Order Code RL33702
CRS Report for Congress
Received through the CRS Web
Health Insurance Basics: Roles for the Market and
Government in Providing, Financing, and
Regulating Private Insurance Coverage
October 20, 2006
Jennifer Jenson
Specialist in Health Economics
Domestic Social Policy Division
Bernadette Fernandez
Analyst in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

---

Health Insurance Basics:
Roles for the Market and Government in Providing,
Financing, and Regulating Private Insurance Coverage
Summary
Both the market and government have important roles in ensuring the
availability, affordability, and adequacy of private health insurance. These roles
complement one another, but even together the market and government have
limitations.
The market provides a variety of insurance products for consumers and
employers with different needs and preferences. These products differ on many
dimensions, including the breadth of provider networks, amount of beneficiary cost-
sharing, and techniques for managing the use of health care services. Large
employers, small employers, and individuals have different health insurance options,
but all must make tradeoffs between the cost of coverage and desired features.

A strength of the market is its flexibility to adapt over time to changing
circumstances. As economic conditions, consumer preferences, and government
policies evolve, the market generates different products with different features. The
primary limitation of the market is its failure to provide affordable options for all
consumers.
The federal government helps ensure access to health coverage through public
programs, such as Medicare and Medicaid, and it influences the market for private
insurance through tax and regulatory policies. Some tax subsidies help people
purchase insurance, and others — including those for Health Savings Accounts —
help pay for medical expenses not covered by insurance. By far the largest subsidy
is the tax exclusion for employer-provided health benefits. Because of this exclusion,
most people get health insurance through work.
Tax subsidies make health insurance and health care seem more affordable for
certain taxpayers, but do not provide equivalent support to everyone. In addition,
subsides may increase health care spending by reducing the apparent cost of health
insurance and health care services.
Regulations affect both access to insurance and the adequacy of benefits. States
have primary responsibility for regulating insurance, but the federal government has
sought to address selected issues regarding health coverage. For example, the Health
Insurance Portability and Accountability Act of 1996 and the Consolidated Omnibus
Budget Reconciliation Act of 1985 include provisions that allow certain people to
obtain or continue health coverage under certain circumstances. In addition, several
federal laws mandate coverage for specific health benefits.
Although regulations provide some protection for consumers, neither federal nor
state rules guarantee access to coverage for everyone. In addition, even where
regulations require insurers or employers to offer coverage, consumers may find this
coverage unaffordable. This report will be updated.

---

Contents
The Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Offering Insurance Products with Different Features . . . . . . . . . . . . . . . . . . 2
Adapting to Changing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Limitations of the Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Tax Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Subsidies for Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Other Subsidies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Limitations of Tax Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Access to Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Adequacy of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Limitations of Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

---

Health Insurance Basics:
Roles for the Market and Government
in Providing, Financing, and Regulating
Private Insurance Coverage
Health insurance coverage facilitates access to health care and protects
individuals and families from catastrophic health expenses.1 Both the market and
government have important roles in helping ensure the availability, affordability, and
adequacy of private health insurance.
In 2005, about two-thirds of Americans had private coverage, including about
60% with employment-based and 9% with directly purchased health insurance. In
the same year, about 27% of the population had government benefits through
Medicare, Medicaid, and military health programs. About 16% of the population was
uninsured.2
The market for private insurance excels in creating new products and adapting
to changing demand, but is not set up to ensure that everyone gets coverage.
Consumers who are sick or poor may not be able to find adequate insurance at an
affordable price, while others may decide that premiums are more than they are
willing to pay. If health insurance were another good or service, people might not
care about consumers who cannot afford it or choose not to buy it. But many think
that health insurance and the health care it pays for are different from other goods and
services.
Government helps ensure access to health coverage where the market might not.
It does this through public programs, such as Medicare and Medicaid, and through
policies that affect the market for private insurance. Federal policies include tax
subsidies and regulations. Subsidies make health insurance more affordable for
consumers and employers, and regulations help ensure access to insurance and the
adequacy of benefits. States play a fundamental role in regulating health insurers and
1 For more information about private health insurance, see CRS Report RL32237, Health
Insurance: A Primer, by Bernadette Fernandez.
2 U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United
States: 2005, Current Population Report No. P60-231, August 2006, p. 60. More
specifically, 67.7% of the population had private insurance (including 59.5% with
employment-based and 9.1% with directly purchased coverage); 27.3% had government
coverage (including 13.0% with Medicaid, 13.7% with Medicare, and 3.8% with military
health care); and 15.9% of the population was uninsured. Some people with private
insurance had both employment-based and directly purchased coverage, and some people
had both private and government coverage.

---

CRS-2
the products they sell. Functions vary by state, and may include licensing insurance
companies and agents, ensuring financial solvency through standards and oversight,
approving rates, and assessing insurance companies to fund programs for consumers.
Of course, there is no bright line between the market and government. Market
limitations prompt government policies, and government policies in turn shape
market trends. In addition, differences among state policies and the interaction
between federal and state requirements create a complex landscape for consumers,
employers, and insurers who wish to buy or provide health benefits.
This report analyzes the roles of the market and government in providing,
financing, and regulating private health insurance. It focuses on federal policy, and
shows that although both the market and government play important roles, both also
have limitations.
The Market
By generating diverse insurance products and by adapting to different and
changing conditions, the market for private health insurance provides choices for
consumers and employers who have different needs and preferences.
Offering Insurance Products with Different Features
Consumers and employers want affordable yet generous coverage. They also
want unfettered access to health care providers and services, but generally they must
make tradeoffs between cost on the one hand and generous coverage and access on
the other. Consumers and employers have varied preferences for making these
tradeoffs. For example, some may be willing to pay higher premiums in exchange
for unrestricted access to health care providers, while others accept restrictions or
higher cost-sharing to make coverage more affordable.
To meet demand, the market offers a variety of health insurance products.
These products include traditional indemnity insurance, relatively restrictive health
maintenance organizations (HMOs), and high-deductible health plans with associated
savings accounts. Certain products are characterized by certain features. For
example, indemnity coverage is associated with a choice of health care providers,
while HMOs are associated with restricted choice, including limited provider
networks and constrained access to care. In practice, distinctions between the
product types are not clear. Any type of product may have nearly any combination
of features, including broad or restricted access to health care providers, low or high
cost-sharing, and limited or fully integrated programs for managing patients’ use of
services.
Consumers and employers choose among different products according to their
preferences, although individuals, small employers, and large employers tend to have
different options. In addition to having more options, large employers can choose
between purchasing insurance and self-insuring and buying administrative services
from an entity that processes paperwork but does not bear financial risk.

---

CRS-3
Adapting to Changing Conditions
In addition to providing a variety of products, the market adapts over time to
changing circumstances. Health insurance products evolve, and different features
become more or less prominent.
In the early 1990s, the trend was toward managed care, with restricted access to
health care providers, low beneficiary cost-sharing, and health plan management to
limit use of services. These strategies slowed growth in premiums for health
insurance, but led to complaints by patients and providers about restrictions on access
to care and interference in the practice of medicine. In response to these complaints,
the market began to offer more flexible products with higher premiums. By the late
1990s, with a booming economy and low unemployment, employers were willing to
pay more for health insurance in an effort to recruit and maintain a qualified
workforce. More recently, as prices have continued to rise, renewed concern by
consumers and employers about the cost of health benefits has led to more changes
in insurance products. Given the managed care backlash, these products have fewer
restrictions on access to care, and instead rely on higher cost-sharing to influence
consumers’ use of services.3
In addition to responding to changing circumstances, the market responds to
policy changes. For example, the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) authorized new tax-advantaged accounts to pay
for medical expenses not covered by insurance or other reimbursements. These
Health Savings Accounts (HSAs) must be paired with high-deductible health plans,
and the market has responded by developing such plans.4 The MMA also established
Medicare drug coverage. Private insurers provide this coverage through Medicare
Advantage (MA) and stand-alone prescription drug plans (PDPs). Depending on
where beneficiaries live, they may be able to choose among several MA plans and
more than 50 PDP options.5
Limitations of the Market
Although private insurers offer a variety of products and respond to changing
conditions, they do not serve everyone equally. Premiums and access to health
insurance vary across and within geographic markets, and for different consumers
3 For more on changes in health care and health insurance during the past decade, see Paul
Ginsburg, “Competition in Health Care: Its Evolution over the Past Decade,” Health Affairs,
vol. 24, no. 6 (Nov./Dec. 2005), pp. 1512-1522.
4 America’s Health Insurance Plans (AHIP), “HSAs and Account-Based Plans: An Overview
of Preliminary Research,” June 2006, at [http://www.ahipresearch.org/pdfs/HSAsOverview
Jun2006.pdf]. Lydia Regopoulos, et al, “Consumer-Directed Health Insurance Products:
Local-Market Perspectives,” Health Affairs, vol. 25, no. 3 (May/June 2006), pp. 766-773.
5 The number of options varies by region. For example, in 2006, beneficiaries in
Pennsylvania and West Virginia could choose between 52 PDP options, while those in
Alaska had 27 options. See Austin B. Frakt and Steven D. Pizer, “A First Look at the New
Medicare Prescription Drug Plans,” Health Affairs-Web Exclusive, May 23, 2006, pp.
W252-W261.

---

CRS-4
and employers. Across markets, premiums vary with differences in the cost of living,
in patterns of health care practice, in the mix of medical providers, and in the relative
market power of providers and insurers. Within markets, premiums vary both
because products differ and because individual consumers and employers differ.
Differences in consumer and employer characteristics affect not just premiums,
but also access to insurance, including the number, type, and generosity of plan
options. Some people and firms have many choices, while others have few. Large
firms and their employees tend to have more options than smaller firms and their
employees. Many people have no employment-based option, either because their
employer does not offer coverage or because they are not working. Lack of
employment-based coverage can be a particular problem for high-risk populations —
including people who are older, sick, or disabled — as they may have few or no
choices in the private market.
A large number of choices may or may not improve insurance coverage. On the
one hand, many options increase the likelihood that consumers and employers will
find a satisfactory combination of benefits and costs. On the other hand, the number
of options may be irrelevant if prices are burdensome or unaffordable.
The Government
Government plays a role in helping ensure access to health coverage. In 2006,
federal spending on Medicare, Medicaid, and the State Children’s Health Insurance
Program (SCHIP) is expected to total $559 billion.6 These programs serve primarily
older, low-income, and disabled people, populations that otherwise would have
difficulty finding adequate and affordable coverage in the private market. For
vulnerable individuals who lack access to employer-paid insurance, government
benefits may be the only viable alternative.
In addition to providing health benefits for vulnerable populations, the federal
government uses tax and regulatory policy to influence the market for private health
insurance. Tax policy supports access to care through subsidies for insurance and
medical care expenses, while regulatory policy supports access by laying ground
rules that affect the availability and adequacy of insurance coverage.
Tax Policy
Federal law includes significant tax benefits for health insurance and medical
care expenses. In addition to supporting access to care, these benefits have shaped
the market for private health insurance. Largely because of tax policy, in 2005 about
60% of Americans got health benefits through work.
6 U.S. Congressional Budget Office, The Budget and Economic Outlook: An Update,
August 2006, pp. 12-13.

---

CRS-5
Subsidies for Health Insurance. By far the largest health-related tax
benefit is the exclusion for employer-paid insurance. For people receiving employer-
paid benefits, premium costs are not counted as income and therefore not subject to
income and employment taxes. In 2006, the income tax exclusion for employer-paid
insurance is expected to be about $91 billion.7 Employers also do not pay
employment taxes on health insurance premiums. These tax benefits help make
insurance more affordable for consumers and employers, but they also reduce federal
revenue that otherwise could be used for different purposes. In effect, consumers
who receive employer-paid insurance transfer part of the cost of coverage to
taxpayers.8
Other tax benefits for health insurance include a deduction for self-employed
taxpayers, and a tax credit for a limited group of individuals who either lost
manufacturing jobs or receive payments from the Pension Benefit Guaranty
Corporation. These tax benefits serve fewer people than the exclusion for employer-
paid coverage. In 2006, the deduction for self-employed workers is expected to be
about $4 billion and the tax credit only about $200 million.9
Other Subsidies. Tax benefits also help consumers pay for qualified medical
expenses not covered by insurance. Taxpayers who itemize may deduct health
insurance premiums and other costs to the extent that qualified expenses exceed 7.5%
of adjusted gross income (AGI).10 Because eligibility depends on high spending
relative to income, this deduction limits financial loss for people who face
catastrophic costs. In 2006, this tax benefit is expected to be about $7 billion.
People also can use several tax-advantaged accounts to pay for qualified medical
expenses. These accounts include Health Savings Accounts (HSAs), Archer Medical
Savings Accounts (MSAs), Health Reimbursement Accounts (HRAs), and Flexible
Spending Accounts (FSAs). The newest such option, HSAs, is expected to provide
about $100 million in tax benefits in 2006.11
7 U.S. Congress, Joint Committee on Taxation (JCT), Estimates of Federal Tax
Expenditures for Fiscal Years 2006-2010, Joint Committee Print #JCS-2-06, Apr. 25, 2006,
p. 39.
8 For more information on the exclusion for employer-provided coverage and other tax
subsidies for health insurance and health care expenses, see CRS Report RL33505, Tax
Benefits for Health Insurance and Expenses: Overview of Current Law and Legislation, by
Bob Lyke.
9 JCT, p 39. For more information on the tax credit, see CRS Report RL32620, Health
Coverage Tax Credit Authorized by the Trade Act, by Julie Stone and Bob Lyke.
10 The medical expense deduction helps people only when their unreimbursed medical
expenses exceed 7.5% of AGI and their total itemized deductions exceed their standard
deduction.
11 JCT, p. 39. For more information on tax-advantaged accounts, see CRS Report RS21573,
Tax-Advantaged Accounts for Health Care Expenses: Side-by-Side Comparison, by Bob
Lyke and Chris Peterson; CRS Report RL32467, Health Savings Accounts, by Bob Lyke et
al.; and CRS Report RL32656, Health Care Flexible Spending Accounts, by Chris Peterson
and Bob Lyke.

---

CRS-6
Limitations of Tax Policy. Although all of these tax benefits help people
pay for health insurance and health care, government — like the market — does not
serve everyone equally. People may or may not be eligible for various benefits; and
if they are eligible, support may or may not affect access.
Because many tax benefits are tied to employment, workers may receive support
that is not available to the unemployed. In addition, higher-income workers realize
greater tax savings than lower-income workers because tax benefits are based on
marginal tax rates. Tax support does not guarantee access, and lack of support does
not preclude it. Low-income people may be unable to afford coverage or all of the
care they desire, even with support. Conversely, high-income people may be able to
buy insurance and whatever care they need, even without support.
In addition to failing to distribute support based on need, tax benefits may
increase health care spending. With subsidies, people can afford more insurance than
they would otherwise; and with insurance, people may use more care.12
Regulation
Regulatory policy is another tool for influencing the market for health insurance.
Regulations affect access to coverage and the adequacy of benefits by setting ground
rules for insurance companies and employers that provide health benefits. States
have primary responsibility for regulating insurance, but the federal government has
sought to address selected issues regarding health coverage. In general, federal
regulations do not address premiums.
Access to Insurance. Federal policy does not guarantee access to private
health insurance, but it does help certain consumers get or keep access to coverage
under certain conditions. For example, the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) helps ensure access to new insurance coverage
for individuals and their families when the policyholder changes jobs. This
protection is called portability. The act also helps ensure continuing coverage when
a beneficiary gets sick. HIPAA accomplishes these guarantees by requiring insurers
to sell or renew both individual and group insurance policies without regard to health
status or claims experience. The law similarly helps small businesses. Insurers that
offer coverage in the small group market must accept every applicant without regard
to the claims history of the group.13
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) also
helps ensure access to health insurance. COBRA allows certain workers and family
12 People use more health care when they are insured primarily because insurance reduces
the apparent cost of services at the time people use them. For more information on demand
with insurance, see David M. Cutler and Richard J. Zeckhauser, “The Anatomy of Health
Insurance,” in Anthony J. Culyer and Joseph P. Newhouse, eds., Handbook of Health
Economics, Volume 1A (Amsterdam: Elsevier Science B.V., 2000), pp. 563-643.
13 For more information about HIPAA, See CRS Report RL31634, The Health Insurance
Portability and Accountability Act (HIPAA) of 1996: Overview and Guidance on Frequently
Asked Questions, by Hinda R. Chaikind, Jean Hearne, Bob Lyke, and Stephen Redhead.

---

CRS-7
members who lose eligibility for group coverage to continue to purchase this
coverage for a limited time period.14 Under the law, firms that employ at least 20
people must allow beneficiaries to continue health coverage following a qualifying
event. For workers, qualifying events include loss of coverage due to job
termination, a reduction in work hours, or a firm’s reorganization due to bankruptcy;
for family members, qualifying events include loss of coverage due to the death of
or divorce from a covered employee.
Adequacy of Benefits. In addition to helping ensure access to insurance,
regulations address the adequacy of coverage. Almost all such regulations come
from the states. According to the Council for Affordable Health Insurance, an
industry group, the number of state-mandated benefits currently tops 1,800. These
mandates require affected insurers to cover specific health benefits, providers, and
patients. Examples include mandated coverage for cancer screening tests, nurse
practitioners, and handicapped dependents.15
Federal law includes a few benefit mandates. These mandates regard parity for
mental health benefits, hospital coverage following normal childbirth or cesarean
delivery, and coverage for prosthetic devices and reconstructive surgery following
a mastectomy.16
Limitations of Regulation. Regulations may facilitate access to insurance
or specific benefits, but they do not serve everyone equally. For example, although
HIPAA and COBRA require insurers and employers to offer coverage to certain
individuals under certain circumstances, these Acts do not guarantee access to
insurance for everyone. In addition, even where regulations require insurers to sell
or employers to offer coverage, eligible people may find coverage unaffordable.
Benefit mandates also do not serve everyone equally. Sometimes the issue is
uniform protection, and sometimes the issue is variable protection. On one hand,
while some argue that benefit mandates help guarantee adequate coverage, others
maintain that mandates increase costs and limit coverage options for consumers.17
On the other hand, because most benefit mandates come from the states, consumers
may or may not be protected, depending on where they live. In addition, while
policies sold by insurance companies generally must comply with state mandates,
firms that self-insure are exempt from the requirements.
14 For more information about COBRA, See CRS Report RL30626, Health Insurance
Continuation Coverage Under COBRA, by Heidi G. Yacker.
15 Council for Affordable Health Insurance, Health Insurance Mandates in the States 2006,
Mar. 2006, at [http://www.cahi.org/cahi_contents/resources/pdf/MandatePub2006.pdf].
16 For more information on federal insurance mandates, See CRS Report RL31657, Mental
Health Parity: Federal and State Action and Economic Impact, by Ramya Sundararaman
and C. Stephen Redhead; CRS Report 98-14 EPW, Newborns’ and Mothers’ Health
Protection Act, by Sharon Kearney Coleman (available on request); and CRS Report
RL31634 on HIPAA, by Hinda Chaikind, Bob Lyke, C. Stephen Redhead, and Jean Hearne.
17 Recent legislation sought to address concern about costs and coverage options by giving
insurers more flexibility to develop products that do not include state-mandated benefits.

---

CRS-8
Conclusion
Both government and the market have important roles in helping ensure the
availability, affordability, and adequacy of private health insurance. The market
excels in creating new products and adapting to changing demand, but is not set up
to guarantee that everyone gets coverage.
Government complements the market through tax and regulatory policies aimed
at improving access to coverage and the adequacy of benefits. Ideally, these policies
would reflect widely held social values, but setting priorities is difficult. Should the
priority be affordability, and if so, for whom? For consumers and employers
purchasing insurance? For taxpayers who subsidize coverage? Or should the priority
be facilitating access to benefits? Again, for whom? For workers; for people with
lower income; for people who are older, sick, or disabled; or for everyone?
Policymakers face a challenge in improving access to health insurance, while
making efficient use of limited public resources and avoiding unnecessary regulations
that might hinder market innovation.

---