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,January 1999 until 13,

A REAPPRAISAL OF PRIVATE EMPLOYERS'ROLE IN PROVIDING HEALTH INSURANCE
OlveenCarrasquillo, M.D., M.P.H.,David U. Himmelstein, M.D., SteflieWoolhandler, M.D., M.p.H., David H. Bor, M.D.
Abstract Accordingto official figures, in 1996, 610/o ot Americansreceivedhealth insurancethroughemployers. personswho rely primarily However, estimate this includes on govemment insurance suchas Medicare; workers whose nothingtowardstheir premiums; employer contributes and govemment whoseprivatecoverage paid for employees is by taxpayers. Methods: To estimate lhe number of persons whose principal healthinsuran@ was paid in wholeor part by private sector employers and the number receiving government-paid insurancewe analyzedftom the 1997 persons CunentPopulation Survey. Approximately 130,000 population representative the U.S. non-institutionalized of were sampled.We consideredpersons to be covered principally privatesectoremployer-paid by healthinsuranc€ if they had no public coverageand were covered by insurance froma nongovemment employer who paidall or part of their premiums.Personswho receivedMedicaid, Medicare, insurance fromformeror cunentmilitary service, or the lndianHealthServicewere considered receiving as govemment insuran@. thisstandard To definition publicly of insuredwe added govemment workersand their covered clependents employer-paid with healthinsurance coverage. (Cl, 42.7o/o 43.5olo) the Results: In 1996, 43.1o/o to of population principally privatesectoremployerdepended on paid heafthinsurance, U.2yo (Cl, 33.8 to 34.6%) had pubficly-tunded insurance,7.1o/o(Cl, 6.8% to 7.6%) purchased their own coverage and 15.6%(Cl, 15.3%to 15.9o/o) uninsured. onlysix states were In was overhalfof the population covered principally by private sector health insurance. employer-paid Concluslons: Cunentdefinitions healthinsurance of overemphasize role of privateemployers underestimate the and govemmentpaid Insuranc€. Less than half of the U.S. population relies for lheir pdncipal health insurance coverage policiesthat are paid for in part or whole by on private sectoremployers. Key words: insurance,health; health policy; medically uninsured; Medicare; blacks; Hispanic Americans rrnssssgssful attempt at President Clinton's comprehensive hcalth care reform. Subsequent incremental strategies such as the Health Insurance Portability Act of 1996 (formerly known as the Kennedy-Kassebaum bill) or recent Congressional proposalst are also designedto improve shortcomings of employer-provided health insurance. However, the Census Bureau's method of classiffing insurance2as "employer provided" (and the similar method adopted by the Agency for Health Care and Policy Research,AHCPR),5 may overstate private employers' role. First individuals who receive both government insurance and private employer coveragein a given year are either included in both categories2 only in the private insurance or category.6 However, in most such cases, the government is the primary insurer. For example, in 1992, while three quarters of elderly Medicare beneficiaries had employer-sponsored retiree health benefits or individually purchased private Medigap plans, Medicare and Medicaid paid 67% of the their total health care costs;private insurancepaid for only l0%; the rest were paid out of pocket.T Second,while military personnel are correctly classified as receiving government insurance, most other federal, state and local government workers who receive health benefits are classified as "privately insured" under an employer-providedplan, which accurately describes their insurance card but not the ultimate

Introduction
Employer-paid health insurance, initially nurtured by World War Il-era wage controls that did not restrict insurancebenefits, has become a cornmon fringe benefit.r As a result, most Americans obtain health insurance through their employer. According to the Census Bureau, in 1996, 61.2% of the U.S. population was covered by employment-related insurance,70.2%bad some fonn of private insurance and 25.9% received insurance through the government.2 As a result, private employers have played a major role in shaping recent changesin our health care system.3'1Furthermore, discussions of health care reform often start from the premise that our health insurance system is predominantly private and employer-based. For example, employer mandateswere the cornerstoneof part was Dr. Carrasquillo During of theresearch, Olveen Medicinc Rescarch Fcllowship HRSA by supported a General grant 2D28 PE500l8-04.
to: correspondence reprintrequests and Address Mcdicine, Division General of Dr. Olveen Carrasquillo, Presbyterian Medical Center, 9 EastRm. 105, PH Columbia New York,NY 100032 622W. 168'! Street, (212) Fax:(212) 305-9349 Phone 305-9782 :canaso@medicine l.cpmc.columbia.edu Email

Manuscript version of New England Journal of Medicine arficle (in press)

We calculated confidence intervals for percentages using SE = . 8. is the percentageand b is a parameter estimate provided by the Census Bureau.3 million) had Medicaid. employees who purchasehealth insurancethrough an employer who pays none of their premium costs are counted as having employer insurance. were consideredas having selfinsurance. The CPS is a Census Bureau survey of the non-institutionalized States covering the United population of approximately 50.4 o/o(90%CI.2 + SEr2)where SE. 160.160.1 to 84.6) people. 55.1 to 161.l to 142. In keeping we considereda with CensusBureau conventions.1 million persons worked for an employer having over 100 employees. the Indian Health Service or various insurance programs sponsoredby individual states were classified as receiving government insurance. taxpayers).5) people received private insurance tbrough an raditional employer without also receiving government insurance.6 employerinsurance. and 3./ (SE.5 to insurance. There were also 69. Of the 160. 18. Among this group. population and which to account for factors such as the CPS' complex and non-interview sampling design. t Standard enors for state data were further adjusted using state specific parameters. We considered persons to have private sector employer-paid health insurance only if they had no public coverage (as traditionally defined) and were covered by insurance from a non-government employer who paid all or part of their premiums.7 to 19. which allow identification of the policyholder.1 million people (Cl. also had Medicare.e.5o/o to 26.0 million (CI. the standard souce of to information on health insurancecoverage. insurance from former or current military service. In this paper we atalyze data from the Current Population Survey. Methods We analyzeddata from 1997 March Supplement to the Current Population Survey (CPS). Standard errors of differences were obtained ustng the formula SE: . who were covered by some form of traditional government insurance. where a is another parameter estimate from the CensusBureau. 51.t For absolute numbers the formula was SE: {(ax2 + bx).7%) of the population living in the United States.84. Results In 1996. including Medicare. and SE. Personswho received Medicaid.7 million) had military-associated 19. difference significant ifthe ninety percent confidence interval did not include zero. Among the .25. estimate the numbers of persons who relied principally on private non-govenunent employers for their insuranceduring 1996. or the Indian Health Service. of households. ll. Medicaid. 225.3 million) persons these were not considered as receiving their principal health insurancefrom private employers. We also calculatethe number of persons for whom the govemment provides coverage.10%(CI.0 to ll.l million (CI./( (p(100-p)*b)/x) where SE is the standarderror. Dependents were classified using new items introduced in the CPS since 1995.4 to 69. 3. Each March the survey asks detailed quesrionsabout health insurance coverage during the previousyear. military-associated health insurance (CHAMPUS/CHAMPVA).Of note.1 million (CI. (Figure l) J[s l6rnxining141. 4. purchased were derived using weights Populationestimates provided by the Census Bureau to allow extrapolation the entke U. x is the number of people in p the base percentage.S.9 to 9.2) employeesor their dependents reported that the employer contributed nothing towards their employer-provided insurance plan and as thus were not considered receiving employer-paid insurance. We added to this standard definition of "publicly insured" an additional group: government workers (and their covered dependents) whose govemment employer paid for all or part of their health insurancepremium. Finally.9. 3. 68.5) had health insurance through an employer (as policyholders or dependents). 259% (Cl. the standard source of national health insurancedata. 3.6% to health 58. We consideredpersons insured if they reported any health insurance coverage during the previous year.3 million (CI. Those with private health insurance that was neither paid for by a private sectoremployer nor the govemment.L payers (i. undercoverage.8 million (CI.9).8 million with ll. Those who reportedbeing coveredby a private plan of someone living outside the household(not in the CPS sample) and who could not be classihedinto one of the above groups were considered as having private employerpaid insurance.0 million (CI. 224.8million (CI.9 to million) 4. 84. reported having some form of health insurance.6 million (CI.000 persons. l4l. Medicare. 8 are the standardenors of each estimate.3 to 225.Thus.000 households with 130.6%) of these 9. either public or private.3%) of the population.

7%o(90%Cl. Hispanics had low rates of private employer(C1. government 57.24. 9 . their contributions accounted for less than 25% of Medicare Expenditures in 1994eand are dwarfed by .zyo. Blacks were much more likely than Hispanics to receive traditional government insurance. classification Table I presents analysesby gender. Adults age 18-64 were more likely to receive private sector employer-paid insurance and much less likely to receive government insurance than children under 18.8% to 34.2o/o) Blacks and ll. only 43Yohad health insurance paid by private sector employers as their primary coverage. 90.7%\ in New Mexico to 53.2o/o Likewise.2% (Cl.6%) and among adultsin the 26. of the $950 billion spent on health care.5% (Cl.6%) self-purchased their own health (Cl.9oA paid insurance.2% (90%Cl.2 to 4. g % ( g . As a result. ll3% to ll.3%\ in Indiana to 51. 35% of the population received insurance which was government provided or purchased. 42. uninsurance rates for Hispanics are particularly high due to low levels of naditional government coverage and lower participation in the government workforce.5%) versus (CI. Lastly. 47.28'2V' to 31. In five statesand the Disrict of Columbia. Our finding that the role of private business in health insurance is not as extensive as commonly assumed is consistent with national health expendituredata.6) receivedinsurancefrom a government employer and thus were not consideredas receiving insurancefrom private sector employers.8% to 27. 15. 6.6yo(C1. l 8 .0o/oto 28.8% to 7.4%). 7 % ) e r s u s 0 .2 million (CI. which we conservatively assumed was paid for by a private employer. principally on private sectoremployer-paid depended in health insurance 1996.o Though employers contribute to the Medicare Hospital Insurance Trust Fund. 33-7% to 36. (Cl. while only 29.8% (90%CI 50. Discussion Prior estimates of health insurance have led to the view that private sector employers provide and pay for most people's health care.and in ten statesthe two rates were not significantly different from each other' In only six stateswas over half of the population covered only by private sector employer-paid health insurance.5 million persons with private sectoremployer-paidilsurance.60/o presentsindependentestimates uninsured. 3 %t o *1s unin5ul3nce rate among 12. 32.2 mlllion employees (and dependents)who had insurancepolicies paid by their goverrunent employer. While both Blacks and Hispanics were much less likely to receive private sector employer-paid coverage than non-Hispanic Whites.8Yo to 55.2 to I15.7% to 43. 114.with the rest coming from non-patient revenues. private business paid for about 2lYo of expenditures.2 million (CI' 21. 4. 7.33.9%) were to insurance and 15. at most 43. 35.6% (C1.0 million with uaditional public coverage plus 22. 8 7 oC I .4o/o to 28.22. more likely to work for the government. the rates of government provided those of Private sector employercoverageexceeded paid coverage.6 to 91.21.6% (90%Cl22. Among ethnic/racialgrouPs' 43.we added4'4 million (Cl. age and raciaVethnic grouPs. 30.6%o in to compared 2l .6 million). l5yo were uninsured and 7Yo selfpurchased their own health insurance.were coveredby insurancethat was provided or purchased by the government. ( 1 v l g .8) Persons' 34.6%) in Alaska.6) persons who were covered as dependents by a plan of someone outside the household.1% to 33. Among the rest. labor force.3%). but rates of governmentinsurancesimilar to 31 to non-Hispanic Whites at 3l. coverage varied from 25.6Yo (CI.1% (Cl. and consumers paid directly for about 26%o.5%) of the population.1% (Cl.4%) in Wisconsin. .2%o\of Blacks received insurance from a governmentsoluce.7oh) in non-Hispanic Whites. In 1994.0%) were covered under a private employer-paid plan. non-elderly adults.7% (Cl.1% (Cl.283% similar to Blacks at29.1% to 35'l%) as Hispanics was 33.3 remaining 132.(Figure 1) 91. Groups most likely to have private sector employer-paid insurance included males.7 million persons.3o/o 15.0% to 22. government paid for 47Vo (includes health expenditures on behalf of government employeesas well as Medicare.Thus. Virtually all people over 64 were covered by government insurance through Medicare.1%). Yet.8 to 22. l t o 2 1 . we found that of while over 70%o the United States population was covered by private insurance in 1996. 42'2o/o to 45. Medicaid and other public programs). Females were more likely to receive government insurance and less likely than males to have private sector employer-paid insurance. in Data for individual statesis presented Table 2' private sector employer-paid insurance Rates of to varied widely from a low of 25. the 69. Figure two of employer and government health insurance from the Census Bureau2 and AHCPR5 using the naditional classification systerq and from our revised system. and non-Hispanic whites.6%) of the population.9 million p€rsons (CI. to the remaining 110. 22. 114.

on averageemployeesthemselves paid for about 20olo to 30% of thesepremiumsin 1996. it is believed thar some people who are eruolled in these prograrns are unaware of their coverage. our estimatesof Medicaid and Medicare coverage are lower than Health Care Financing Administration (HCFA) enrollment data.3 million Medicare and 36.re while the CpS reported 34.pays for their own insurance or is uninsured.2 million Medicaid enrollees. we assigned all 4. Non_ sampling errors (e.2r... currently estimated about $ 100billion a year. While these assumptions may understateprivate employers' role in health insurance. While these employers made no financial contributions towards health insurancepremiums.g.2 For example in 1995. First. The majority of the US population receives insurance provided or purchased by the government. made several we assumptions that tend to overstate their role. a decline in unionization. The standard errors for CpS estimates indicate the magnitude of the sampling error. we classifiedpersons as receivingemployer-paidinsuranceif the employer made any contribution whatsoever. as the CpS does not ask individuals whose employers pay only part of their premiums how much the employerspay. they may have negotiated for lower premiums and more generousbenefits than theu employees would have obtained had they purchased coverage individually from insurance companies. decisions regarding health care frnancing and organizationare mattersof public policy that should be made througha democraticprocess.22 with As all surveys sampling and non-sampling errors occur in the CPS. there is some disagreementas to whether responsesare acrually closerto point-in-trmeestimates.'-. We classified persons simultaneously covered by traditional government insurance and by private sector employers in the government insurance category. as the CPS uses self-reported dara.fusing healthcare use costshave also causedsome employerswho provided insurance either drop coveragealtogetheror (more to rj commonly) to increaseemployee'scontributions. Second. While the CpS asks respondents about their coverage during the entire previous year. the relative contributions by each type of insurance may vary. employers'health care decisionsmay be driven more by cost concerns than by the best interests of their employees.o at Prior studies of employer-provided health lnsurancehave highlighted declinrng rates of coverage.E In conclusion.9 million Medicaid recipients.'t Most studies attribute this decrease to a shift of workers to service industries that often do not provide coverage. less than half the population receives their principal health insurance coverage from private employers.a Certain caveatsapply to our study. including the regressive nature of premiums and disruptions of continuity of care due to changes in health plan by the employer or employment by the employee.About 5 million of these people had insurance through large employers. Current classifications of employer_ provided healthinsurance over-emphasize role of the private employersand may have encouragedceding to private frms an inappropriately large role rr health care decision making. .a'r7In addition.4 million dependents receiving coveragethrough an out of householdpolicy-holder to the private employer-paid coverage category. Over half of these were Medicare benefrrciaries for whom Medicare is the primary payer.In our view.'5 Other limitations of the CpS should also be highlighted.rs Among the g million with Medicaid or military-associated insurancewho also received private insurance during that year. HCFA reported 37.ra.7 Medicare and 31. definitional difficulties and errors in data collection and processing) are harder to estimate. which has resulted in many low wage workers declining coverage. and increased of part-time workers.4 tax subsidiesfor employer-provided healthinsurance.0 From l9g0 to 1995levelsof private insurance coveragedroppedby 9 percentaga poirrt . However. We also considered workers whose employer contributed nqrhing to their insurance premiums as having self-purchased rnsurance.'o Analysts have also highlighted other problems of employer-provided health msurance.2o Last. Accordingly. debateson the future of our health care system (and tabulations by the Census Bureau and AHCpR) should more accuratelyreflect the more limited role that private employersplay in providing coverage. respondents'inability to recall accurate information.

Estimatesof self-purchased insurancealso include those who receive government insurance.Also had Government insurance (e. Policy Research2 70_ 60 50 P+o (u q) o !30 20 l0 1 CensusBureau 6AHCPR a RevisedSystem Errpbyer Govenrrprf SelFpuchased Uninsured Census Bureau estimatesof ernployer insuranceinclude all personsreceiving insurance from an ernployer. Estimates of health insurance from the CensusBureaur.Employer did not contribute towards insurancepremiums 132.5million O 114.t million . miliury health insurance.O million .Census Bureau tabulationsexceed 100%. thoseernployedby the govemment. AHCPR estimatesof employer insuranceinclude all persons receiving insurancefrom an employer. However. Agency for Health Care and (AHCPR) and the revised classification system3(using Census Bureau data).or local) f 10.state.Medicaid. Self-purchasedinsuranceincludes those whose employer did not conribute towards their insurancc premium but excludes thosereceiving governmentinsurance.8 million O covered a policypurchased or through employer by by an \+ tg. .For these reasons.Coveredby someone outsidethe household . military etc. 160.9 * a. Like the Census Bureau. Our revised classification of private sector employer-paidhealth insuranceexcludes those who receive governmcnt insurancesuch as Medicare. Personsreceivingtheir principal health insurancefrom private employersin 1996. AHCPR estimates of govemment insurance exclude anyone who receivesprivate or self-purchased (seereferencenumber 6) insurance.) 141.Governmentworkersor dependents (federal.8million O (+ g. Medicare. and thosewhose ernployerpays none of their health insuranceprcmium costs.Privatesectoremployer-paid healthinsurance milliOn Figure 2. (seereferencenumber 2) AHCPR estimatesof health insuranceare from the Medical ExpenditurePanel Survey.Medicaid.Zmillion . and tndian Health Service. We use the same categoriesas the Census Bureau for govemment insuranceand also include those who receive insurance from a govemment employer. Estirnatesof govemment insuranceinclude all those who receive Medicare.Figure l.l mittion .g.7million S * ZZ. statesponsoredinsuranccplans.

0 Uninsured t2.5 29.0 96.age and race.2 28.3 28.8 r8 .l 2 4.4 Ll? 47.7 36.5 44.72 3r .1 t6.1 50.22 2032 25.9 l1i ra.7 20.4 20.7 41.0 6.02 6. 6 7.5 33.72 7.9 Jt.l Uninsured 15.6 I 1.6.2 Setf-purchaGE Insurance t.Columbia2 Florida Georgiat Hawaii ldahol lllinoisl Indianal lowa' Kansasl Kentucky Louisiana Ma.71 14. Private EmFtofti Total Gender Maler Female Age <lg I 8-39 40-641 >64 Race/Ethnicify Non Hisp.6 42.l 14.7 5.92 33.J t7.0 13. State Alabamal Alaska2 Arizona PrivateEmpto@ Paid fnsurance 46.4 6.I Arkansas Californial Coloradol Connecticutr Delawarel Dist.2 5.12 9.1 5.4 Governmenf Insurance 33.6 44.5 46.22 44.52 31.8 7.9 31.4 49.1 2t.5 21.3 I1.2 35.inel 33.0 4t.1 47. statrsrrcally srgnificantdifferencefrom reference group p <.62 33.9 34. 14.3 r 0.2 7.4 29.9 32.6 5t.4 7.6 t .6 16.8 5 .8 13.12 7.3 r4.0 43.3 6.1 25. Heatth fnsurance by State.1 33. I 37.1 32.6 I 1.92 50.2 28.8 22.4 t5.1 10. 9 17.4 1.6 9.s 35.2 43.0 54.7 7. Whiter Black Hispanic Paid lnsurance 43.7 39.72 33.6 r 1.8 8.62 29.0 50.l Self-PurchaGeE' Insurance 7.8 6.1 Governmeil lnsurance 34.2 39.4 9.9 49. l0 Table 2.8 6.8 10.9 0.9 36.Tabre l' percent ofpersons with hearthinsurance by gender.9 I.0 50.1 32.0 36.62 I Denotesreference group z.1 7.3 37.6 6.5 4t.9 31.92 rI.4 24.3 37.5 I 1.I 49.

Rockville (MD): Agency for Health Care and Policy research. 97-0030.MEPS Research Findings No.3 t2.4 13.4 l 1.338 (first of two parls):1003 .NEJM 1998.3 6. Govemment significantly more likely to provide insurance p than private ernployers <.0 SouthCarolinal 40.5 8.7 32.9 8.1997.6 8.Republicans draft tax bilt to aid personswithout health insurance. No.8 22. Available tiom URL: hhtp//www.9 31.338(secondoftwo paru): l0g4-10g7 J PearR.3 41.0 n.2 5.2 34.8 9.7 Ohio' 50.1 35.8 Texasl 38.5 35.5 9.0 16.3 9.8 Oklahoma2 34.7 7.bls. Warren JL' EggersPw.0 8.5 5.9 NorthDakota' 42.5 t3. Sourceand accuracy of the data for the March 1997Cunent PopulationSurvey microdatafile.9 5.2 30.8 Nebraskal 40.3 Rhodelslandr 48.9 t7.6 16.0 WestVirginia 38.4 42.census.4 Nevadar 49.9 t0.l 9.9 44.0 34. Health Insurance by State. SourceBook ofHealth Insurance Data:1996.0 32.5 13.2 18.0 9. [cited 1997 October l].0 Aa1 Virginial Washingtonl 42.8 I 1.6 l 1.0 l.2 Oregon' 45.8 6.4 12.5 29.6 36. The New york Timcs l99g March 30.0 New Hampshirel 53. Thirty yearsof Medicare: Irnpacton the coveredpopulation.4 4.5 Missourir 43. Scct A:l o Vistenes JP.7 Mississippi 36.Table 2.3 38.3 34.2 37. Privateernployerssignificantly more likely to provide insurancethan govemmentp<.9 39.4 4.1 Montana2 33. .(CONT) Private EmployerPaid Insurance Maryland 40. l.5 8.l 12.5 14.3 7. 7 Gomick ME.5 Vermontr 45.8 New Mexico? 2s.9 7.8 Wyoming 39.2 24.Health Care Financing Rev 1996.5 33.6 New York 39. How large ernployersare shapingthe healthcare market place.htm.3 Michiganl s3.2 13.3 17.5 8. l Wisconsin' 53.8 5.6 9.7 6.7 'fl Uninsured I1.5 6.4 New Jersey' 47.NEJM I 998.6 tt.2 44.4 9. et al.9 8.0 30.7 t3.8 36.7 7.gov/cps/ads/l 997lssrcacc. l 42.4 SouthDakota 40.5 l7. l0 ' Health Insurance AssociationofAmerica.2 36.6 Minnesota' 48.6 32.1 32.t8(2):179-231 8 Moore T.4 32.10 2. Health insurancestatusof the civilian non-institutionalized population:1996.5 5.3 31.AnnapolisJnct Md: Health InsuranceAssociafionof A m e r i c a :1 9 9 7 I Bennefield RL. Health insurance coverage: 996 Cun pop Rep I 997:p60-l 99 I I BodenheimerT Sullivan KHow large ernployersare shapingthe healthcare market place.1 32.5 32.5 State Government Insurance 39.5 6.4 15.0 NorthCarolina' 42.0 7.2 Tennessee2 33.2 Pennsylvanial 49.2 Self-Purchased lnsurance 9. AHCpR pub.6 7.5 15.2 5. l 43.0 Massachusettsr 50. MonheitAC.0 15.8 Utah' 47.1007 I Bodenheimer T Sullivan K.

American StatisticalAssociation Joint StatisticalMeetings 1996 August 6 Chicago IL . 1 4 4 6 .b a s e d a l t hi n s u r a n c e o he b e t w e e n1 9 8 8a n d 1 9 9 3 . H e a l t hi n s u r a n c e o v e r a s e : 1 9 9 C u r r P o p R e p 1 9 9 6 : P 6 0 -9 5 c 5 R l 2r Swartz K. W a n t e d :A c l e a r l ya r t i c u l a t e d o c i a le t h i c f o r t s A m e r i c a nH e a l t hC a r e .l n q u i r y 1 9 9 6 . 3 3 : 3 1 7 2t5 r r A c s G . A comparativeanalysisof health insurance coverageestimates:Data from CPS and SIPP. 9 9 4 H e a l t hC a r e F i n a n c i n g e r a 1 R I 9 9 6 :I 7 ( S u m m e r )I:5 7 -I 7 9 I 0R e t n h a r d U E .part-time work.14:233-242 :2 Bennefield RL.1 4 4 7 " Long SH RodgersJ.I 4 ( l ) : I 6 3 .18 I reHealth Care FinancingAdministration. 1 2I :tl . GAO/HEHS97-3 5 r5Ceneral Accounting Office.16:142-149 I'Swartz K. Waldo DR. Privatehealth insurance: continuederosionofcoverage coveragelinked to cost pressures. EconomicsSoc Measurerncnt J 1986. Interpretingestimatesfrom four national surveysofthe number ofpeople without health insurance. 1 0 2 . 1997. J Health Politics Policy Law 1990. L H o u s e h o l d s . B u s i n e s s .e C o w a n C A B r a d e nB R M c D o n e l l C A S i v a r a j a n .1995HCFA Publication 03373 r 0 B e n n e f i e l d L . E x p l a i n i n gt r e n d si n h e a l t hi n s u r a n c e o v e r a g e e t w e e n1 9 8 8a n d l 9 9 l I n q u i r y 1 9 9 5 : 3 2 . Baltimore Md: Health Care FinancingAdminisu-ation. Health Affairs 1997.J A M A 1 9 9 7 : 2 7 8 .&IEHS-97122 'o Cooper PF SchoneBS. Eppig FJ. GAO. More offers. 1995 HCFA Statistics. Why requiring employersto provide health insuranceis a bad idea. fewer takersfor ernployment-based health insurance:1996 and 1987. Do shifts toward service industnes. 1997. Hogan MO. n d G o v e m m e n tH e a l t hS p e n d i n g . and self-employmentexplain the nsing uninsuredrate? lnquiry 1 9 9 5 .15:779-796 It Chulis CS.l c b l0 '' GeneralAccounting Office. A n e x a m i n a t i o n f t h e d e c l i n ei n e m p l o y m e n t .l l 6 r 2F r o n s t i nP S n i d e rS C . Employment-based healthinsurancecoverage:costs increase and family coveragedecreases. Amett RH Health Insurance and the Elderly: Data from MCBS Health Care Fin Rev I 9 9 3 .