The Health and Wealth of a Nation: Employer-Based Health Insurance and the Affordable Care Act

This book examines the behavior of firms with respect to their provision of health care prior to policymakers deliberations on the Affordable Care Act (ACA) and uses those behaviors to forecast changes in employer-sponsored health insurance (ESI) offers and provisions once the ACA is fully implemented. Her analysis focuses on potential changes in ESI access and quality that may occur because of implementation of the ACA.

Maxwell bases her work on the California Health and Employment Survey (CHES), which includes responses from a cross section of 1,427 private firms having five or more employees. Administered in 2005 2006, CHES makes possible examination of firms behavior prior to the ACA. Three key observations gleaned from the survey are as follows:
1. The offer of ESI differed between firms with a majority of low-skilled workers and those with a majority of high-skilled workers.
2. When health care costs increased, the vast majority of firms that offered ESI shared costs with workers in ways that affected workers compensation.
3. Most small firms that did not offer health insurance felt its cost was too high for the firm or its workers. These observations provide the basis for assessing how firms behavior might change following implementation of the ACA and how those changes might affect disparities in who receives health insurance from an employer.

Maxwell s analysis of the CHES data leads to four key insights about the potential influence of the ACA on employers:
1. The ACA will likely influence the behavior of virtually all firms that offered health insurance at the time of its passage.
2. The ACA is unlikely to incentivize small firms to offer health insurance if they did not already offer it when the act was passed.
3. The differences in ESI coverage and quality of the offer made to low-wage and high-wage workers is likely to converge when the ACA is fully implemented.
4. Disparities in the offer of benefits other than health insurance might increase between low-wage and high-wage firms.