Mandated Employer Provided Health Insurance

ISSUE DEFINITION BACKGROUND AND ANALYSIS Uninsured Population Working U n i n s u r e d Move Toward Mandated H e a l t h B e n e f i t s I s s u e s R e l a t e d t o M a n d a t i n g Employer-Provided H e a l t h I n s u r a n c e Q u e s t i o n o f Employer R e s p o n s i b i l i t y Mandated Employer-Provided I n s u r a n c e and C o m p e t i t i v e n e s s S m a l l Employers and Mandated Employer-Provided H e a l t h I n s u r a n c e U n d e r i n s u r a n c e and C a t a s t r o p h i c C o v e r a g e H i s t o r y o f F e d e r a l Employer Mandates T i t l e X o f COBRA M e d i c a r e Working Aged and Working D i s a b l e d S e c o n d a r y P a y e r Requirements Bowen C a t a s t r o p h i c P r o p o s a l T y p e s o f Mandated C o v e r a g e P r o p o s a l s D e f i n i n g t h e A p p l i c a t i o n , N a t u r e and S c o p e o f Mandated H e a l t h Benefits D e f i n i n g P o p u l a t i o n t o b e Covered and D u r a t i o n o f C o v e r a g e D e f i n i n g t h e L i a b i l i t y o f Employers a n d Employees LEG1 SLATION CONGRESSIONAL HEARINGS, REPORTS, AND DOCUMENTS FOR ADDITIONAL READING MANDATED EMPLOYER PROVIDED HEALTH INSURANCE Between 25 and 3 7 m i l l i o n Americans u n d e r t h e a g e of 65 l a c k h e a l t h insurance. Recent e s t i m a t e s h a v e drawn s p e c i a l a t t e n t i o n t o t h e w o r k i n g u n i n s u r e d : o v e r t w o - t h i r d s o f t h e u n i n s u r e d a r e employed o r t h e d e p e n d e n t s of employed i n d i v i d u a l s . The g r o w t h i n t h e number of u n i n s u r e d h a s o c c u r r e d a t a t i m e when c h a n g e s i n reimbursement p o l i c y by p r i v a t e i n s u r e r s and t h e F e d e r a l Government h a v e made i t more d i f f i c u l t f o r h o s p i t a l s t o s h i f t t h e c o s t s of t r e a t i n g t h e uninsured t o p r i v a t e l y insured p a t i e n t s . Consequently, a c c e s s t o h e a l t h c a r e f o r p e r s o n s l a c k i n g i n s u r a n c e i s a growing c o n c e r n . T h e s e d e v e l o p m e n t s have l e d t o new c o n g r e s s i o n a l i n t e r e s t i n t h e p r o b l e m s of t h e m e d i c a l l y u n i n s u r e d . Faced w i t h s u b s t a n t i a l F e d e r a l b u d g e t solutions, d e f i c i t s a n d d i m i n i s h e d i n t e r e s t i n Government-financed C o n g r e s s h a s begun t o l o o k t o e m p l o y e r s a s a p o t e n t i a l s o u r c e of e x p a n d i n g a c c e s s t o h e a l t h i n s u r a n c e coverage. Under one a p p r o a c h g a i n i n g some s u p p o r t i n C o n g r e s s , t h e F e d e r a l Government would mandate t h a t e m p l o y e r s p r o v i d e h e a l t h i n s u r a n c e c o v e r a g e a n d / o r s p e c i f i c h e a l t h b e n e f i t s t o t h e i r employees a n d , i n some c a s e s , a l s o t o t h e i r employees' f a m i l i e s . T h e r e i s , however, s u b s t a n t i a l c o n t r o v e r s y over t h i s approach. Proponents argue t h a t p r o v i d i n g h e a l t h They s a y t h a t c u r r e n t l y , t h e insurance i s an employer's responsibility. c o s t s o f p r o v i d i n g c a r e t o u n i n s u r e d w o r k e r s a r e b e i n g s h i f t e d by h e a l t h c a r e p r o v i d e r s t o t h o s e e m p l o y e r s who p r o v i d e and pay f o r h e a l t h insurance. Opponents of mandated employer-provided i n s u r a n c e a r g u e t h a t i t i s not an employer's r e s p o n s i b i l i t y t o provide h e a l t h insurance. In a d d i t i o n , t h e y s a y t h a t many e m p l o y e r s , e s p e c i a l l y s m a l l e r o n e s , c a n n o t afford t o o f f e r insurance. Opponents a l s o a r g u e t h a t t h e added c o s t s o f h e a l t h i n s u r a n c e would r e d u c e e m p l o y e r s ' a b i l i t y t o compete, harming t h e o v e r a l l n a t i o n a l economy. A s a r e s u l t of p a s t a c t i o n s by C o n g r e s s , e m p l o y e r s who o f f e r h e a l t h i n s u r a n c e have t o conform t o s p e c i f i c r e q u i r e m e n t s a f f e c t i n g t h e n a t u r e of t h e i r h e a l t h i n s u r a n c e p l a n s and t h e e n t i t l e m e n t co t h o s e p l a n s . Most l a r g e r e m p l o y e r s have t o o f f e r t h e i r employees t h e o p t i o n of becoming members of f e d e r a l l y q u a l i f i e d H e a l t h Maintenance O r g a n i z a t i o n s . Also, e m p l o y e r s a r e p r o h i b i t e d from d i s c r i m i n a t i n g i n employee b e n e f i t p l a n s on t h e b a s i s o f d i s a b i l i t i e s a r i s i n g on a c c o u n t o f pregnancy. Certain e m p l o y e r s have t o o f f e r M e d i c a r e - e l i g i b l e w o r k e r s and t h e i r s p o u s e s t h e o p t i o n t o e l e c t t h e e m p l o y e r ' s h e a l t h p l a n a s t h e i r p r i m a r y s o u r c e of insurance. F i n a l l y , c e r t a i n e m p l o y e r s a r e now r e q u i r e d t o make a v a i l a b l e c o n t i n u e d h e a l t h i n s u r a n c e c o v e r a g e t o q u a l i f i e d employees and t h e i r f a m i l i e s who would o t h e r w i s e l o s e c o v e r a g e a s a r e s u l t o f s p e c i f i c e v e n t s . I n t h e 100th Congress, t h e r e i s i n t e r e s t i n r e q u i r i n g t h a t a l l e m p l o y e r s p r o v i d e b a s i c h e a l t h i n s u r a n c e c o v e r a g e . While some b i l l s would expand a c c e s s t o h e a l t h i n s u r a n c e by mandating t h a t e m p l o y e r s p r o v i d e b a s i c h e a l t h insurance, o t h e r s seek t o d e f i n e t h e s p e c i f i c n a t u r e of t h e b e n e f i t s t o be o f f e r e d . I n a d d i t i o n , H e a l t h and Human S e r v i c e s S e c r e t a r y , O t i s Bowen, h a s recommended t h a t t h e F e d e r a l Government e n c o u r a g e employers t o provide i n s u r a n c e f o r c a t a s t r o p h i c medical expenses. ISSUE DEFINITION Most Americans h a v e h e a l t h i n s u r a n c e c o v e r a g e t h r o u g h p r i v a t e g r o u p p l a n s o f f e r e d by t h e i r e m p l o y e r o r t h r o u g h t h e two m a j o r F e d e r a l Government f i n a n c e d p r o g r a m s , M e d i c a r e and M e d i c a i d . A much s m a l l e r number o f Americans p u r c h a s e i n d i v i d u a l p o l i c i e s t h r o u g h t h e p r i v a t e h e a l t h i n s u r a n c e market. However, between 25 and 37 m i l l i o n Americans have no h e a l t h i n s u r a n c e coverage. Moreover, t h e p e r c e n t a g e o f u n i n s u r e d Americans h a s been c l i m b i n g , i n c r e a s i n g by some e s t i m a t e s by a s much a s 15% f o r t h e u n d e r a g e 65 p o p u l a t i o n between 1982 and 1985. R e c e n t U.S. Census Bureau e s t i m a t e s h a v e drawn s p e c i a l a t t e n t i o n t o t h e w o r k i n g u n i n s u r e d : o v e r t w o - t h i r d s o f t h e u n i n s u r e d a r e employed o r t h e d e p e n d e n t s of employed i n d i v i d u a l s . For t h e s e Americans, employment o r c o n n e c t i o n t o employment t h r o u g h a working f a m i l y member h a s f a i l e d t o r e s u l t i n coverage under a h e a l t h insurance plan. The g-rowth i n t h e u n i n s u r e d p o p u l a t i o n h a s o c c u r r e d a t a t i m e when c h a n g e s i n t h e r e i m b u r s e m e n t p o l i c i e s of p r i v a t e i n s u r e r s and t h e F e d e r a l Government h a v e made i t more d i f f i c u l t f o r h o s p i t a l s t o s h i f t t h e c o s t s of t r e a t i n g t h e uninsured t o p r i v a t e l y insured patients. Consequently, t h e r e i s growing c o n g r e s s i o n a l concern about t h e decreased a c c e s s t o h e a l t h c a r e f o r persons lacking insurance. I n s e a r c h of a s o l u t i o n t h a t w i l l n o t r e s u l t i n major Federal spending, Congress has t u r n e d t o employers a s a p o t e n t i a l s o u r c e of expanding a c c e s s t o h e a l t h i n s u r a n c e coverage. In p a s t y e a r s , C o n g r e s s h a s mandated t h a t e m p l o y e r s who o f f e r h e a l t h i n s u r a n c e t o t h e i r w o r k e r s must meet s p e c i f i c r e q u i r e m e n t s a f f e c t i n g t h e n a t u r e o f t h e i r h e a l t h i n s u r a n c e p l a n s and t h e e n t i t l e m e n t t o t h o s e p l a n s . I n t h e 100th Congress, l e g i s l a t i o n i s being considered t o mandate t h a t employers provide b a s i c h e a l t h i n s u r a n c e t o t h e i r employees and t o r e q u i r e t h a t employers provide s p e c i f i c h e a l t h b e n e f i t s i n t h e i r insurance plans. These p r o p o s a l s have s t i m u l a t e d s u b s t a n t i a l c o n g r e s s i o n a l d e b a t e . BACKGBOUWD AND ANALYSIS The U n i n s u r e d P o p u l a t i o n The number o f u n i n s u r e d Americans i s s u b s t a n t i a l : E s t i m a t e s f o r 1985 a n d 1986 r a n g e from 25 m i l l i o n ( b a s e d on t h e 1986 N a t i o n a l A c c e s s S u r v e y done f o r t h e R o b e r t Wood Johnson F o u n d a t i o n ) t o 37 m i l l i o n ( b a s e d on t h e The 1986 C u r r e n t P o p u l a t i o n S u r v e y [CPS] o f t h e U.S. Census B u r e a u ) . number h a s a l s o been i n c r e a s i n g . I n "The U n i n s u r e d and Uncompensated C a r e , " S u l v e t t a and S w a r t z r e p o r t t h a t i n t h e l a t e 1 9 7 0 s , between 1 3 a n d 14.5% of t h e under-65 p o p u l a t i o n w e r e u n i n s u r e d . T h i s number i n c r e a s e d t o 17% by 1984. E s t i m a t e s v a r y , and some s t u d i e s r e p o r t t h a t t h e number of m e d i c a l l y u n i n s u r e d a c t u a l l y peaked d u r i n g t h e economic r e c e s s i o n o f t h e (The w i d e v a r i a t i o n s i n e a r l y 1 9 8 0 s , and i s now on a downward t r e n d . e s t i m a t e s o f t h e u n i n s u r e d a r e e x p l a i n e d by t h e d i f f e r e n t q u e s t i o n s and methods o f s a m p l i n g used i n t h e s u r v e y s . Researchers a r e attempting t o r e s o l v e t h i s measurement problem.) The e f f e c t s on a n i n d i v i d u a l o f n o t h a v i n g h e a l t h i n s u r a n c e a r e n o t w e l l documenced. What i s known i s t h a t t h e u n i n s u r e d a r e l e s s L i k e l y t o u s e h e a l t h s e r v i c e s and a r e more l i k e l y t o b e i n p o o r e r h e a l t h t h a n t h e insured population. The 1986 N a t i o n a l Access Survey r e p o r t s , f o r example, t h a t t h e u n i n s u r e d had a p p r o x i m a t e l y 40% f e w e r a m b u l a t o r y v i s i t s and 19% fewer h o s p i t a l i z a t i o n s than t h e insured. Of t h o s e i n d i v i d u a l s s u r v e y e d who had c h r o n i c i l l n e s s e s , 20% o f t h e u n i n s u r e d f a i l e d t o s e e a p h y s i c i a n o r o t h e r p r o v i d e r o v e r t h e c o u r s e o f a y e a r , compared t o 17% o f t h e insured. While d a t a on t h e h e a l t h c o n s e q u e n c e s o f l a c k i n g i n s u r a n c e a r e s c a r c e , s e v e r a l s t u d i e s do p r o v i d e i n f o r m a t i o n on who make up t h e uninsured population. They i n d i c a t e t h a t low-income h o u s e h o l d s a r e more l i k e l y t o l a c k h e a l t h i n s u r a n c e t h a n t h o s e w i t h m i d d l e o r h i g h incomes. They a l s o i n d i c a t e t h a t t h e v a s t m a j o r i t y of u n i n s u r e d a r e employed o r l i v e i n f a m i l i e s where t h e head of t h e h o u s e h o l d i s employed. A c c o r d i n g t o a s t u d y by r e s e a r c h e r s a t t h e N a t i o n a l C e n t e r f o r H e a l t h S e r v i c e s R e s e a r c h ( u s i n g d a t a from t h e 1977 N a t i o n a l Medical E x p e n d i t u r e S u r v e y and t h e 1980 N a t i o n a l Medical Care U t i l i z a t i o n and E x p e n d i t u r e This is S u r v e y ) , 55% o f t h e u n i n s u r e d a r e employed p a r t of t h e t i m e . c o n s i s t e n t w i t h an ' a n a l y s i s done by t h e Employee B e n e f i t R e s e a r c h I n s t i t u t e (EBRI) u s i n g March 1986 d a t a from t h e CPS, which f o u n d t h a t when s p o u s e s a n d d e p e n d e n t s a r e a d d e d , o v e r t w o - t h i r d s of t h e u n i n s u r e d l i v e i n f a m i l i e s where t h e head of c h e h o u s e h o l d i s employed. In addition, the number o f w o r k e r s w i t h o u t c o v e r a g e grew by more t h a n 22% between 1982 a n d 1985. The Working Uninsured L a r g e l y a s a r e s u l t o f l a b o r u n i o n p r e s s u r e s f o r b e t t e r employee b e n e f i t s , and F e d e r a l t a x i n c e n t i v e s t h a t a l l o w e m p l o y e r s t o d e d u c t t h e c o s t s of p r o v i d i n g h e a l t h b e n e f i t s t o t h e i r e m p l o y e e s , e m p l o y e r - r e l a t e d h e a l t h i n s u r a n c e became i n c r e a s i n g l y commonplace a f t e r World War 11. Today, a f t e r p a i d v a c a t i o n s , i t i s t h e most comnon f r i n g e b e n e f i t o f f e r e d by e m p l o y e r s . For t h e n i n e o u t o f t e n Americans w i t h p r i v a t e g r o u p As a i n s u r a n c e , t h a t i n s u r a n c e i s p r o v i d e d i n t h e employment s e t t i n g . r e s u l t ( a n d i n c o n t r a s t t o o t h e r w e s t e r n n a t i o n s where h e a l t h and p e n s i o n b e n e f i t s a r e provided through public programs), workers i n t h e United S t a t e s have grown t o r e l y on employer-provided b e n e f i t s f o r t h e s e b a s i c protections. However, a s t h e f o l l o w i n g s t a t i s t i c s r e v e a l , n o t a l l e m p l o y e r s o f f e r h e a l t h b e n e f i t s a n d , when o f f e r e d , n o t a l l employees a c c e p t them. Some a n a l y s t s a r g u e t h a t t h e d e c l i n e i n c o v e r a g e i s d u e t o t h e s h i f t i n g o f o u r economy from j o b s t h a t c a r r y h e a l t h i n s u r a n c e t o o n e s I t i s t r u e t h a t while c i v i l i a n , n o n a g r i c u l t u r a l jobs t h a t do n o t . i n c r e a s e d by a b o u t 7% between 1982 and 1985, t h e number o f j o b s w i t h h e a l t h i n s u r a n c e prov'ided by a n employer i n c r e a s e d by l e s s t h a n 5%. However, more i m p o r t a n t may be c h a n g i n g d e m o g r a p h i c s . For example, t h e r e a p p e a r s t o b e an i n c r e a s e i n t h e number of young a d u l t s w i t h o u t h e a l t h i n s u r a n c e l i v i n g i n h o u s e h o l d s i n which t h e p a r e n t s have i n s u r a n c e . In a d d i t i o n , dependent coverage has d e c l i n e d . E B R I ' S May 1987 a n a l y s i s of CPS d a t a on t h e working u n i n s u r e d r e v e a l t h a t i n 1985, 17 m i l l i o n w o r k e r s ( o r a b o u t 15% of t h e n o n - a g r i c u l t u r a l , c i v i l i a n work f o r c e ) r e p o r t e d no c o v e r a g e from a n employer p l a n . Of t h a t number, 10.2 m i l l i o n were t h e head of a f a m i l y (meaning t h e f a m i l y member w i t h t h e g r e a t e s t e a r n i n g s o r an i n d i v i d u a l w i t h o u t a f a m i l y ) . A n o t h e r 6 . 8 m i l l i o n were o t h e r f a m i l y w o r k e r s and n o t t h e head o f t h e h o u s e h o l d . The m a j o r i t y o f u n c o v e r e d w o r k e r s were low wage e a r n e r s . I n 1985, 75% o f a l l u n i n s u r e d w o r k e r s e a r n e d l e s s t h a n $10,000; 93% e a r n e d l e s s t h a n $ 2 0 , 0 0 0 . More t h a n 35% o f a l l u n i n s u r e d w o r k e r s e a r n e d , on a v e r a g e , l e s s t h a n t h e F e d e r a l minimum wage i n 1985; 50% of a l l u n i n s u r e d w o r k e r s e a r n e d l e s s t h a n 125% of t h e minimum wage. Most of t h e s e i n d i v i d u a l s worked f u l l - t i m e . I t i s a l s o u s e f u l t o l o o k a t t h e working u n i n s u r e d a c c o r d i n g t o t h e i r p r i m a r y s o u r c e o f employment. According t o E B R I , w o r k e r s i n c e r t a i n employment s e c t o r s a r e r o u g h l y 50% more l i k e l y t o have no h e a l t h i n s u r a n c e c o v e r a g e t h a n t h e a v e r a g e American worker u n d e r a g e 65. These i n c l u d e w o r k e r s i n r e t a i l t r a d e ; s e r v i c e s ( b u s i n e s s , r e p a i r , e n t e r t a i n m e n t and p e r s o n a l ) ; and c o n s t r u c t i o n . Also i n c l u d e d i n t h i s c a t e g o r y a r e t h e self-employed. Workers i n o t h e r employment s e c t o r s ( i n c l u d i n g manufacturing, finance, t r a n s p o r t a t i o n , and w h o l e s a l e t r a d e ) l a c k i n s u r a n c e c o v e r a g e o n l y o n e - t h i r d t o one-half a s o f t e n a s w o r k e r s i n t h e a b o v e employment s e c t o r s . The Move Toward Mandated H e a l t h B e n e f i t s S i n c e t h e e a r l y y e a r s of t h i s c e n t u r y , n a t i o n a l h e a l t h i n s u r a n c e h a s been a h o t l y d e b a t e d i s s u e i n t h e U n i t e d S t a t e s . While i n t h e l a t e 1960s and 1 9 7 0 s , t h e d e b a c e r e v o l v e d around w h e t h e r t o e n a c t a program of u n i v e r s a l n a t i o n a l h e a l t h c o v e r a g e , i n t h e 1980s t h e e m p h a s i s h a s been on incremental expansions of h e a l t h i n s u r a n c e coverage. P r o p o s a l s have f o c u s e d on e x p a n d i n g c o v e r a g e f o r s p e c i f i c segments of t h e p o p u l a t i o n ( s u c h a s l a i d - o f f w o r k e r s , low-income e l d e r l y , and c h i l d r e n ) and f o r p e o p l e who, b e c a u s e o f a m a j o r p r e - e x i s t i n g h e a l t h c o n d i t i o n , a r e u n a b l e t o o b t a i n h e a l t h i n s u r a n c e through t h e p r i v a t e market. Faced w i t h s u b s t a n t i a l F e d e r a l budget d e f i c i t s and an a p p a r e n t d i m i n i s h e d i n t e r e s t i n Government-financed s o l u t i o n s , Congress h a s begun t o l o o k t o e m p l o y e r s a s a p o t e n t i a l s o u r c e of expanding a c c e s s t o h e a l t h i n s u r a n c e coverage. One a p p r o a c h g a i n i n g some s u p p o r t i n Congress f a l l s u n d e r t h e g e n e r a l h e a d i n g of e m p l o y e r mandates. Under t h i s a p p r o a c h , t h e F e d e r a l Government would mandate t h a t e m p l o y e r s ( p r i v a t e e m p l o y e r s a s w e l l a s S t a t e and l o c a l governments) provide i n s u r a n c e coverage and/or s p e c i f i c h e a l t h b e n e f i t s t o t h e i r employees a n d , i n some c a s e s , a l s o t o t h e i r e m p l o y e e s ' f a m i l i e s . This approach i s c o n s i s t e n t with t h e c u r r e n t r e a l i t y t h a t i n t h e United S t a t e s , h e a l t h i n s u r a n c e f o r a l l b u t t h e o l d , d i s a b l e d , and v e r y p o o r , i s p r i m a r i l y obt'ained through an employer's group plan. I n t h e 9 9 t h C o n g r e s s , l e g i s l a t i o n was e n a c t e d t h a t r e q u i r e d c e r t a i n e m p l o y e r s t o o f f e r c o n t i n u e d h e a l t h i n s u r a n c e c o v e r a g e t o t h e i r employees who would o t h e r w i s e l o s e c o v e r a g e f o r c e r t a i n r e a s o n s . Also, c e r t a i n e m p l o y e r s were r e q u i r e d t o o f f e r t h e i r M e d i c a r e - e l i g i b l e d i s a b l e d w o r k e r s primary coverage under t h e employers' h e a l t h i n s u r a n c e plans. In the 100th Congress, t h e r e i s i n t e r e s t i n r e q u i r i n g t h a t employers p r o v i d e b a s i c o r c a t a s t r o p h i c h e a l t h insurance coverage. I s s u e s R e l a t e d t o Mandating E m p l o y e r P r o v i d e d H e a l t h I n s u r a n c e The d e b a t e o v e r mandating t h a t e m p l o y e r s p r o v i d e h e a l t h i n s u r a n c e r a i s e s p h i l o s o p h i c a l i s s u e s s u c h a s t h e n a t u r e of a n e m p l o y e r ' s o b l i g a t i o n t o h i s o r h e r employees, and w h e t h e r i t i s a p p r o p r i a t e f o r t h e F e d e r a l government t o r e q u i r e t h a t e m p l o y e r s o f f e r i n s u r a n c e . In addition, it r a i s e s q u e s t i o n s a b o u t t h e p o t e n t i a l economic e f f e c t s of m a n d a t e s on e m p l o y e r s a s w e l l a s on t h e h e a l t h o f t h e n a t i o n a l economy. The Q u e s t i o n o f Employer R e s p o n s i b i l i t y P r o p o n e n t s of mandatory employer-provided h e a l t h i n s u r a n c e a r g u e t h a t e m p l o y e r s have a b a s i c o b l i g a t i o n t o e n s u r e t h a t t h e i r employees h a v e a c c e s s t o h e a l t h i n s u r a n c e j u s t a s t h e y have an o b l i g a t i o n t o p r o v i d e a l i v e a b l e wage. They a s s e r t t h a t a minimum h e a l t h b e n e f i t s l a w s h o u l d be e s t a b l i s h e d i n t h e same manner a s t h e F e d e r a l Government h a s e s t a b l i s h e d a minimum wage law. They s a y t h a t i t w i l l u l t i m a t e l y l o w e r t h e N a t i o n ' s In h e a l t h b i l l b e c a u s e more p e o p l e w i l l h a v e a c c e s s t o h e a l t h c a r e . a d d i t i o n , t h e y a r g u e t h a t r e q u i r i n g employers t o p r o v i d e coverage i s i n k e e p i n g w i t h t h e N a t i o n ' s heavy r e l i a n c e on e m p l o y m e n t - r e l a t e d i n s u r a n c e . They f u r t h e r a s s e r t t h a t r e l y i n g on p r i v a t e r a t h e r t h a n governmentp r o v i d e d i n s u r a n c e b u i l d s upon o u r N a t i o n ' s t r a d i t i o n of l e a v i n g h e a l t h i n s u r a n c e t o t h e c o m p e t i t i v e market place. Proponents a l s o argue t h a t t h i s approach w i l l i n c r e a s e e q u i t y a c r o s s e m p l o y e r s and t a x p a y e r s . C u r r e n t l y , h e a l t h i n s u r a n c e premiums a r e p r i c e d t o i n c l u d e n o t only t h e d i r e c t c o s t of providing h e a l t h c a r e s e r v i c e s t o t h e e m p l o y e r ' s w o r k e r s , b u t a l s o o t h e r c o s t s b o r n e by t h e p r o v i d e r s of h e a l t h c a r e f o r uninsured o r underinsured i n d i v i d u a l s , a s u b s t a n t i a l p o r t i o n o f which a r e u n i n s u r e d w o r k e r s . Employers who a r e p a y i n g f o r h e a l t h c a r e c o v e r a g e f o r t h e i r employees a r e t h u s s u b s i d i z i n g t h o s e e m p l o y e r s who a r e n o t p a y i n g f o r c o v e r a g e . F i n a l l y , p r o p o n e n t s a r g u e t h a t e m p l o y e r s who p r o v i d e h e a l t h b e n e f i t s a r e a l s o s u b s i d i z i n g o t h e r e m p l o y e r s by i n s u r i n g many of t h e l a t t e r ' s workers through family coverage. According t o EBRI ( b a s e d on March 1986 CPS d a t a ) , 16.7 m i l l i o n working Americans r e c e i v e c o v e r a g e t h r o u g h e m p l o y e r s f o r whom t h e y a r e n o t d i r e c t l y working. Moreover, i n d i v i d u a l s who a r e n o t o f f e r e d i n s u r a n c e by t h e i r e m p l o y e r s a r e p a y i n g some o f t h e $30 b i l l i o n i n t a x e s t h a t a r e used t o s u b s i d i z e ( t h r o u g h t a x e x p e n d i t u r e s ) h e a l t h i n s u r a n c e f o r o t h e r , g e n e r a l l y higher-paid workers. The o p p o n e n t s o f mandatory employer-provided h e a l t h i n s u r a n c e c o u n t e r by a r g u i n g t h a t e m p l o y e r s have no i n h e r e n t o b l i g a t i o n t o p r o v i d e h e a l t h benefits. They a s s e r t t h a t t h e i n d i v i d u a l h a s a responsibility t o purchase i n s u r a n c e i n t h e p r i v a t e market. For t h o s e i n d i v i d u a l s who c a n n o t a f f o r d t o pay f o r h e a l t h i n s u r a n c e , t h e n t h e p u b l i c s e c t o r s h o u l d p r o v i d e a minimum l e v e l of h e a l t h c a r e . Moreover, o p p o n e n t s a r g u e t h a t a n e m p l o y e r ' s d e c i s i o n t o p r o v i d e i n s u r a n c e o r t o p r o v i d e a s p e c i f i c s e t of h e a l t h b e n e f i t s s h o u l d n o t be d i c t a t e d by t h e Government. Rather, i t is labor-management n e g o t i a t i o n s o r f r e e - m a r k e t c o m p e t i t i o n among i n s u r e r s vying f o r employers' business t h a t should determine whether employers p r o v i d e i n s u r a n c e and i f s o what h e a l t h s e r v i c e s s h o u l d be c o v e r e d u n d e r the policy. Such r e l i a n c e on t h e m a r k e t p l a c e w i l l a l s o e n s u r e g r e a t e r e f f i c i e n c i e s i n t h e s u p p l y and demand of h e a l t h c o v e r a g e and s e r v i c e s , t h u s h e l p i n g t o h o l d down c o s t s . T h e r e a r e a l s o t h o s e who r e j e c t mandates b e c a u s e t h e y would, i n t h e i r view, u n d e r m i n e t h e v o l u n t a r y n a t u r e of e m p l o y e r - p r o v i d e d health insurance. They a r g u e t h a t t h e m a j o r i t y of e m p l o y e r s a l r e a d y p r o v i d e coverage; i t i s a b e n e f i t t h a t t h e s e employers have p r i v a t e l y chosen t o p r o v i d e i n a form t h a t i s most a p p r o p r i a t e t o t h e i r own employees. Some e m p l o y e r s who a l r e a d y i n s u r e t h e i r employees a r g u e t h a t a F e d e r a l law m a n d a t i n g t h a t e m p l o y e r s p r o v i d e i n s u r a n c e ( p a r t i c u l a r l y i f t h a t law were t o r e q u i r e a b a s i c minimum l e v e l of b e n e f i t s ) would r e s u l t i n h i g h e r employee b e n e f i t c o s t s and new a d m i n i s t r a t i v e b u r d e n s . C r i t i c s o f mandated employer-provided c o v e r a g e a l s o a r g u e t h a t s u c h a p o l i c y might i n c r e a s e t h e c o s t s of l a b o r t o t h e p o i n t where c o m p a n i e s , e s p e c i a l l y s m a l l e r o n e s , would r e d u c e t h e i r l a b o r f o r c e o r r e d u c e wages. The Small B u s i n e s s Health insurance is a r e l a t i v e l y expensive benefit. A d m i n i s t r a t i o n (SBA) r e p o r t s a v e r a g e employer h e a l t h c a r e c o s t s t o t . a l l e d F o r t h e 35% of $1,500 ( r o u g h l y 7 5 c e n t s p e r h o u r ) p e r worker i n 1986. u n i n s u r e d w o r k e r s who a r e p a i d l e s s t h a n t h e minimum wage ($3.35 i n 1 9 8 7 ) , t h e added h o u r l y c o s t of a h e a l t h i n s u r a n c e b e n e f i t c o u l d b e p r o h i b i t i v e , even i f t h e employee were r e q u i r e d t o pay a s h a r e of t h e premium. A l t h o u g h a mandated i n s u r a n c e package might be l e s s c o m p r e h e n s i v e and t h e r e f o r e l e s s e x p e n s i v e t h a n t h e a v e r a g e p o l i c y c i t e d by t h e SBA, i t c o u l d s t i l l p r o d u c e r e d u c t i o n s i n t h e employment o f low wage w o r k e r s a s employers a t t e m p t t o a d j u s t t o h i g h e r l a b o r c o s t s . Mandated EmployerProvided Insurance and Competitiveness I n a d d i t i o n t o t h e d e b a t e a b o u t employer r e s p o n s i b i l i t y , t h e r e i s a d i f f e r e n t s e t of i s s u e s r e l a t i n g t o t h e p o t e n t i a l e f f e c t s of m a n d a t i n g b e n e f i t s on e m p l o y e r s ' a b i l i t y t o compete i n d o m e s t i c and w o r l d m a r k e t s . Much of t h e a n a l y s e s o f t h e s e e f f e c t s i s s p e c u l a t i v e ; however, t h e b a s i c a r g u m e n t s t e n d t o be a r t i c u l a t e d a s f o l l o w s . Opponents o f mandated employer-provided h e a l t h c o v e r a g e s a y t h a t mandated i n s u r a n c e would d r i v e up t h e c o s t o f d o i n g b u s i n e s s and r e d u c e t h e a b i l i t y of f i r m s t o compete, b o t h i n t h e d o m e s t i c and w o r l d m a r k e t s . I n d u s t r i e s t h a t compete a g a i n s t f o r e i g n m a n u f a c t u r e r s ( e s p e c i a l l y t h o s e from c e r t a i n T h i r d World n a t i o n s ) a r e competing a g a i n s t e m p l o y e r s who do n o t a s a r u l e p r o v i d e h e a l t h and o t h e r f r i n g e b e n e f i t s . This helps f o r e i g n m a n u f a c t u r e r s t o h o l d t h e i r p r i c e s down. Small e m p l o y e r s , e s p e c i a l l y , b e l i e v e t h a t m a n d a t i n g h e a l t h i n s u r a n c e c o v e r a g e might c a u s e them t o l o s e w h a t e v e r c o m p e t i t i v e edge t h e y may have s i n c e t h e y would h a v e t o o f f s e t t h e c o s t o f t h e new b e n e f i t s by r a i s i n g t h e i r p r i c e s . While many s m a l l e r f i r m s do n o t d i r e c t l y e n g a g e i n i n t e r n a t i o n a l t r a d e , some p r o p o r t i o n of them a r e s u p p l i e r s t o l a r g e companies t h a t do compete internationally. H i g h e r c o s t s f o r a s u p p l i e r a f f e c t t h e c o s t s of t h e purchasing firms: i f h e a l t h i n s u r a n c e c o v e r a g e were r e q u i r e d , s m a l l e m p l o y e r s might p a s s t h e c o s t of t h e c o v e r a g e o n t o t h e i r c l i e n t s . This r e a s o n i n g i s a l s o extended t o domestic competition. 1887 168 CRS- 7 10-1 1-88 P r o p o n e n t s o f mandated b e n e f i t s d i s m i s s t h e c o m p e t i t i v e n e s s argument I n t h e i r eyes, it i s not a r e a l i s s u e b e c a u s e t h e companies t h a t a r e s t r u g g l i n g t o m a i n t a i n t h e i r c o m p e t i t i v e e d g e ( s u c h a s t h e a u t o m a n u f a c t u r e r s ) a r e t h e v e r y companies t h a t a l r e a d y provide h e a l t h insurance. The m a j o r i t y of t h e working u n i n s u r e d a r e n o t f o u n d i n t h e t r a n s p o r t a t i o n and m a n u f a c t u r i n g i n d u s t r i e s b u t i n t h e s e r v i c e and r e t a i l t r a d e i n d u s t r i e s , which a r e c o m p a r a t i v e l y u n a f f e c t e d by foreign competition. I t i s t h e s e l a t t e r i n d u s t r i e s t h a t have experienced t h e most g r o w t h s i n c e 1979: t h e s e r v i c e s i n d u s t r y i s p r o j e c t e d by t h e Bureau of Labor S t a t i s t i c s t o i n c r e a s e from a b o u t 21% of t o t a l U.S. j o b s i n 1979 t o o v e r 26% i n 1995; t h e r e t a i l t r a d e i n d u s t r y i s p r o j e c t e d t o i n c r e a s e f r o m 22% t o 23% o v e r t h e same p e r i o d . M a n u f a c t u r i n g and t r a n s p o r t a t i o n , which have t r a d i t i o n a l l y c o v e r e d most of t h e i r w o r k e r s , a r e predicted t o decline. These s t a t i s t i c s n o t e d , mandated b e n e f i t s p r o p o n e n t s c o n c l u d e t h a t t h e r e a r e more c r i t i c a l v a r i a b l e s , s u c h a s e x c h a n g e r a t e s , u n d e r m i n i n g American c o m p e t i t i v e n e s s t h a n t h e c o s t t o American f i r m s o f t h e i r employee b e n e f i t packages. as i n v a l i d o r n o t c o m p e l l i n g . Small Employers and Mandated Employer-kovided Health Insurance I t i s o f t e n assumed t h a t s m a l l e r e m p l o y e r s a r e l e s s l i k e l y t o o f f e r h e a l t h ' b e n e f i t s b e c a u s e o f t h e h i g h c o s t s of premiums, a d m i n i s t r a t i v e b u r d e n s and t h e p e r c e p t i o n t h a t w o r k e r s p r e f e r c a s h wages t o b e n e f i t s . E s t i m a t e s p l a c e t h e c o s t s of i n s u r a n c e f o r small e m p l o y e r s a t anywhere from 1 0 t o 40% h i g h e r t h a n f o r l a r g e e m p l o y e r s . The SBA r e p o r t s t h a t v e r y small f i r m s t h a t do n o t o f f e r h e a l t h b e n e f i t s spend a b o u t 7% o f p a y r o l l on fringe benefits. Those which do o f f e r c o v e r a g e spend 10%. A c c o r d i n g t o t h e SBA, i n 1986, 46% o f f i r m s w i t h f e w e r t h a n 10 work. e r s o f f e r e d h e a l t h b e n e f i t s , compared t o 78% w i t h 10 t o 24 w o r k e r s , of f i r m s w i t h 25 t o 99, 98% o f f i r m s w i t h 100 t o 4 9 9 , and 100% o f f i r m s w i t h 500 o r more w o r k e r s . 84% of a l l w o r k e r s who worked . f o r e m p l o y e r s w i t h o u t h e a l t h p l a n s worked i n f i r m s w i t h l e s s t h a n 25 employees. Based on s u r v e y s and o t h e r s t u d i e s , t h e SBA h a s c o n c l u d e d t h a t s m a l l e r employers tend n o t t o o f f e r h e a l t h i n s u r a n c e because t h e y ( a ) f a c e h i g h e r p e r worker premiums s i n c e t h e r i s k f o r i n s u r e r s i s s p r e a d o v e r f e w e r p e r s o n s ; ( b ) do n o t b e n e f i t t o t h e same e x t e n t a s l a r g e r f i r m s from t h e t a x advantages associated with o f f e r i n g h e a l t h insurance; (c) e x p e r i e n c e h i g h e r f i x e d c o s t s i n c h o o s i n g and a d m i n i s t e r i n g a h e a l t h p l a n ; ( d l h a v e r e l a t i v e l y h i g h e r worker t u r n o v e r r a t e s and a g r e a t e r u s e of p a r t - t i m e and s e a s o n a l employees which i n c r e a s e t h e i r a d m i n i s t r a t i v e f e e s r e l a t i v e t o t h e f e e s c h a r g e d f o r l a r g e r f i r m s ; and ( e ) t e n d t o h a v e n a r r o w e r p r o f i t m a r g i n s from which t o pay r e l a t i v e l y h i g h e r premiums. A s s o c i a t i o n s r e p r e s e n t i n g small e m p l o y e r s u s e s u c h f i n d i n g s t o a r g u e t h a t f o r c i n g small employers t o o f f e r h e a l t h i n s u r a n c e w i l l r e s u l t i n h i g h e r p r i c e s , l o w e r wages, more b u s i n e s s f a i l u r e s and f e w e r j o b s . They c o n t e n d t h a t s m a l l f i r m s s i m p l y c a n n o t spend more o f t h e i r r e c e i p t s on employee b e n e f i t s . A n o t h e r argument u s e d a g a i n s t mandated c o v e r a g e f o r s m a l l e m p l o y e r s i s t h a t low-wage w o r k e r s p r e f e r t o r e c e i v e c a s h b e n e f i t s o r a r e a l r e a d y c o v e r e d i n d i r e c t l y t h r o u g h a f a m i l y member's i n s u r a n c e p o l i c y , and s h o u l d n o t be f o r c e d t o a c c e p t r e d u c e d e a r n i n g s . However, an SBA s u r v e y of e m p l o y e r s found t h a t 14% o f e l i g i b l e w o r k e r s i n s m a l l f i r m s ( l e s s t h a t 10 e m p l o y e e s ) which o f f e r c o v e r a g e t u r n i t down, compared t o t h e 13% a v e r a g e across a l l firms. Many p r o p o n e n t s o f mandated c o v e r a g e a g r e e t h a t s m a l l e m p l o y e r s m i g h t be a d v e r s e l y a f f e c t e d i f t h e y were r e q u i r e d t o o f f e r ( a s w e l l a s pay some portion o f ) health insurance. They s u g g e s t , however, t h a t p o t e n t i a l problems f o r s m a l l e m p l o y e r s c o u l d be reduced t h r o u g h mechanisms d e s i g n e d t o l o w e r b o t h t h e c o s t s and t h e a d m i n i s t r a t i v e b u r d e n s o f o f f e r i n g h e a l t h insurance. T h e s e mechanisms a r e g e n e r a l l y d e s i g n e d t o p o o l l a r g e numbers of s m a l l e m p l o y e r s i n one l a r g e g r o u p , e n a b l i n g them t o o b t a i n h e a l t h i n s u r a n c e a t l o w e r c o s t s . For example, t h e C o u n c i l of S m a l l e r E n t e r p r i s e s (COSE) i n C l e v e l a n d , Ohio, a r r a n g e s w i t h a number of i n s u r a n c e companies g r o u p h e a l t h i n s u r a n c e f o r a b o u t 4500 f i r m s , which i n t u r n p r o v i d e i n s u r a n c e t o more t h a n 100,000 employees. COSE i s a b l e t o n e g o t i a t e l e s s e x p e n s i v e p o l i c i e s t h a n would o t h e r w i s e be a v a i l a b l e t o t h e s e e m p l o y e r s i f t h e y s o u g h t t h e i n s u r a n c e on t h e i r own. Such p o o l i n g mechanisms have been employed w i t h mixed s u c c e s s . O b s e r v e r s s a y t h a t t h e y a r e n o t a s e f f e c t i v e f o r t h e smallest e m p l o y e r s , which a r e s t i l l s u b j e c t t o m e d i c a l u n d e r w r i t i n g . They a l s o t e n d n o t t o a t t r a c t t h o s e e m p l o y e r s who have n e v e r o f f e r e d c o v e r a g e . In addition, t h e i r e f f e c t i v e n e s s i n h o l d i n g down premium r a t e s i s l i m i t e d by t h e v o l a t i l i t y of t h e s m a l l g r o u p i n s u r a n c e m a r k e t . However t h e s e p r o b l e m s l a r g e 1 y c o u l d be e l i m i n a t e d i f e m p l o y e r s w e r e r e q u i r e d t o p a r t i c i p a t e i n t h e pool. U n d e r i n s u r a n c e and C a t a s t r o p h i c Coverage Some a n a l y s t s a d v o c a t e t h a t a n a p p r o p r i a t e compromise between t h e two e x t r e m e s of d o i n g n o t h i n g and mandating t h a t a l l e m p l o y e r s o f f e r h e a l t h i n s u r a n c e i s t o r e q u i r e t h a t a l l employers o f f e r coverage under a catastrophic i l l n e s s policy. These p o l i c i e s p r o v i d e c o v e r a g e f o r o n l y very l a r g e medical expenses a f t e r t h e b e n e f i c i a r y has paid a l a r g e d e d u c t i b l e ; t h e premium c o s t o f s u c h c o v e r a g e i s , however, g e n e r a l l y l o w e r t h a n f o r more c o m p r e h e n s i v e p o l i c i e s . A c a t a s t r o p h i c i l l n e s s p o l i c y would e n s u r e p r o t e c t i o n of i n d i v i d u a l s a g a i n s t t h e d e v a s t a t i n g f i n a n c i a l b u r d e n s On of a m a j o r i l l n e s s b u t would be l e s s c o s t l y f o r e m p l o y e r s t o o f f e r . t h e o t h e r h a n d , s u c h a n a p p r o a c h would n o t a d d r e s s t h e n e e d o f t h e medically uninsured f o r basic health services. H i s t o r y o f F e d e r a l Employer Mandates The F e d e r a l Government h a s t r a d i t i o n a l l y l e f t t h e r e g u l a t i o n of ~ c c o r d i n g t o Blue C r o s s and B l u e S h i e l d insurance t o the states. A s s o c i a t i o n , t h e r e a r e o v e r 600 State-mandated b e n e f i t l a w s g o v e r n i n g health insurance. They i n c l u d e s p e c i f i c s e r v i c e s ( e . g . , maternity c o v e r a g e and newborn c a r e ) , t h e s e r v i c e s of s p e c i f i c p r o v i d e r s ( e . g . , d e n t i s t s and c h i r o p r a c t o r s ) , a s w e l l a s r e q u i r e m e n t s t h a t p l a n s p r o v i d e f o r c o n t i n u a t i o n and c o n v e r s i o n o p t i o n s . The S t a t e s v a r y i n t h e numbers and t y p e s of mandates. Some o b s e r v e r s i n t h e b u s i n e s s and i n s u r a n c e communi t i - e s c o n t e n d t h a t t h e s e mandated b e n e f i t l a w s a r e l a r g e l y r e s p o n s i b l e f o r t h e h i g h c o s t s of h e a l t h i n s u r a n c e . Advocates of S t a t e m a n d a t e s s a y t h a t t h e y i n c r e a s e a c c e s s t o n e e d e d h e a l t h s e r v i c e s and e n c o u r a g e g r e a t e r freedom o f c h o i c e o f p r o v i d e r s , which i n t u r n promotes c o m p e t i t i o n and l o w e r s h e a l t h c a r e c o s t s . While t h e b u s i n e s s o f i n s u r a n c e h a s been l e f t l a r g e l y t o t h e S t a t e s t o r e g u l a t e , employee w e l f a r e b e n e f i t p l a n s a r e g o v e r n e d by t h e Employee R e t i r e m e n t Income S e c u r i t y Act (ERISA), a F e d e r a l l a w e n a c t e d i n 1974. ( H a w a i i i s an e x c e p t i o n . ERISA was amended t o a l l o w Hawaii t o c o n t i n u e i t s law r e q u i r i n g e m p l o y e r s t o p r o v i d e h e a l t h i n s u r a n c e c o v e r a g e . ) I n c l u d e d u n d e r employee w e l f a r e b e n e f i t p l a n s a r e s e l f - i n s u r e d h e a l t h p l a n s , where t h e employer assumes t h e r i s k f o r p a y i n g c l a i m s , i n s t e a d of p a y i n g premiums t o a n i n s u r a n c e company which i n t u r n assumes t h e r i s k . T h u s , w h i l e t r a d i t i o n a l l y i n s u r e d companies a r e a f f e c t e d by S t a t e m a n d a t e s , s e l f - i n s u r e d companies a r e r e g u l a t e d by ERISA. ERISA r e g u l a t e s s u c h a s p e c t s of w e l f a r e b e n e f i t p l a n s a s p l a n d i s c l o s u r e , b u t u n t i l r e c e n t l y , e m p l o y e r s u n d e r ERISA were r e l a t i v e l y f r e e t o s t r u c t u r e p l a n s a s t h e y d e s i r e d o r , i f t h e i r employees were r e p r e s e n t e d by a u n i o n , t h r o u g h A s d i s c u s s e d below, t h i s changed w i t h t h e c o l l e c t i v e bargaining process. t h e e n a c t m e n t of T i t l e X o f t h e C o n s o l i d a t e d Omnibus Budget R e c o n c i l i a t i o n Act (COBRA, P.L. 99-272). I n t h e 1 9 7 0 s , c h a n g e s were made i n F e d e r a l law t o mandate t h a t e m p l o y e r s o f f e r i n g h e a l t h i n s u r a n c e meet s p e c i f i c r e q u i r e m e n t s . For example, t h e H e a l t h Maintenance O r g a n i z a t i o n Act o f 1973 (P.L. 93-222) r e q u i r e s t h a t c e r t a i n e m p l o y e r s w i t h 25 o r more employees o f f e r a n HMO o p t i o n i n t h e i r h e a l t h p l a n i f a q u a l i f i e d HMO e x i s t s i n t h e i r a r e a . In 1 9 7 8 , C o n g r e s s amended t h e C i v i l R i g h t s Act t o e x t e n d t h e p r o h i b i t i o n a g a i n s t s e x d i s c r i m i n a t i o n i n employment t o i n c l u d e d i s c r i m i n a t i o n on t h e b a s i s o f p r e g n a n c y , c h i l d b i r t h , o r r e l a t e d m e d i c a l c o n d i t i o n s (P.L. 95-555). A s a r e s u l t , employer h e a l t h p l a n s must t r e a t women a f f e c t e d by t h e s e c o n d i t i o n s s i m i l a r l y t o o t h e r e m p l o y e e s , b a s e d on t h e i r a b i l i t y o r i n a b i l i t y t o work. P r o p o s a l s t o mandate e m p l o y e r s t o p r o v i d e c o v e r a g e d a t e b a c k t o t h e Nixon A d m i n i s t r a t i o n . The C a r t e r A d m i n i s t r a t i o n d e v e l o p e d 1 e g i s l a t i o n . t o r e q u i r e e m p l o y e r s t o p r o v i d e b a s i c h e a l t h i n s u r a n c e a s a n employee benefit. The C a r t e r p r o p o s a l would have a l s o expanded F e d e r a l programs t o I t was i n c l u d e t h o s e who r e m a i n uncovered u n d e r employer p l a n s . c r i t i c i z e d by r e p r e s e n t a t i v e s of s m a l l b u s i n e s s who a r g u e d t h a t r e q u i r i n g them t o p r o v i d e i n s u r a n c e would add s i g n i f i c a n t l y t o t h e i r l a b o r c o s t s and threaten their viability. I t a l s o f e l l v i c t i m t o t h e absence of consensus among o t h e r h e ~ l t hp o l i c y a c t o r s . F e d e r a l m a n d a t e s on e m p l o y e r s who p r o v i d e h e a l t h c o v e r a g e h a v e c o n t i n u e d i n t o t h e 1980s. I n a d d i t i o n , new e f f o r t s h a v e been made t o b r o a d e n t h e s c o p e of t h e mandates t o t h o s e e m p l o y e r s who do n o t a l r e a d y o f f e r health insurance. T i t l e X o f COBRA The p a s s a g e of T i t l e X of t h e C o n s o l i d a t e d Omnibus Budget ' R e c o n c i l i a t i o n Act (COBRA) i n A p r i l 1986, marked a m a j o r d e p a r t u r e i n F e d e r a l law and r e g u l a t i o n o f e m p l o y e r s ' w e l f a r e b e n e f i t p l a n s . I t was t h e f i r s t t i m e t h a t t h e F e d e r a l Government mandated a s p e c i f i c b e n e f i t i n employee w e l f a r e b e n e f i t p l a n s . While COBRA d o e s n o t mandate t h a t e m p l o y e r s p r o v i d e h e a l t h i n s u r a n c e , i t d o e s r e q u i r e t h a t e m p l o y e r s w i t h 20 o r more employees who do p r o v i d e h e a l t h b e n e f i t s o f f e r q u a l i f i e d e m p l o y e e s and t h e i r f a m i l i e s t h e o p t i o n of c o n t i n u e d h e a l t h i n s u r a n c e a t g r o u p r a t e s when f a c e d w i t h l o s s o f t h e i r c o v e r a g e b e c a u s e o f c e r t a i n q u a l i f y i n g events. Under COBRA, t h e q u a l i f y i n g e v e n t s i n c l u d e t e r m i n a t i o n o r r e d u c t i o n i n h o u r s o f employment, d e a t h , d i v o r c e , e l i g i b i l i t y f o r M e d i c a r e , o r t h e end of a c h i l d ' s dependency u n d e r a p a r e n t ' s h e a l t h i n s u r a n c e p o l i c y . When a c o v e r e d employee e x p e r i e n c e s t e r m i n a t i o n o r r e d u c t i o n o f h o u r s of employment, t h e n t h e c o v e r a g e o f t h e employee and a n y q u a l i f i e d b e n e f i c i a r i e s must c o n t i n u e f o r 18 months. For a l l t h e o t h e r q u a l i f y i n g e v e n t s , t h e c o v e r a g e f o r t h e q u a l i f i e d b e n e f i c i a r i e s must be c o n t i n u e d f o r 36 months. The e m p l o y e r ' s h e a l t h p l a n may r e q u i r e t h e employee o r b e n e f i c i a r y t o pay t h e premium f o r t h e c o n t i n u a t i o n c o v e r a g e , b u t t h e premium may n o t e x c e e d 102% o f t h e o t h e r w i s e a p p l i c a b l e premium f o r t h a t period. ( S e e a l s o CRS I s s u e B r i e f 87182, P r i v a t e H e a l t h I n s u r a n c e C o n t i n u a t i o n Coverage, by Beth C. Fuchs. ) F a i l u r e t o provide continued h e a l t h coverage could r e s u l t i n t h e l o s s of t a x d e d u c t i b i l i t y f o r employer c o n t r i b u t i o n s t o t h e i r e m p l o y e e s ' h e a l t h i n s u r a n c e , and p e n a l t i e s u n d e r ERISA. I n a d d i t i o n t o t h e new r e q u i r e m e n t s imposed on p r i v a t e s e c t o r e m p l o y e r s , T i t l e X o f COBRA a l s o imposes s i m i l a r r e q u i r e m e n t s on g r o u p h e a l t h p l a n s m a i n t a i n e d by a n y s t a t e o r p o l i t i c a l s u b d i v i s i o n t h a t r e c e i v e s f u n d s u n d e r t h e P u b l i c H e a l t h S e r v i c e Act. I n t h e Tax Reform Act o f 1986 (P.L. 99-5141, C o n g r e s s i n c l u d e d a Some of t h e number o f t e c h n i c a l c o r r e c t i o n s t o T i t l e X of COBRA. p r o v i s i o n s were c l a r i f i c a t i o n s ; some imposed new p a r a m e t e r s on t h e n a t u r e of t h e c o n t i n u e d h e a l t h i n s u r a n c e b e n e f i t . I n 1986, C o n g r e s s a l s o c o n s i d e r e d a d d i t i o n a l e x p a n s i o n s o f COBRA. For example, u n d e r S. 2402 (Kennedy), S. 2403 ( D u r e n b e r g e r ) and H.R. 4742- ( S t a r k ) , COBRA would h a v e been amended t o r e q u i r e e m p l o y e r s t o p r o v i d e c o n t i n u e d h e a l t h c o v e r a g e t o While t h e s e l a i d - o f f w o r k e r s f o r 4 months a t t h e e m p l o y e r ' s e x p e n s e . m e a s u r e s d i d n o t p a s s , C o n g r e s s d i d p r o v i d e i n t h e Omnibus Budget R e c o n c i l i a t i o n Act of 1986 (P.L. 99-509) a n e x p a n s i o n of T i t l e X t o r e q u i r e c o n t i n u a t i o n c o v e r a g e f o r r e t i r e e s i n c a s e s where t h e e m p l o y e r f i l e s f o r bankruptcy. ( S e e CRS I s s u e B r i e f 87182.) M e d i c a r e Working Aged and Working D i s a b l e d S e c o n d a r y P a y e r R e q u i r e m e n t s A d i f f e r e n t t y p e of employer mandate was l e g i s l a t e d t h r o u g h c h a n g e s i n t h e M e d i c a r e program and amendments t o t h e Age D i s c r i m i n a t i o n i n Employment Act of 1967. P r i o r t o 1982, e m p l o y e r s g e n e r a l l y u s e d M e d i c a r e coverage a s t h e b a s i c h e a l t h insurance f o r t h e i r Medicare-eligible employees supplemented by an employer-provided p o l i c y which f i l l e d i n g a p s i n t h e Medicare c o v e r a g e . This tended t o e n s u r e t h a t h e a l t h c a r e c o s t s f o r t h e i r o l d e r w o r k e r s were c o n f i n e d t o s u p p l e m e n t a l a s opposed t o b a s i c h e a l t h c a r e coverage. I n 1982, a s p a r t of t h e Tax E q u i t y a n d F i s c a l R e s p o n s i b i l i t y Act (TEFRA, P.L. 97-248), Congress a d o p t e d a p r o p o s a l by t h e Reagan A d m i n i s t r a t i o n t o r e q u i r e t h a t p r i v a t e e m p l o y e r s w i t h 20 o r more e m p l o y e e s , o f f e r t h e i r employees and t h e i r employees' s p o u s e s , a g e 65-69, t h e i r h e a l t h i n s u r a n c e p l a n , which would be t h e p r i m a r y p a y e r f o r a l l c l a i m s . T h i s p r o v i s i o n was a d o p t e d t o r e d u c e M e d i c a r e e x p e n d i t u r e s by s h i f t i n g t h e h e a l t h c a r e c o s t s of o l d e r w o r k e r s o n t o e m p l o y e r s . The II v o r k i n g aged" o r " s e c o n d a r y payer" r e q u i r e m e n t was expanded t h r o u g h subsequent laws. The D e f i c i t R e d u c t i o n Act o f 1984 (DEFRA, P.L. 98-369) expanded t h e s p o u s a l c o v e r a g e t o i n c l u d e a l l b e n e f i c i a r i e s 65-69 w i t h w o r k i n g s p o u s e s u n d e r a g e 65. COBRA, (P.L. 99-272) made M e d i c a r e b e n e f i t s s e c o n d a r y t o t h o s e p a y a b l e u n d e r employer g r o u p p l a n s f o r employed i n d i v i d u a l s a g e 65 o r o v e r , and t h e s p o u s e s a g e 65 o r o l d e r , o f a n y employed i n d i v i d u a l r e g a r d l e s s of age. OBRA (P.L. 99-509) i n c l u d e d a Reagan A d m i n i s t r a t i o n p r o p o s a l r e q u i r i n g e m p l o y e r s w i t h 100 e m p l o y e e s o r more t o o f f e r t h e i r d i s a b l e d w o r k e r s and t h e i r s p o u s e s t h e o p t i o n of c o v e r a g e u n d e r t h e i r e m p l o y e r s ' h e a l t h p l a n as t h e p r i m a r y i n s u r a n c e policy. Bowen C a t a s t r o p h i c Proposal I n November 1986, O t i s Bowen, S e c r e t a r y o f H e a l t h and Human S e r v i c e s , r e l e a s e d a r e p o r t t o P r e s i d e n t Reagan on c a t a s t r o p h i c i l l n e s s e x p e n s e s . T h i s r e p o r t was i n r e s p o n s e t o t h e p r e s i d e n t ' s d i r e c t i v e i n h i s Feb. 6 , 1 9 8 6 , S t a t e o f t h e Union a d d r e s s t h a t t h e S e c r e t a r y r e p o r t t o him "by year-end w i t h r e c o r n e n d a t i o n s on how t h e p r i v a t e s e c t o r and Government c a n work t o g e t h e r t o a d d r e s s t h e problems o f a f f o r d a b l e i n s u r a n c e f o r t h o s e whose l i f e s a v i n g s would o t h e r w i s e be t h r e a t e n e d when c a t a s t r o p h i c i l l n e s s strikes." While t h e Bowen r e p o r t d i s c u s s e s a number o f o p t i o n s t o e n c o u r a g e e m p l o y e r s t o p r o v i d e c a t a s t r o p h i c c o v e r a g e , i t recomnends t h a t S t a t e s It r e q u i r e t h a t such coverage be o f f e r e d i n a l l employment-related p l a n s . s p e c i f i e s t h a t e m p l o y e r s s h o u l d n o t be r e q u i r e d t o f i n a n c e s u c h c o v e r a g e , and a l s o recomnends t h e e x t e n s i o n o f f u l l t a x d e d u c t i o n s f o r h e a l t h i n s u r a n c e t o t h e s e l f - e m p l o y e d and u n i n c o r p o r a t e d b u s i n e s s e s ( c u r r e n t l y a t 25%) a s long a s coverage i s included f o r c a t a s t r o p h i c expenses. A 1 though t h e Reagan Admini s t r a t i o n promoted S e c r e t a r y Bowen's p r o p o s a l s f o r r e s t r u c t u r i n g Medicare t o c o v e r c a t a s t r o p h i c i l l n e s s e x p e n s e s , i t d i d n o t e n d o r s e t h e recommendations i n t h e S e c r e t a r y ' s r e p o r t f o r m a n d a t i n g c a t a s t r o p h i c i l l n e s s i n s u r a n c e u n d e r employerprovided h e a l t h benefit plans. However, some o f t h e s e o p t i o n s h a v e been i n c o r p o r a t e d i n l e g i s l a t i o n i n t r o d u c e d i n t h e 1 0 0 t h C o n g r e s s , s u c h a s H.R. 2300 ( G r a d i s o n ) , which d e n i e s tire t a x d e d u c t i o n f o r e m p l o y e r - p r o v i d e d h e a l t h i n s u r a n c e t o e m p l o y e r s who f a i l t o p r o v i d e c a t a s t r o p h i c c o v e r a g e . Types o f Mandated Coverage Proposals A v a r i e t y of a p p r o a c h e s t o m a n d a t i n g c o v e r a g e a r e i n c o r p o r a t e d i n l e g i s l a t i o n t h a t h a s been i n t r o d u c e d i n r e c e n t y e a r s . While most a r e aimed a t e x p a n d i n g a c c e s s t o b a s i c h e a l t h i n s u r a n c e by m a n d a t i n g t h a t employers provide h e a l t h coverage, o t h e r s s e e k a l s o t o d e f i n e t h e n a t u r e of t h e b e n e f i t s t o be o f f e r e d . There a r e a l s o p r o p o s a l s t h a t r e q u i r e employers t o provide t h e i r e x i s t i n g b e n e f i t packages t o employees, l a i d o f f e m p l o y e e s , r e t i r e e s a n d / o r d e p e n d e n t s who e x p e r i e n c e a c h a n g e i n j o b or family status, F i n a l l y , o t h e r p r o p o s a l s r e q u i r e e m p l o y e r s who a l r e a d y o f f e r i n s u r a n c e t o o f f e r s p e c i f i c b e n e f i t s , s u c h a s well-baby c a r e . D e f i n i n g t h e A p p l i c a t i o n , N a t u r e and Scope o f Uandated H e a l t h B e n e f i t s One o f t h e c o n t r o v e r s i e s i n p r o v i d i n g f o r a n y F e d e r a l mandate i s w h e t h e r o r n o t i t s h o u l d a p p l y t o a l l e m p l o y e r s , and i f n o t , where t h e l i m i t s s h o u l d b e drawn. The Medicare working aged and COBRA T i t l e X p r o v i s i o n s exempt e m p l o y e r s w i t h f e w e r t h a n 20 e m p l o y e e s , a l t h o u g h t h e M e d i c a r e working d i s a b l e d p r o v i s i o n s e n a c t e d i n OBRA o f 1986 (P.L. 99-509) a p p l y t o o n l y t h o s e e m p l o y e r s w i t h more t h a n 100 employees. Congress h a s been wary o f a p p l y i n g mandates t o s m a l l e r e m p l o y e r s l a r g e l y b e c a u s e of c o n c e r n s t h a t t h e y a r e n o t a s e a s i l y a b s o r b e d by s u c h f i r m s and c o u l d c r e a t e economic h a r d s h i p s . Congress h a s a l s o e x c l u d e d t h e F e d e r a l Government and r e l i g i o u s o r g a n i z a t i o n s from c e r t a i n p r o v i s i o n s . The d e b a t e o v e r mandated b e n e f i t s i s i n f l u e n c e d by c o n c e r n s a b o u t t h e l a c k o f c o v e r a g e a s w e l l a s a b o u t c o n c e r n s t h a t working Americans a r e n o t a d e q u a t e l y p r o t e c t e d a g a i n s t t h e c o s t s of a c a t a s t r o p h i c i l l n e s s . Consequently, t h e r e a r e p r o p o s a l s t o r e q u i r e t h a t employers p r o v i d e b a s i c h o s p i t a l and m e d i c a l i n s u r a n c e a s w e l l a s t h o s e t h a t would mandate o n l y c a t a s t r o p h i c i l l n e s s p r o t e c t i o n ( s u c h a s recommended i n t h e Bowen r e p o r t ) . A more complex i s s u e i s w h e t h e r t h e mandate s h o u l d s p e c i f y t h e n a t u r e o f h e a l t h b e n e f i t s t o be o f f e r e d by employers. Again, t h e p r o p o s a l s v a r y i n t h e i r approach. Some, s u c h a s t h e Kennedy-Waxman p r o p o s a l (S.1265, H.R. 2 5 0 8 ) , r e q u i r e a minimum l e v e l o f b e n e f i t s i n t h e h e a l t h i n s u r a n c e package. However, a n a c t u a r i a l e q u i v a l e n c y p r o v i s i o n a l l o w s e m p l o y e r s , t o o f f e r d i f f e r e n t mixes of b e n e f i t s and employee c o s t - s h a r i n g r e q u i r e m e n t s . O t h e r b i l l s l e a v e t h e n a t u r e of t h e b e n e f i t package u n s p e c i f i e d . There a r e a l s o more n a r r o w 1 y d e f i n e d p r o p o s a l s t h a t mandate t h a t e m p l o y e r s who a l r e a d y provide h e a l t h i n s u r a n c e i n c l u d e w i t h i n t h e i r b e n e f i t package s p e c i f i c s e r v i c e s , such a s coverage f o r p e d i a t r i c preventive h e a l t h c a r e (H.R. 1449, S. 9 6 8 ) . D e f i n i n g the P o p u l a t i o n t o b e Covered and t h e D u r a t i o n o f Coverage it is necessary t o d e f i n e t h e Whichever a p p r o a c h i s p u r s u e d , b e n e f i c i a r i e s who would r e c e i v e t h e mandated h e a l t h c o v e r a g e . The e m p l o y e r ' s r e s p o n s i b i l i t y c o u l d be l i m i t e d t o a c t i v e f u l l t i m e e m p l o y e e s , o r expanded t o i n c l u d e a n y o r a l l o f t h e f o l l o w i n g : p a r t - t i m e e m p l o y e e s , s e a s o n a l e m p l o y e e s , r e t i r e d employees, s p o u s e s , widowed a n d / o r d i v o r c e d s p o u s e s , d e p e n d e n t f a m i l y members, and employees who h a v e t e r m i n a t e d t h e i r employment, e i t h e r v o l u n t a r i l y o r i n v o l u n t a r i l y . T i t l e X of COBRA and i t s s u b s e q u e n t amendments p r o v i d e a n example of a b r o a d d e f i n i t i o n of beneficiaries. I n t h e same v e i n , some p r o p o s a l s a r e d i r e c t e d a t e n s u r i n g t h a t e m p l o y e r s o f f e r h e a l t h b e n e f i t s beyond t h e p o i n t a t which t h e employee ( a n d h i s / h e r d e p e n d e n t s ) h a s an i m n e d i a t e c o n n e c t i o n w i t h t h e e m p l o y e r . I n t h e p a s t , Congress h a s c o n s i d e r e d p r o p o s a l s t o r e q u i r e t h a t e m p l o y e r s pay f o r t h e c o n t i n u e d g r o u p c o v e r a g e of l a i d - o f f employees f o r a d e f i n e d p e r i o d of time. I n t h i s c a s e , t h e b e n e f i t package may o r may n o t be defined. Such c o n t i n u a t i o n of c o v e r a g e mandates may e x t e n d t o l a i d - o f f o r o t h e r w i s e t e r m i n a t e d e m p l o y e e s , r e t i r e e s o f t h e f i r m and d e p e n d e n t s p o u s e s and d e p e n d e n t s o f s u c h employees. D e f i n i n g t h e L i a b i l i t y o f E h p l o y e r s and Employees The p r o p o s a l s t o mandate employer-provided i n s u r a n c e a l s o g e n e r a l l y d e f i n e t h e l i m i t s o f t h e e m p l o y e r ' s f i n a n c i a l o b l i g a t i o n t o pay f o r t h o s e benefits. I n T i t l e X o f COBRA, C o n g r e s s a u t h o r i z e d e m p l o y e r s t o r e q u i r e t h e employee t o pay f o r t h e c o n t i n u e d h e a l t h c o v e r a g e , p l u s a s m a l l f e e t o cover t h e employer's administrative costs. I n other proposals, t h e focus i s t o k e e p t h e e m p l o y e e ' s c o s t s f o r c o v e r a g e low by r e q u i r i n g e m p l o y e r s t o pay a l a r g e p o r t i o n of t h e premium. The Kennedy-Waxman p l a n (S. 1 2 6 5 , H.R. 2 5 0 8 ) , f o r example, r e q u i r e s t h a t t h e employer pay 80% of t h e e m p l o y e e ' s i n s u r a n c e premium ( a n d 100% f o r l o r i n c o m e e m p l o y e e s ) which i n t u r n i s d e d u c t i b l e from t h e e m p l o y e r ' s t a x e s a s a c o s t of d o i n g b u s i n e s s . 1449 ( J e n k i n s ) , S. 968 ( C h a f e e l C h i l d H e a l t h I n c e n t i v e s Reform Program. Amends t h e I n t e r n a l Revenue Code of 1986 t o deny an employer a d e d u c t i o n f o r g r o u p h e a l t h p l a n expenses u n l e s s such plan includes f i r s t d o l l a r coverage f o r p e d i a t r i c H.R. 1449 i n t r o d u c e d Mar. 5 , 1987; r e f e r r e d t o C o m n i t t e e on health care. Ways and Means. S. 968 i n t r o d u c e d Apr. 9 , 1987; r e f e r r e d t o C o m n i t t e e on Finance H.R. . H.R. 2300 ( G r a d i s o n ) C a t a s t r o p h i c I l l n e s s Expense P r o t e c t i o n Amendments of 1987. Amends t h e I n t e r n a l Revenue Code of 1986 t o d e n y a d e d u c t i o n f o r g r o u p h e a l t h p l a n e x p e n s e s u n l e s s an e m p l o y e r ' s p l a n i n c l u d e s p r o t e c t i o n a g a i n s t c a t a s t r o p h i c p h y s i c i a n and h o s p i t a l e x p e n s e s a s p a r t o f t h a t c o v e r a g e . L i m i t s e m p l o y e e l i a b i l i t y f o r p h y s i c i a n and h o s p i t a l e x p e n s e s t o out-of-pocket c o s t s of $200.0 f o r i n d i v i d u a l s and $3,500 f o r f a m i l i e s . A p p l i e s t o e m p l o y e r s w i t h 20 employees o r more. I n t r o d u c e d May 6 , 1987; r e f e r r e d t o C o m n i t t e e on Ways and Means. H A . 4951 ( S t a r k ) Employee H e a l t h B e n e f i t Improvement Act of 1988. Amends t h e I n t e r n a l Revenue Code of 1986 t o impose a t a x on e m p l o y e r s t h a t f a i l t o p r o v i d e h e a l t h b e n e f i t p l a n s t o t h e i r employees and t h e i r d e p e n d e n t s . Prescribes c o v e r a g e and premium r e q u i r e m e n t s f o r s u c h p l a n s , and e s t a b l i s h e s a t a x c r e d i t f o r employee h e a l t h c a r e premium payments. Provides f o r t h e e s t a b l i s h m e n t of a Federal h e a l t h i n s u r a n c e pool i n any S t a t e t h a t f a i l s t o provide a q u a l i f i e d pool. R e q u i r e s t h e S t a t e o r F e d e r a l p o o l t o make h e a l t h i n s u r a n c e a v a i l a b l e t o a l l e m p l o y e r s and i n d i v i d u a l s i n t h a t S t a t e . I n t r o d u c e d J u n e 2 9 , 1988; r e f e r r e d t o C o m n i t t e e on Ways and Means. S. 1265 (Kennedy), H . R . 2508 (Waxmen) Minimum H e a l t h B e n e f i t s f o r a l l Workers Act. Amends t h e P u b l i c H e a l t h S e r v i c e A c t , t h e F a i r Labor S t a n d a r d s A c t , and t h e Employee R e t i r e m e n t Income S e c u r i t y Act t o r e q u i r e t h a t e m p l o y e r s e n r o l l t h e i r employees i n a h e a l t h b e n e f i t plan t h a t c o v e r s s p e c i f i e d h e a l t h s e r v i c e s , and p r o v i d e s p r o t e c t i o n a g a i n s e c a t a s t r o p h i c i l l n e s s e x p e n s e s . Limits t h e d e d u c t i b l e t o $250 p e r p e r s o n ($500 p e r f a m i l y ) and l i m i t s copayments t o 20% o f t h e c o s t of a n y s e r v i c e ( e x c l u d i n g c e r t a i n s e r v i c e s f o r which copayments a r e p r o h i b i t e d ) . L i m i t s t h e e m p l o y e e ' s s h a r e t o 20% of t h e c o s t o f c o v e r a g e , and r e q u i r e s t h e employer t o c o v e r t h e f u l l c o s t of t h e premium f o r low wage w o r k e r s . Provides t h a t employers can p r o v i d e b e n e f i t s t h a t a r e e q u i v a l e n t on an a c t u a r i a l b a s i s t o t h o s e s p e c i f i e d . Employers who d o n o t have a p l a n t h a t m e e t s t h e minimum b e n e f i t s t a n d a r d s would b e r e q u i r e d t o j o i n r e g i o n a l i n s u r a n c e p o o l s t o b e e s t a b l i s h e d by t h e S e c r e t a r y of H e a l t h and Human S e r v i c e s . F a i l u r e by a n e m p l o y e r t o p r o v i d e i n s u r a n c e would r e s u l t i n t h e l o s s of e l i g i b i l i t y f o r g r a n t s , c o n t r a c t s , l o a n s o r l o a n g u a r a n t e e s under t h e P u b l i c H e a l t h S e r v i c e Act o r c i v i l penalties u n d e r t h e F a i r Labor S t a n d a r d s Act. Provides t h a t an i n d i v i d u a l may s u e i n F e d e r a l c o u r t f o r i n j u n c t i v e r e l i e f . S. 1265 i n t r o d u c e d May 21, 1987; r e f e r r e d t o C o n m i t t e e on Labor and Human Resources. On Feb. 1 7 , 1988, t h e Committee v o t e d t o r e p o r t S. 1 2 6 5 , a s H.R. 2508 i n t r o d u c e d May 21, 1987; r e f e r r e d t o amended, t o t h e S e n a t e . C o n m i t t e e s on Energy and Commerce, and E d u c a t i o n and Labor. COUGEESSIONAL ~ I N C S ,REPORTS, AND D O C U I I ~ U.S. Congress. House. Committee on E d u c a t i o n and Labor. S u b c o m n i t t e e on Labor-Management R e l a t i o n s . Access t o h e a l t h i n s u r a n c e . Hearing, 1 0 0 t h C o n g r e s s , 2d s e s s i o n . J u n e 9 , 1988. ( u n p u b l i s h e d ) ----- C o r n i t t e e on Energy and Comnerce. Subcommittee on H e a l t h . Minimum H e a l t h B e n e f i t s f o r A l l Workers Act of 1987 and r e l a t e d b i l l s . Hearing, 1 0 0 t h C o n g r e s s , 2d s e s s i o n . Apr. 1 4 , 1 5 , 1988. (unpublished) ----- Committee on d e a r i n g s , 100th Washington, U.S. S e r i a l no. Small B u s i n e s s . The h e a l t h i n s u r a n c e problem. Congress, 1 s t s e s s i o n . May 6 , J u n e 1 6 , 1 8 , 1987. Govt. P r i n t . O f f . , 1987. 100-7 ----- C o w i t t e e on Ways and Means. Subcommittee on H e a l t h . Insurance p r o t e c t i o n f o r c a t a s t r o p h i c h e a l t h expenses f o r i n d i v i d u a l s under a g e May 1 2 , 1987. 65. Hearing, 1 0 0 t h C o n g r e s s , 1st s e s s i o n . (unpublished) ----- The Employee H e a l t h B e n e f i t Improvement Act o f 100th Congress, 2nd s e s s i o n . Aug. 9 and (unpubl i shed) U.S. 1988. Sept. Hearings, 22, 1988. Congress. Senate. Committee on F i n a n c e . H e a r i n g on t h e U n i n s u r e d . H e a r i n g , 1 0 0 t h C o n g r e s s , 2nd s e s s i o n . J u l y 2 5 , 1988. (unpublished) ----- C o m n i t t e e on Labor and Human R e s o u r c e s . Essential health care: r e v i e w i n g a c c e s s t o minimum e s s e n t i a l h e a l t h c a r e . Hearing, 100th Congress, 1 s t session. May 19, 1987. Washington, U.S. Govt. P r i n t . O f f . , 1987. S.Hrg. 100-267 ----- Minimum H e a l t h B e n e f i t s f o r A l l Workers Act of 1987. H e a r i n g , 1 0 0 t h Congress, 1 s t session. J u n e 24, 1987. Washington, U.S. Govt. P r i n t . O f f . , 1987. S.Hrg. 100-376, P a r t 1 ----- Minimum H e a l t h B e n e f i t s f o r A l l Workers Act. C o n g r e s s , 1 s t s e s s i o n . Nov. 4 , 1987. ( u n p u b l i s h e d ) ----- Hearing, 100th Minimum H e a l t h B e n e f i t s f o r A l l Workers A c t ; r e p o r t . May 25, 1988. ( 1 0 0 t h C o n g r e s s , 2d s e s s i o n . S e n a t e . R e p o r t no. 100-360) ----- C o m n i t t e e on Small B u s i n e s s . To examine t h e c o s t and a v a i l a b i l i t y o f h e a l t h c a r e b e n e f i t s f o r s m a l l b u s i n e s s e s and p r o p o s a l s f o r f e d e r a l l y mandated h e a l t h b e n e f i t s . Hearing, 100th Congress, 1 s t s e s s i o n . Apr. 23, 1987. U.S. Govt. P r i n t . O f f . , 1987. S.Hrg. 100-144 FOB ADD1 TIONAL BEAD1 NG U.S. L i b r a r y of Congress. Congressional Research Service. h e a l t h insurance continuation coverage, by B e t h C . [ W a s h i n g t o n ] 1987. (Updated r e g u l a r l y ) CRS I s s u e B r i e f 87182 Private Fuchs. ----- P r i v a t e h e a l t h insurance c o n t i n u a t i o n coverage: l e g i s l a t i v e h i s t o r y [ W a s h i n g t o n ] J u l y 1 5 , 1987. o f T i t l e X of COBRA, by B e t h C. Fuchs. CRS R e p o r t 87-613 EPW ----- H e a l t h i n s u r a n c e and t h e u n i n s u r e d : background d a t a and a n a l y s i s , p r e p a r e d f o r t h e Subcommittee on Labor Management R e l a t i o n s and t h e S u b c o r n n i t t e e on Labor S t a n d a r d s of t h e House C o m n i t t e e on E d u c a t i o n and L a b o r , and t h e Subcommittee on H e a l t h and t h e Environment of t h e House Committee o n Energy and Commerce, and t h e S e n a t e S p e c i a l Committee on Aging. by B e t h Fuchs, [ W a s h i n g t o n ] May 1988. CRS R e p o r t 88-537 EPW ----- - Employer provided h e a l t h insurance: comparison o f t h e m a j o r p r o v i s i o n s o f t h e "Minimum H e a l t h B e n e f i t s f o r A l l Workers ~ c t "(S. 1265lH.R. 2508) a s i n t r o d u c e d , S. 1265 a s r e p o r t e d by t h e S e n a t e Labor and Human R e s o u r c e s Committee, and t h e "Employee H e a l t h B e n e f i t s Improvement ~ c t " (H.R. 49511, by B e t h C. Fuchs and L i n d a Akiyana. [ W a s h i n g t o n ] S e p t . 2 , 1988. CRS R e p o r t 88-588 EPW