c Differences in mean adjusted expenditures paid by private health insurance between nongroup enrollees and ESI enrollees within age group is statistically significant at p<.05.

a Differences in mean expenditures paid by private health insurance between nongroup enrollees and ESI enrollees within age group is statistically significant at p<.05.

Table 1 compares payments by private insurance for nongroup and ESI enrollees. Because health care spending, on average, increases with age, enrollees are divided into four age groups. Average and median values are shown for each age category.

Enrollees in each coverage group were primarily covered by private insurance, and were classified as having employer coverage or nongroup coverage if the individual had 6 months or more of private, employer-sponsored or Tricare insurance, or nongroup insurance, respectively. People who had public coverage or were uninsured in any month were excluded from the analysis. On average, both nongroup enrollees and ESI enrollees had just less than 12 months of coverage during the year. Average ages were 35 for nongroup enrollees and 34 for ESI enrollees.

For the analysis, we use data from Medical Expenditures Panel Survey Household Component (MEPS HC), which is a national survey conducted annually by the Agency for Healthcare Research and Quality that provides annual estimates relating to the health status, expenditures, coverage and use of the U.S. civilian non-institutionalized population. 3 To increase sample size within insurance groups, we pooled data from the 2004-2007 MEPS HC. Expenditure amounts were adjusted to account for differences in spending between years. 4 The amounts shown are expenditures for health care services and do not include premium payments. The analysis was done using SUDAAN (Release 10.0).

The next section of the paper describes the source of data for the analysis. The following sections compare for nongroup and ESI enrollees: (1) amounts paid by private insurance; (2) share of expenditures that are out-of-pocket; and (3) self-reported health status and mental health status. The final section concludes with some observations for policy.

We also look at the self-reported health status of nongroup and ESI enrollees. Another possible reason why premiums for nongroup coverage may be lower than premiums for employer-sponsored insurance is that, on average, nongroup enrollees are in better health than ESI enrollees. People in better health should use less health care, which would result in lower payments by private insurance on their behalf.

This brief looks at the amount of coverage provided in the nongroup market by comparing the spending of nonelderly people with nongroup coverage (“nongroup enrollees”) to nonelderly people with employer-sponsored health insurance (“ESI enrollees”). In particular, for each group of enrollees we look at the relative amounts paid by private insurance and at the relative percentages of spending that are out-of-pocket. The average expenditures paid by private insurance tell us how much insurance pays for each enrollee; a significant difference between the average for nongroup and the average for ESI enrollees would suggest a difference in the level of coverage between the two markets. In addition, the percentage of expenditures that people pay out-of-pocket also provides information about the level of coverage that they have. Once people have insurance, it is fair to assume that they would prefer to pay for health care that they use with their insurance rather than out-of-pocket. If we see that one group of enrollees pay for a much higher share of their health expenditures out-of-pocket than the other group of enrollees, it would suggest that the first group has a lower level of coverage.

Understanding the costs for and benefits provided by nongroup coverage is important for those considering policies that would build on or expand the nongroup market. This is particularly important for policies that would extend nongroup coverage to the uninsured, who disproportionately are lower income. Data from convenience samples of insurers and from on-line brokers suggest that nongroup premiums are much lower on average than premiums for employer-sponsored insurance – maybe as much as 50% lower. 1 They also suggest that cost sharing may be higher, on average, in nongroup policies than in employer-sponsored plans. 2 For policy makers, the attractiveness of the apparent low price for nongroup policies needs to be balanced against questions about of how much coverage these policies provide. Policies with high cost-sharing may not be attractive to lower income people with few resources to meet high out-of-pocket demands.

The nongroup health insurance market has received an increasing amount of attention as Congress considers health reform. Expanding the nongroup market is a key element in national health reform proposals presented by Congress and the President Obama, often coupled with broader market reforms. In addition, the health reforms enacted in Massachusetts require people who do not get insurance through their work to directly purchase coverage.

Data from the insurance industry and reviews of premiums offered through on-line sellers show that premiums for nongroup health insurance are lower than premiums reported on national surveys for employer-sponsored health insurance (ESI). This paper uses pooled data from the 2004 through 2007 Medical Expenditure Panel Survey to compare the insurance payments for and out-of-pocket payments by people with nongroup health insurance and people with ESI. While premiums for non-group coverage are lower than ESI premiums, the average payments made by those policies on behalf of their enrollees are also lower than the average insurance payments for people with ESI. Nongroup enrollees also pay a higher share of health expenses out-of-pocket compared to ESI. The higher out-of-pocket shares paid by nongroup enrollees suggests that nongroup policies have higher cost sharing and/or cover fewer health expenditures than employer-sponsored insurance. Nongroup enrollees also are more likely than ESI enrollees to report that their health status and mental health status are excellent, another factor helping to explain why nongroup premiums are lower than premiums for ESI.

The average and median annual amounts paid by private health insurance are higher for ESI enrollees than for nongroup enrollees for most age groups. The results are presented two ways: the first column for each enrollee group shows total annual expenditures by private health insurance and the second column for each group shows annual expenditures for private health insurance adjusted to remove payments for dental and vision services. Since dental and vision services, when covered, are often covered by separate or supplemental insurance policies, the adjusted amounts should provide a more accurate picture of expenditures for basic benefits usually covered by insurance. ESI enrollees also are much more likely than nongroup enrollees to have any health insurance payments for vision and dental services, suggesting that coverage for these services is more prevalent for people who get coverage though work than for those who must buy it directly.

Average and median amounts paid by private insurance are statistically significantly higher for ESI enrollees than nongroup enrollees in each age group, except age group 18-34. Relative to the values for nongroup enrollees, the average expenditures paid by private insurance for ESI enrollees are 98% higher for people ages 0 to 17, 73% higher for people ages 35 to 49, and 77% higher for people ages 50 to 64. The percentage differences within age groups do not change appreciably when expenditures for vision and dental services are removed.5



These very large differences in payments by private insurance for nongroup and ESI enrollees suggest that nongroup policies are providing less coverage than employer-sponsored insurance. The results are consistent with the information from insurance industry sources that suggest that nongroup policies have higher up-front cost sharing than employer-sponsored insurance,6 although health status or other differences between nongroup and ESI enrollees also could help explain the differences in the amount paid by private insurance. The next section looks at another way to measure level of coverage – the proportion of expenses that people pay out-of-pocket for people who have health expenditures.

Out-of-Pocket Spending as a Share of Total Health Expenditures

This part of the paper looks at the share of health expenditures that people pay out-of-pocket as a proxy for the level of coverage that people have – in other words would the coverage be expected to pay for a relatively smaller or larger share of the health care expenditures that a person might have. We assume that people who have insurance would rather use that insurance to pay for their health care expenses than to pay for them out-of-pocket. Therefore, people who pay for a relatively large share of their spending out-of-pocket do so because a relatively large share of their health expenditures is not covered by their insurance. This may be due to coverage restrictions or relatively high deductibles and other cost sharing.

For the people in our enrollee groups, payments from private insurance and out-of-pocket payments constitute the vast majority of their spending (99% for nongroup enrollees and 97% for ESI enrollees). The small remainder is made up of spending from other sources such as workers compensation, Veterans Administration or public programs. For this analysis, we exclude the payments made by these other sources from the calculations because they may be paying for services that would not normally be covered by health insurance, such as work-related injuries. Excluding expenditures from these sources does not materially affect the results. Therefore, “total expenditures” refers to the sum of private insurance expenditures and individual out of pocket expenditures.

We look at out-of-pocket shares three ways. In Table 2, for nongroup and ESI enrollees, we show the average total out-of-pocket expenditures as a proportion of the average total expenditures. Table 3 shows the average and median out-of-pocket shares for nongroup and ESI enrollees who have health expenditures. For this table, we calculate the out-of-pocket share for each enrollee and summarize the results. The percentages in Table 3 are higher than in Table 2 because enrollees with lower spending, who make up the majority of enrollees, have relatively high out-of-pocket shares. Enrollees with high total spending make up a small share of enrollees but a large share of total spending. These enrollees have relatively low out-of-pocket shares. Table 4 demonstrates this difference more directly by showing the average and median out-of-pocket shares for nongroup and ESI enrollees who were among the top 20% and the top 5% in total health expenditures in their respective enrollee groups.

TABLE 2

Total Out-of-Pocket Expenditures by Nonelderly as a Proportion of Total Health Expenditures, by Enrollee Group

Nongroup Enrollee Group ESI Enrollee Group Total Out-of-Pocket as Share of Total Expenditures (%) Total Out-of-Pocket as Share of Total Expenditures (%) Adjusted (No Vis or Dental) Total Out-of-Pocket as Share of Total Expenditures (%) Total Out-of-Pocket as Share of Total Expenditures (%) Adjusted (No Vis or Dental) 41% 35% 20% 16%

The story is similar for each way of looking at out-of-pocket shares. Looking at aggregate spending across all nongroup and ESI enrollees, 41% of total heath expenditures by nongroup enrollees are paid out-of-pocket, as compared to 20% for ESI enrollees (Table 2). The percentages fall somewhat when expenditures for vision and dental are removed from the calculation, but the large difference between nongroup and ESI enrollees remains.

TABLE 3

Average and Median Percentages of Total Expenditures Paid Out-of-pocket by Nonelderly Nongroup and ESI Enrollees with Health Expenditures

Nongroup Enrollees ESI Enrollees Percentage Expenditures Paid Out-of-Pocket (%) Percentage Adjusted Expenditures Paid Out-of-Pocket (%) (No Vis or Den) Percentage Expenditures Paid Out-of-Pocket (%) Percentage Adjusted Expenditures Paid Out-of-Pocket (%) (No Vis or Den) Mean 58% a 52% a 32% 30% Median 59% b 47% b 25% 22%

Source: Pooled MEPS 2004-2007, HC

a Differences in mean percentage of expenditures paid out-of-pocket for nongroup enrollees and ESI enrollees is statistically significant at p<.05.

b Differences in median percentage of expenditures paid out-of-pocket for nongroup enrollees and ESI enrollees is statistically significant at p<.05.

For people with health expenditures, Table 3 shows that nongroup enrollees on average paid a much higher share of their health expenditures out-of-pocket than ESI enrollees. The median nongroup enrollee with expenditures also has a much higher out-of-pocket share than the median ESI enrollee with expenditures. The pattern is similar whether expenditures for vision and dental services are included or excluded.

In Table 4 we extend the analysis to see if the difference in out-of-pocket shares persists for nongroup and ESI enrollees with high health care expenditures. We looked at the out-of-pocket shares of enrollees who were among the top 20% and the top 5% in total health expenditures. These groupings are not exclusive: enrollees in the top 5% of spending are by definition also in the top 20% of spending. We find that average out-of-pocket shares and median out-of-pocket shares became smaller among both nongroup and ESI enrollees as total health spending rises (compare Tables 3 and 4), but that significant differences between nongroup and ESI enrollees persist.

TABLE 4

Average and Median Percentages of Total Expenditures Paid Out-of-pocket by Nonelderly Nongroup and ESI Enrollees with High Health Care Expenditures

Nongroup Enrollees ESI Enrollees Percentage of Expenditures Paid Out of Pocket Top 20% Spenders Top 5% Spenders Top 20% Spenders Top 5% Spenders With Vision/Dental Mean 45% a 30% a 23% 13% Median 38% b 22% b 18% 8% Without Vision/Dental Mean 41% a 28% a 19% 11% Median 35% b 17% b 14% 7%

Source: Pooled MEPS 2004-2007, HC

a Differences in mean percentage of expenditures paid out-of-pocket for nongroup enrollees and ESI enrollees within spending tier is statistically significant at p<.05.

b Differences in median percentage of expenditures paid out-of-pocket for nongroup enrollees and ESI enrollees is statistically significant at p<.05.

Tables 2 through 4 suggest that nongroup insurance is less likely than employer-sponsored health insurance to pay for health care expenditures that people have, leaving nongroup enrollees to pay for a relatively high share of their health care expenditures out-of-pocket. This is true whether looking at total spending over all nongroup and ESI enrollees or looking at the average or median out-of-pocket shares of enrollees with health spending. Even among enrollees with very high total health care expenditures, nongroup enrollees have higher average and median out-of-pocket shares than ESI enrollees. Again, these results are consistent with the information from insurance industry sources indicating that nongroup insurance policies, on average, have higher cost sharing than employer-sponsored coverage. These results also show that the size of the difference in protection is meaningful.

Health Status of Nongroup and ESI Enrollees

This section briefly looks at the self-reported health status of nongroup and ESI enrollees. Another potential reason why nongroup coverage might cost less than employer-sponsored coverage would be that nongroup enrollees are healthier on average than ESI enrollees.

The MEPS HC asks respondents to classify their health status and their mental health status on 5-point scales: excellent, very good, good, fair, or poor. Table 5 shows that nongroup enrollees are more likely than ESI enrollees to classify their health status as excellent (45% vs. 36%). Table 6 shows a similar result for mental health status. The differences in the distributions of responses between nongroup and ESI enrollees are statistically significant in both tables; the differences in the percentage of respondents reporting that their health or mental health status is excellent also are statistically significant.

Table 5

Perceived Health Status of Nonelderly Nongroup and ESI Enrollees

Nongroup Enrollees* ESI Enrollees Perceived Health Status Excellent 44.8%** 35.8% Very Good 31.8 35.7 Good 17.7 23.0 Fair 4.7 4.4 Poor 1.0 1.0