some people from working more hours by reducing their real hourly wage rate.[8]

The House and Senate Employer Mandates

Although the final details of the employer man­date are not yet available, under H.R. 3200, the play-or-pay mandate would require the following:

  • Employers with more than $250,000 in annual payroll must offer their employees health insur­ance coverage or pay an amount equal to 2 to 8 percent of each worker's wages into a Health Insurance Exchange Trust Fund.
  • If a worker does not accept the employer's cover­age because he is covered by someone else's health insurance, or he is covered by Medicaid, Medicare, or military insurance, the employer does not have to pay the 2 to 8 percent of each worker's wages into a Health Insurance Exchange Trust Fund.
  • The health insurance offered must have an actu­arial value equal to at least70 percent of an essential benefits package, as defined by the fed­eral government, with annual cost-sharing limits of $5,000 for individual coverage, and $10,000 for family coverage.
  • Employers must contribute at least 72.5 percent of the premium for individual health insurance and 65 percent of the premium for family coverage.
  • Employers who do not offer the required mini­mum coverage and premium contributions to their employees and have annual payrolls of more than $400,000 per year must pay 8 percent of each worker's wages into a Health Insurance Exchange Trust Fund. Employers with annual payrolls between $250,000 and $400,000 per year would be required to pay 2 percent to 6 per­cent on a sliding scale.
  • Employers with fewer than 10 employees and average annual employee compensation of less than $20,000 will receive a credit equal to 50 percent of the employer's health care expenses. The credit phases out as the number of employ­ees increases from 10 to 25 and the average annual compensation of employees increases from $20,000 to $40,000. The small business credit would not be available for workers with wages above $80,000.
  • Employers must notify the federal government if they are going to offer health insurance to their workers or pay into the trust fund. Employers can make different coverage choices for full-time workers, part-time workers, and separate lines of business.

Under the House Blue-Dog compro­mise the exemption to the play-or-pay mandate covers 592,000 more small businesses than under H.R. 3200. The compromise would require:

Employers with $500,000 or more in annual payroll must offer their employees health insurance or pay 8 percent of each worker's wages into a Health Insurance Exchange Trust Fund. Small businesses with less than $500,000 in annual pay­roll are not subject to the play-or-pay mandate.

Under the Senate Health, Educa­tion, Labor and Pensions (HELP) Committee bill, the play-or-pay man­date would require:

  • Employers with more than 25 workers must offer their employ­ees qualifying health insurance coverage or pay a fee. Employers with fewer than 26 workers are not subject to the play-or-pay mandate.
  • All employers must contribute at least 60 percent of the premium for health insurance coverage.
  • Employers who do not offer the required mini­mum level of coverage and premium contribu­tions to their employees must pay $750 per year for each full-time worker (35 or more hours per week), and $375 per year for each part-time worker. For employers subject to the assess­ment, the first 25 workers would be exempted from the fee.
  • Employers with fewer than 10 workers will receive a credit of $1,000 (for individual cover­age) to $2,000 (for family coverage) for each employee, with bonus payments of $200 to $400 per worker for each 10 percent of the health insurance expenses exceeding 60 percent that are paid by the small employer. The credit phases out as the number of full-time employees increases from 10 to 50.

Who Is Covered by the Mandates?

Under H.R. 3200, approximately 1.4 million businesses with 104.6 million wage and salary employees would be covered by the play-or-pay mandate. (See Table 1.) Under the "Blue-Dog" com­promise, approximately 784,000 businesses with 97.4 million employees would be covered by their play-or-pay mandate. Under the HELP Committee bill, approximately 509,000 businesses with 95.4 million employees would be covered by their play-or-pay mandate.

Under H.R. 3200, 63.8 million workers in cov­ered firms already have employer-based health insurance in their own name, and 16.7 million are dependents with employer-based health insurance under another worker's plan.[9] (See Table 2.) Signif­icantly, it is not clear how the employer mandate will affect the 7.3 million multiple jobholders.[10] For example, will both employers have to offer health insurance to these workers?

Under the Senate HELP Committee bill, 60.9 million workers in covered firms already have employer-based health insurance in their own name, and 14.5 million are dependents with employer-based health insurance under another worker's plan. (See Table 2.)[11]

Most important, 34.4 million to 40.9 million employees who are covered by a mandate do not have employment-based health insurance in their own name and would have to be offered insur­ance in order for their employer to avoid a penalty. (See Table 2.)

Under the House bill, 42.8 million workers in covered businesses would be eligible to receive a partial credit for the cost of purchasing health insur­ance through the exchanges that would be created (36.7 million under the HELP Committee bill). (See Table 2.) Moreover, under the House bill, 9 million of the workers in these covered businesses would be automatically eligible for Medicaid (10.4 million under the HELP Committee bill).

Most of the workers in covered businesses who do not have employment-based health insurance are employed in industries defined by the Census Bureau as: restaurants (12 percent), department stores (3 percent), grocery stores (3 percent), colleges and universities (3 percent), other amuse­ment (a subset of amusement), gambling, and rec­reation industries (2 percent), nursing care (1.7 percent), and employment services (1.5 percent). (See Table 3.) Their median weekly earnings are between $387 and $400. They are disproportion­ately Hispanic women in families, ages 16 to 25, who are not citizens.[12]

How a Mandate Will Change Employment-Based Health Insurance

The Congressional Budget Office estimates that under H.R. 3200, some firms would decide to stop offering health insurance, and 3 million workers would lose their employment-based coverage, because, from the employer's perspective, it is more costly to "pay" than to "play" under the mandate, particularly for low-wage workers.[13] This finding is consistent with the fact that private-sector employ­ers currently pay 10 to 12 percent of wages to pro­vide health insurance, significantly more than the 8 percent firms would have to pay if they choose to no longer offer health insurance.[14]

The CBO also estimates that under H.R. 3200, 3 million low-wage workers who would be covered by employment-based insurance would instead choose to purchase insurance through the new health insurance exchanges with a subsidy.[15] Another 3 million part-time workers would likely decline to enroll in their employer's health insur­ance and instead purchase insurance through the new exchanges with a subsidy.[16]

Finally, the CBO estimates that under H.R. 3200, 12 million workers who are currently uninsured would enroll in their employer's health insurance coverage.[17] This increase is driven by two factors: (1) the individual mandate will increase the take-up rates for eligible workers who currently decline coverage for a variety of reasons; and (2) some employers will find it less costly to play than to pay, especially for higher-income workers, and begin to offer coverage.

Under the Senate HELP Committee bill, there will be substantially different changes in coverage because employers that do not offer the qualified health insurance to their employees would have to pay only $750 per year for each full-time worker, and $375 per year for each part-time worker, sub­stantially less than the 8 percent tax in H.R. 3200 and the cost of providing health insurance.

The Cost to Businesses

There are a number of costs to employers in H.R. 3200 and the HELP Committee bill that are related to the play-or-pay mandate, including: (1) the cost of not offering health insurance (the pay part of play-or-pay); (2) the cost of providing health insuranceto workers who do not currently have coverage (the play part of play-or-pay); and (3) the increased cost of providing health insurance that meets the essential benefits package mandated by the legislation.

  • According to the CBO, the cost of not offering qualifying health insurance and paying the tax is an average of $23.3 billion per year.[18]
  • The cost of providing 3 million more workers with qualified health insurance is $11.3 billion to $14.6 billion per year depending on what cov­erage (individual or family) the workers will enroll in.[19]
  • The cost of increasing the share of the premium employers pay in order to meet the qualifying coverage standard under the House mandate will be an additional $14.8 billion per year.[20]

Therefore, the total cost of the play-or-pay mandate for employers will be at least $49.4 billion to $52.7 billion per year.

The Mandate: 5.2 Million Low-Wage Employees at Risk

Several factors influence the degree to which requiring employers to offer health insurance will affect prices, wages, employment, and profits.

  1. What is the likely cost of the mandate both in terms of specific benefits and in terms of lost flexibility for employers? Besides increasing costs for employers who do not provide insur­ance, a mandate that specifies generous benefits will increase the costs for some employers who already provide insurance.
  2. How much of the increased cost of employing workers is passed on to consumers in the form of higher prices for the goods and services they purchase?
  3. How much of the cost is borne by employees in the form of reduced wages, slower wage growth, or reductions in other benefits? There is substan­tial evidence that the cost of health insurance mandates will be shifted to employees, resulting in lower wages.[21] Moreover, raising prices also reduces the real inflation-adjusted wages of workers. Firms can also shift the cost of the man­date to other workers who are not affected by the mandate (for example, those already covered by employment-based health insurance).
  4. How many workers not currently covered by employer-sponsored insurance are subject to wage rigidities that prevent accommodation of increased costs through reduced wages and other forms of compensation? In this situation any mandate may have a substantial effect on employment.
  5. How much of the increased cost is borne by shareholders and business owners in the form of lower profits and proprietor income?
  6. How much can firms offset the higher cost of employing workers by increasing productivity without reducing the hours of work?
  7. How will any exemptions, such as those for small businesses, dependents with health insur­ance, or subsidies for employers and workers, affect the impact of any mandate?

Hiring decisions are based on the total compen­sation of employment, including wages and bene­fits, such as paid vacation and holidays, paid sick leave, retirement benefits, and health insurance. If a worker's compensation is sufficiently high to absorb the entire cost of the new mandate, the mandate will likely change the composition of compensation (lower wages, more benefits) but not the total value of compensation.

However, a problem arises when a worker's compensation consists primarily of wages and is not high enough to absorb the cost of the man­date without bumping into the minimum wage. In this case, the play-or-pay mandate will have the same effect on employment as an increase in the minimum wage and will likely reduce the employment of, and job opportunities for, low-skilled workers.

Impact on Prices.Since the beginning of 2008, when San Francisco mandated employers to offer health insurance to workers or pay a fee to the city to fund health care, restaurants have explicitly passed on the cost of the mandate to consumers in the form of a health surcharge that shows up on the restaurant bill as a flat fee or as a percentage (like a sales tax). Most important, any increase in prices associated with the enactment of a play-or-pay man­date is effectively a hidden tax on savers and those on fixed-incomes.

If firms in the same industry and local market are mandated to provide health insurance and if the demand for their goods and services is rela­tively inelastic, then these firms could raise prices to offset the cost of the mandate. However, the ability of firms to raise prices will be constrained by the presence and degree of international com­petition they face and at what point in the busi­ness cycle the mandate is enacted. (For example, it will be more difficult for employers to raise prices in a recession and recovery when consum­ers are also increasing their savings and reducing their debt.) Moreover, the firms that provide health insurance prior to enactment of the man­date will gain a competitive advantage over those firms that do not currently provide health insur­ance and are subject to the mandate.

Impact on Employment.The play-or-pay man­date will put 5.2 million workers at risk of unem­ployment, working fewer hours, and providing fewer job opportunities (see Table 4), and up to 382,000 workers could lose their jobs.[22] See the methodology below for a description of how these estimates were calculated. These workers are dis­proportionately likely to be single, Hispanic or black, under 30 years of age, non-citizens, and are part-time or part-year employees working in food preparation, sales, or transportation.

In addition, the employers of another 10.2 mil­lion workers will see their labor costs rise because the employers will be required to increase the share of the premium they pay in order to meet the qual­ifying coverage standard under the House man­date.[23] This will put their employees at risk of slower wage growth, fewer hours of work, and reduced job opportunities.

Conclusion

The play-or-pay employer mandates that Con­gress is currently debating will impact 95.4 million to 104.6 million workers, and 509,000 to 1.4 mil­lion employers, including up to 1 million small businesses. The mandates will cost businesses at least $49.4 billion to $52.7 billion per year, and result in up to 382,000 low-wage unskilled workers losing their jobs. All told, 5.2 million low-wage workers will be at risk of losing their jobs or having their hours of work reduced, and they will likely have fewer job opportunities in the future. Another 10.2 million workers are at risk of slower wage growth and cuts in other benefits, and some of the cost of any play-or-pay mandate will be passed on to Americans in higher prices for the goods and ser­vices they buy--an indirect tax on savers and those on fixed incomes.

D. Mark Wilson is a consultant for The Heritage Foundation and a former Deputy Assistant Secretary for Employment Standards Administration at the U.S. Department of Labor.

APPENDIX:

Methodology

The findings in this report on the number of workers who are "at risk" of negative employment effects from the play-or-pay employer mandate, and the static job loss estimates that such a mandate would cause, were generated using the Census Bureau's "March 2008 Annual Social and Economic Supplement" (ASEC).

To estimate the number of workers who are at risk and the estimated jobs that would be lost due to the employer mandate in H.R. 3200, the following steps were taken:

Health insurance variables for "total private," "employment-based," "direct purchase," "total public," "Medicaid," "Medicare," "Military Health Care," and "not covered" were con­structed using ASEC variables to match the Cen­sus Bureau estimates published in "Income, Poverty, and Health Insurance Coverage in the United States: 2007," Table C-1, August 2008.

Only those observations with the following con­ditions were selected for analysis: (age > 15 & age 1 & (NoHI = 1 or DirPurch = 1). That is, non-elderly people who reported working last year as wage and salary employees in firms with 10 or more workers and either had no health insur­ance, or directly purchased health insurance, and, therefore, would likely to be covered by employer mandate.

Average hourly pay was calculated using ((WSal-Val / WksWork) / HrsWk).

The amount of payroll tax to be paid per hour for the worker observed was calculated using a 4 percent payroll tax for workers in firms with 10 to 24 employees (emplsz = 2), and 8 percent for workers in firms with 25 or more employees.

The amount of the payroll tax was then sub­tracted from the worker's current hourly pay. If the resulting amount was above $4.35 (60 per­cent of the current federal minimum wage) and below the applicable federal or state minimum wage, the worker was considered "at risk."

For those at-risk observations, the difference between (a) their hourly pay minus the payroll tax costs per hour and (b) the prevailing fed­eral or state minimum wage was calculated. That difference was then divided by the worker's current hourly pay to find the percentage increase in compensation effectively mandated for that worker.

That percentage was then multiplied by the assumed elasticity of employment (0.03) to mandated wage increases.

The sum of the probabilities of job loss for at-risk workers, using the appropriate ASEC weight, was calculated to estimate the national employment loss estimate.

Show references in this report

[1]There are three different versions of H.R. 3200: (1) the Ways and Means Committee bill at http://waysandmeans.house.gov/media/pdf/
111/AAHCA09001xml.pdf
(August 24, 2009), (2) the Education and Labor Committee substitute at http://edlabor.house.gov/documents/111/pdf/
markup/FC/HR3200-AmericasAffordableHealthChoicesActof2009/MILLCA_158.pdf
(August 24, 2009), and (3) the "Blue-Dog compromise" at /static/reportimages/43FC0A9F05B07940A3059669CDF55E08.pdf (August 24, 2009).

[2]The Senate Health, Education, Labor and Pensions (HELP) Committee bill is available at /static/reportimages/90086E43E1361BA163F3183D8CAE88E2.pdf (August 24, 2009).

[3]The "Blue-Dog compromise" amendment for the employer mandate is available at http://energycommerce.house.gov/Press_111/20090731/
hr3200_ross_2.pdf
(August 24, 2009)

[4]Applied Economic Strategies LLC estimates.

[5] Ibid.

[6] Ibid.

[7]Congressional Budget Office, "Additional Information Regarding the Effects of Specifications in the America's Affordable Health Choices Act Pertaining to Health Insurance Coverage," July 26, 2009, at http://www.
cbo.gov/ftpdocs/104xx/doc10400/07-26-InfoOnTriCommProposal.pdf
(August 24, 2009).

[8]Congressional Budget Office, "Effects of Changes to the Health Insurance System on Labor Markets," July 13, 2009, at http://www.cbo.gov/ftpdocs
/104xx/doc10435/07-13-HealthCareAndLaborMarkets.pdf
(August 24, 2009).

[9]Applied Economic Strategies, LLC estimate based on U.S. Census Bureau 2008 ASEC Supplement data.

[10]Press release, "Table A-13. Persons Not in the Labor Force and Multiple Jobholder by Sex, not Seasonally Adjusted," Bureau of Labor Statistics, August 7, 2009, at http://www.bls.gov/news.release/empsit.t13.htm (August 26, 2009).

[11]Applied Economic Strategies, LLC estimate based on U.S. Census Bureau 2008 ASEC Supplement data.

[12]The Census Bureau data contains a variable on the citizenship status of individuals. The variable makes no distinction between legal and illegal aliens. It distinguishes only between citizens and non-citizens.

[13]Congressional Budget Office, "Additional Information Regarding the Effects of Specifications in the America's Affordable Health Choices Act Pertaining to Health Insurance Coverage."

[14]Press release, "Employer Costs for Employee Compensation--March 2009," Bureau of Labor Statistics, June 10, 2009, at http://www.bls.gov
/news.release/pdf/ecec.pdf
(August 25, 2009), and Congressional Budget Office, "Additional Information Regarding the Effects of Specifications in the America's Affordable Health Choices Act Pertaining to Health Insurance Coverage."

[15]Congressional Budget Office, "Additional Information Regarding the Effects of Specifications in the America's Affordable Health Choices Act Pertaining to Health Insurance Coverage."

[16] Ibid.

[17] Ibid.

[18]Congressional Budget Office, "H.R. 3200, America's Affordable Health Choices Act of 2009," July 17, 2009, Table: "Preliminary Analysis of the Insurance Coverage Specifications Provided by the House Tri-Committee Group," at /static/reportimages/8AD262514DF44F5604AF878C5DD5137B.pdf (August 26, 2009).

[19]Applied Economic Strategies, LLC estimate based on the CBO estimate of $5,000 per year for individual health insurance and $12,000 per year for family coverage, times the share of the insurance premium that employers would be required to pay under the H.R. 3200 mandate, times the share of the 3 million workers who are individuals, family heads, and dependents. The share of workers who are individuals, family heads, and dependents was estimated from Census Bureau data on workers who report having no health insurance coverage.  

[20]Applied Economic Strategies, LLC estimate based on CBO data and Kaiser Family Foundation, "Employer Health Benefits 2008 Annual Survey," Exhibit 6.11. The share of workers who are individuals or family heads was estimated from Census data.

[21]Phillip Cryan, "Will A 'Play-or-Pay' Policy For Health Care Cause Job Losses?" Institute for America's Future and the Economic Policy Institute, June 2009; Katherine Baicker and Helen Levy, "Employer Health Insurance Mandates and the Risk of Unemployment," National Bureau of Economic Research Working Paper No. 13528, October 2007; Craig Olsen, "Do Workers Accept Lower Wages in Exchange for Health Benefits?" Journal of Labor Economics, Vol. 20, No. 2 (2002); Norman Thruston, "Labor Market Effects of Hawaii's Mandatory Employer-Provided Insurance," Industrial and Labor Relations Review (October 1997); Price Fishback and Shawn Kantor, "Did Workers Gain from the Passage of Workers' Compensation Laws?" Quarterly Journal of Economics (August 1995); Jonathan Gruber, "The Incidence of Mandated Maternity Benefits," American Economic Review (June 1994); Jonathan Gruber and Alan Kruger, "The Incidence of Mandated Employer-Provided Insurance: Lessons from Workers' Compensation Insurance," Tax Policy and the Economy, Vol. 5 (1991); and Lawrence H. Summers, "Some Simple Economics of Mandated Benefits," The American Economic Review, Vol. 79, No. 2 (May 1989).

[22]Applied Economic Strategies LLC estimates based on methodology used in Cryan, "Will A 'Play-or-Pay' Policy for Health Care Cause Job Losses?" and Katherine Baicker and Helen Levy, "Employer Health Insurance Mandates and the Risk of Unemployment," National Bureau of Economic Research Working Paper No. 13528, October 2007.  See the Methodology. Congressional Budget Office, "Effects of Changes to the Health Insurance System on Labor Markets."

[23]Kaiser Family Foundation, "Employer Health Benefits 2008 Annual Survey," Exhibit 6.11.

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