needed2

“Will Employers Drop Health Insurance Coverage because of the Affordable Care Act?” Health Affairs 32(9): 1522–1530

Thomas Buchmueller, Ross School of Business, University of Michigan, Ann Arbor

Colleen Carey, and School of Public Health, University of Michigan

Helen G. Levy Institute for Social Research and the Ford School of Public Policy, University of Michigan

Abstract

Since the passage of the Affordable Care Act, there has been considerable speculation about how

many employers will stop offering health insurance once the major coverage provisions of the Act

take effect. While some observers predict little aggregate effect, others believe that 2014 marks

the beginning of the end for our current system of employer- sponsored insurance. We address the

question “how will employer health insurance offering respond to health reform?” using

theoretical and empirical evidence. First, we describe economic models of why employers offer

insurance. Second, we recap the relevant provisions of health reform and use our economic

framework to consider how they may affect employer offers. Third, we review the various

predictions that have been made on this subject. Finally, we offer some observations on

interpreting early data from 2014.

“If you like the plan you have, you can keep it.

” President Obama

Since the passage of the Affordable Care Act, there has been considerable speculation about

how many employers will stop offering health insurance to their workers once the major

coverage provisions of the Act health insurance exchanges, premium tax credits for low-

income families, individual and employer mandates, and a Medicaid expansion take effect.

Speculation has only increased since the recent announcement by the Department of the

Treasury that the implementation of the employer penalty for not offering insurance will be

delayed until 2015.

The response of employers to health reform is important for several reasons. First, less

employer coverage may increase Federal outlays if more workers receive premium tax

credits in the exchanges or enroll in Medicaid. Second, if the employers who drop coverage

have relatively less healthy workers, this worsens the exchange risk pool, driving up average

premiums. Finally, the Affordable Care Act was presented to the American public as a

reform that would not seriously disrupt existing employer-sponsored coverage. To the

approximately 160 million Americans who have such coverage and are for the most part

NIH Public Access Author Manuscript Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.

Published in final edited form as: Health Aff (Millwood). 2013 September ; 32(9): 1522–1530. doi:10.1377/hlthaff.2013.0526.

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quite satisfied with it, large-scale employer dropping of coverage would be an unwelcome

surprise.

Some observers predict that health reform will have relatively little aggregate effect on

employer-sponsored coverage. Others believe that 2014 marks the beginning of the end for

our current system of employer-sponsored health insurance. This disagreement is driven at

least in part by fundamental differences in assumptions about employer behavior. To put it

more simply, what you think about how health reform will affect employer-sponsored

coverage depends on why you think employers provide insurance in the first place. We will

soon have early data on employers’ health insurance offerings for 2014. Making sense of

these data determining whether it is business as usual or the beginning of the end requires an

underlying model of how employers respond to incentives in choosing a menu of employee

benefits.

In this essay, we address the question “how will employer health insurance offering respond

to health reform?” from multiple perspectives. First, we briefly describe economic models of

why employers offer insurance and how they might respond to the changes that health

reform brings. Second, we recap the relevant provisions of health reform and use our

economic framework to consider how they are likely to affect employer offers. Third, we

review the various predictions that have been made on this subject. Finally, we offer some

observations on what to look for as early data from 2014 begin to come in.

1. The Economics of Employer Health Insurance Offering

Employers currently face no requirement to provide health insurance and yet most do; nearly

80% of full-time workers are eligible for employer-sponsored coverage (1). The economic

explanation for this relies on three factors: employers have a comparative advantage in

providing health insurance; workers bear the cost of health insurance through lower wages;

and employer benefit offerings reflect, albeit imperfectly, worker demand for health

insurance.

Employers have a comparative advantage in providing health insurance

There are three reasons why employer-sponsored insurance tends to be a better deal than

coverage in the individual market. First, employer-sponsored health insurance premiums are

not subject to federal or state income taxes or the Social Security payroll tax. For a typical

worker in the 15 percent tax bracket, the tax exclusion reduces the cost of insurance by

roughly one-third (2). For higher income workers, the subsidy is even greater. Research has

shown that this tax subsidy increases the likelihood that small firms offer insurance and

leads employers of all sizes to provide more generous coverage (3, 4). Second, employer

provision of insurance mitigates adverse selection. Workers in a large firm constitute an

effective risk pool, with premiums from the healthy subsidizing expenditures on the sick,

and aggregate medical claims that are fairly predictable from one year to the next. In

contrast, adverse selection in the individual market greatly limits the availability of

coverage. Third, since administrative and marketing costs are relatively fixed, employers

enjoy significant economies of scale. For a large group, the “loading factor” per enrollee -

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which includes profits and any risk premium in addition to administrative and marketing

costs - may be as little as half what it would be for individually purchased insurance (5).

Workers bear the cost of health insurance through lower wages

Economists are in near-unanimous agreement that workers ultimately pay for health

insurance through lower wages (6–8), unless minimum wages are a binding constraint (9).

The logic is that employers care about the cost of total compensation, not how compensation

is split between wages and benefits and, therefore, will only offer insurance if wages adjust

to keep total compensation constant. Because of the cost advantages just described, workers

who want health insurance will find this trade-off to be a good deal, particularly if the

marginal tax rate on earned income is high. There is considerable empirical evidence of a

compensating wage differential for health insurance (10–13).

Employer benefit offerings take into account worker preferences

Not all workers want health insurance, in the sense that they are not willing to trade off the

amount of wages required to pay for it. Even among workers who want insurance, some will

want more generous coverage than others. Because of both practical considerations and

Federal non-discrimination rules, employers generally cannot tailor health benefits to the

preferences of each individual worker (14, 15). Rather, they must balance the preferences of

workers who have a strong demand for insurance against those who are less willing to trade

wages for benefits, although it is not entirely clear how they do this (16–18). Firms may also

tailor employee premium contribution requirements or the scope of benefits in response to

diversity in worker demand for insurance (19). Clearly, the problem is simpler for employers

with workers who are similar to one another in their demand for insurance, although firms

may need to hire diverse workers depending on the nature of their business.

The advantages afforded to employer-sponsored insurance explain why most Americans

receive their health coverage through the workplace. Nonetheless, as increases in health care

costs have outpaced wage and price inflation, employer-sponsored coverage has declined

(20).

Exhibits 1 and 2 illustrate three features of the current market landscape that are important

for understanding the potential impact of the Affordable Care Act on employer-sponsored

coverage. First, the size of the circles highlights a fundamental feature of the labor market:

while most firms are very small roughly 60 percent of all private-sector employers have

fewer than 10 employees nearly two-thirds of private sector workers are employed at firms

with more than 100 employees. This means that the aggregate effect of the Affordable Care

Act on employer-sponsored insurance will depend disproportionately on the decisions made

by large employers and their workers.

Second, because both administrative economies of scale and the benefits of risk pooling

increase with group size, there is a strong positive relationship between firm size and

insurance offers. Only 36 percent of workers in firms with fewer than 10 employees are

offered coverage, compared to over 96 percent of workers in firms with 50 or more

employees. Part of this difference is likely due to the fact that small employers do not enjoy

the economies of scale and risk pooling that large employers do; in these respects, the

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market for small group coverage is characterized by some of the same problems as the

market for individual coverage. The data in Exhibit 1 also show that while employer-based

insurance rates have been stable for large firms, small business offer rates have fallen.

Third, Exhibit 2 shows that holding constant firm size, there is a strong relationship between

employee wages and employer-sponsored insurance coverage. The red circles correspond to

employers in which the majority of workers are “low-wage” workers, defined here as

workers earning less than $11.50 per hour. The dotted blue circles represent employers

where the majority of workers earn more than this amount. For all but the largest size

category, workers at high-wage firms are substantially more likely to be offered coverage

than those working at low-wage firms. The relationship between wages and employer-

sponsored insurance is in part driven by the tax exclusion for employer premiums, which

presents greater tax savings to higher-income workers. Other work has documented the

regressive nature of this tax expenditure (21).

2. Relevant Provisions of the Affordable Care Act

With these facts in mind, we consider which provisions of the Affordable Care Act are

likely to affect employers’ decisions about whether or not to offer insurance. First, though,

we note that there are other dimensions on which employers may respond to these

provisions. They may change employee premium contribution requirements; they may

adjust plan generosity; they may offer more or fewer plans; they may change their policies

for which workers are eligible for coverage. We do not attempt to consider these infra-

marginal decisions here, focusing instead on the bottom line offer/not offer decision, which

has been the focus of most policy attention.

Exhibit 3 describes the provisions of the ACA that are most relevant to employer health

insurance offering. We group these provisions into two categories: those that affect

employer decisions about offering health insurance coverage directly, and those that affect

this decision indirectly, through their effect on worker demand for coverage from their

employers. Provisions with direct effects include employer penalties for not offering

affordable coverage, small business health insurance exchanges, and small business health

insurance tax credits. Provisions that affect employers indirectly through their effect on

workers’ demand include health insurance exchanges, premium tax credits, Medicaid

expansion, and the individual mandate. While we do not attempt to predict the impact that

all of these provisions will have on employer offering this would, in effect, replicate the

work of the microsimulation models discussed in the next section some general observations

come from the simple economic understanding of firm behavior that is outlined above.

We begin by noting that the provisions affecting employers directly some of which affect

only large firms (50 or more full time employees) and some of which affect only small firms

all increase the likelihood that firms will offer coverage. Consider, first, the effect of the

employer “responsibility requirement” facing large employers who do not offer affordable

coverage to their full-time workers. As already noted, nearly all firms large enough to face

this penalty already offer coverage. The small minority of large firms that do not currently

offer insurance will face a choice of either offering coverage (and presumably reducing cash

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wages) or paying the penalty. For a typical full-time employee (40 hours per week, 50 weeks

per year) a $2,000 penalty raises the employer’s cost by $1/hour (although the per-employee

cost is reduced by the fact that the penalty does not apply to an employer’s first thirty

employees). Some employers in this group may decide that it is now worth offering

insurance. Others will not and will simply pay the penalty. Others will find ways to appear

to be “small” employers in order to avoid the penalty, such as reducing hours below the

ACA definition of “full time” (30 hours) or converting employees to contractors. For small

employers, who face no penalty for not offering coverage, the cost of offering coverage is

reduced by both the small business tax credits and the Small Business Health Options

Program (“SHOP exchanges”), insurance marketplaces intended to give small employers the

administrative efficiencies and risk-pooling long enjoyed by large employers.

Offsetting these incentives for employers to offer insurance is the fact that with one

exception (the individual mandate), the indirect provisions listed in Exhibit 3 largely

decrease worker demand for employer coverage. They do this by creating viable alternatives

to employer-sponsored coverage that cost low-income workers less than employer coverage.

The net effect of these new alternatives on employers’ incentive to offer coverage depends

on the characteristics of the firm and its workforce (22). In particular, for low-income

workers, the benefit of exchange coverage subsidized by premium tax credits exceeds the

value of the tax exclusion associated with employer-sponsored coverage, while for higher-

income workers the opposite will be true. Blumberg et al. identify 250% of the Federal

Poverty Level as the threshold at which the value of this credit will (on average) exceed the

value of the tax exclusion for employer-sponsored insurance (23), although the calculation

will depend on household circumstances, employee contributions, and plan parameters.

Since subsidized exchange coverage is available only for lower-income workers without

access to affordable employer-sponsored coverage, some lower-income workers who

wanted employer coverage in the past will now prefer not to be offered it, since it stands

between them and a generous tax credit. For employers who are already balancing the varied

demands of different workers in deciding whether or not to offer coverage this may tip the

balance against offering coverage. Or it may not.

Back on the other side of the ledger (i.e. in favor of employers continuing to offer

insurance), the individual mandate should increase workers’ demand for employer-

sponsored coverage. Indeed, the fact that employer offering actually increased after reform

was implemented in Massachusetts has largely been credited to the fact that workers want to

avoid paying tax penalties (24–27). This “crowd-in” effect for some workers potentially

offsets the reduction in demand for employer-sponsored coverage among others.

3. Projections of How the Affordable Care Act Will Affect Employer Offers

These competing incentives make it difficult to make simple predictions of how employers

and employees will respond. It is particularly hard to predict how small employers will

respond to the new incentives under the ACA. On the one hand, the factors just described

reduce small employers’ cost of offering coverage relative to what it is now; on the other

hand, they do not face penalties for not offering coverage, and to the extent that their

workers can now obtain affordable coverage through the exchanges, they do not necessarily

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need to offer coverage in order to attract workers. As noted above, however, the decisions of

large employers will drive the aggregate impact of the ACA on offering of employer-

sponsored insurance.

In light of this theoretical uncertainty, two main approaches have been used to make

projections about how the number of Americans with employer-sponsored insurance will

change after all provisions of the Affordable Care Act are in place. The most widely cited

estimates, including that of the Congressional Budget Office (CBO) who calculate

legislation’s budgetary “score”, are based on a microsimulation methodology (28, 29). The

second approach is to ask employers directly about how, if at all, their decisions concerning

health insurance are likely to change in 2014 and beyond. We review both types of

predictions.

Microsimulations

Microsimulation models combine data from nationally representative surveys with the best

evidence from the research literature to predict how families, employers and insurers will

respond to policies that alter their incentives (30, 31). The models used to simulate the

effects of health reform are based on the conventional economic theory summarized above,

although details vary across models. Employers are assumed to set their compensation

policies to attract and retain the desired number and type of employees, who implicitly pay

for employer-sponsored insurance with reduced wages. Employer and employee behavior is

modeled within the context of key institutional features of the system, such as Federal non-

discrimination rules that essentially prohibit firms from offering benefits to some full-time

workers but not others. Insurance premiums, which are a key input to these decisions, are

assumed to depend on the expected medical costs of the individuals who are insured and on

market regulations, such as guaranteed issue and community rating.

In addition to CBO, organizations that have conducted microsimulation analyses include the

Urban Institute (32, 33), the RAND Corporation (34), the Lewin Group (35), and the Office

of the Actuary (OACT) of the Center for Medicare and Medicaid Services (36). The bottom-

line predictions from these analyses about how health reform will affect employer offering

are summarized in Exhibit 4. Given the number of assumptions that must be made and the

complexity of the models, it is not surprising that different models yield different results.

However, it is clear from Exhibit 4 that even with different assumptions, the various models

tell a similar story. Consistent with economic logic discussed above, the models predict that

the Affordable Care Act will cause little change in the number of Americans covered by

employer-sponsored health insurance. The predicted change in employer-sponsored

coverage ranges from the CBO’s estimate of a 1.8 percentage point decline to RAND’s

estimate of a 2.9 percentage point increase. These estimated changes represent the net effect

of some workers and their dependents gaining coverage and others moving from employer

coverage to other categories.

These modest effects stand in contrast to a prediction by the American Action Forum (AAF)

that 43 million workers will lose access to employer coverage (37). We believe that a critical

assumption driving this difference is that while most microsimulation models assume that in

deciding whether or not to offer coverage employers aggregate their workers’ demand for

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health insurance as described above, the AAF estimates appear to assume employers offer

insurance to those who want it and withhold it from those who do not. This could happen

only if employers ignore federal non-discrimination regulations or dramatically restructure

firms so that workers with low demand for employer-based insurance are isolated in separate

firms or in part-time/temporary jobs. In addition, the AAF estimates overstate the number of

workers below 250 percent of the poverty line currently enrolled in employer coverage and

fail to include any offsetting increases in employer coverage due to factors such as the

individual mandate.

Because there is substantial uncertainty associated with projecting the effects of any policy,

especially one this significant, modelers typically conduct sensitivity analyses, varying key

behavioral assumptions. For example, in a 2012 report, the CBO discusses how alternative

assumptions about employers’ responsiveness to employee utility and their willingness to

restructure their firms affect their results (29). The most important finding that emerges from

this sensitivity testing is that even when alternative assumptions yield divergent estimates of

the number of workers with employer-sponsored insurance, they produce similar estimates

of overall insurance coverage and of the Federal budgetary cost of the coverage provisions.

The main reason for this latter result is that greater exchange enrollment entails greater

spending on premium tax credits, but lower tax expenditures for premiums as well as

increased revenue from employer penalties.

The estimates summarized in Exhibit 4 pertain to the Affordable Care Act as enacted in

March 2010. Recent developments such as states declining to expand Medicaid eligibility

and the one-year delay in the enforcement of the employer mandate are not reflected, since

most researchers have not released updated estimates. As of this writing, only CBO has

released updated estimates to reflect the fact that not all states will expand Medicaid; CBO

assumed that 30 percent of those otherwise eligible for Medicaid would reside in states that

do not fully expand eligibility and would instead enroll in the exchanges or go uninsured

(38). The Urban Institute predicts that the delay in the employer mandate will have no

effects on rates of coverage (39). These findings reinforce our view that rates of employer-

sponsored coverage are driven by the business case for benefits for the firm’s workers.

Predictions Based on Employer Surveys

Two caveats apply to interpreting survey evidence on firm behavior. Firstly, because most

firms are small but most employees work for large firms, estimates of the number of firms

adding or dropping coverage can be difficult to translate into corresponding numbers of

individuals affected. Secondly, surveys of employers currently offering insurance the

sampling frame of the surveys described below will miss offsetting increases from firms

beginning to offer benefits, and therefore cannot predict net changes in coverage.

With those caveats noted, the results of a number of surveys are consistent with the

predictions from microsimulation models. Most surveys suggest that most employers

offering health insurance now will continue to offer it in 2014, and that the vast majority of

individuals enrolled in employer-sponsored insurance will continue in it next year. In one

2012 survey, 9% of currently offering large firms, representing 3% of the workforce, said

that they anticipated dropping coverage in the next three years, an estimate consistent with

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the microsimulation estimates of gross flows from employer-based coverage (40). In a 2013

survey, nearly all (98%) of very large firms (firms with more than 1000 employees, which

account for about half of total employment) said that they expected health benefits to be an

important component of compensation three to five years from now (41).

These survey results suggest that reports of the demise of employer-sponsored coverage

soon after the Act’s passage (42) may have reflected a lack of awareness of its true effects

on employers’ incentives. The International Foundation of Employee Benefit Plans has

surveyed plans repeatedly since the Affordable Care Act became law (43, 44). Over the last

two years, it reports that fewer employers are “taking a ‘wait-and-see’ approach” and more

employers have “modeled the financial impact of reform”. Over the same period, the

number of employers who are considering dropping benefits has fallen by half to 2% and the

share of employers reporting they will definitely offer coverage in 2014 jumped from 46%

to 69%.

At the same time, employers continue to report uncertainty about various provisions of the

Affordable Care Act. In March 2013, 84% of employers reported that they were still

studying the Act (44). Only two-thirds of large employers are “familiar” with the shared

responsibility penalty (40). As firms see the Act’s provisions in action, they may explore

new health insurance options. Among firms with 50 to 100 employees, 71% reported that

they would be more likely to participate in the SHOP exchanges if a large choice of plans

were available at the employer’s targeted benefit level (40).

4. Summing up and looking ahead

For an employer, deciding whether or not to offer health insurance already requires a

complex calculus that takes into account a host of factors including employee preferences,

wages, taxes, and regulations. The Affordable Care Act throws more into the mix new taxes,

new subsidies, new requirements, new insurance markets. But it does not fundamentally

change the economics of the firm. Microsimulation models built on sound economic

principles have for the most part predicted relatively small declines in employer-sponsored

coverage as a result of the Affordable Care Act, and we believe that these predictions are

likely to be correct.

If we are wrong, though, how will we know? Inevitably, reports will come in that some

employers are dropping coverage. Although it will be tempting to attribute reported changes

to the Affordable Care Act, it is important to interpret new data on employer-sponsored

insurance coverage within the context of the basic economics of firm behavior and pre-

existing trends. For decades, the combination of rising health care costs and stagnant

earnings for middle income workers have led to a gradual, but steady decline in employer-

sponsored insurance. This trend is the appropriate baseline against which to measure the

impact of health reform.

It is, perhaps, stating the obvious to add a caution against reading too much into anecdotal

reports. But, for reasons described above, even surveys with large samples can produce

results that are difficult to interpret. Fortunately, there are several high quality data resources

that will be useful for monitoring changes in employer-sponsored insurance and drawing

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inferences about the effect of health reform. We expect that the earliest data on rates of

coverage will come in September 2014, when both the National Health Interview Survey

and the Current Population Survey should report on individuals’ sources of coverage in early

2014. If historical patterns hold, the Kaiser Family Foundation’s survey of employer-

sponsored insurance will be published the same month. A year later, in September 2015 the

American Community Survey will provide state and metro-area estimates of individual-level

coverage patterns, and in July 2015 the Medical Expenditure Panel Survey will provide

further information on employer offerings. Of course, effects in early 2014 will not be the

last word as individuals and employers may take a wait-and-see approach. And since the

employer penalty for not offering coverage will not take effect until 2015, it may be several

years before the true effects of these policies become evident.

These data will begin to answer the question posed in our title. Given the historical

importance of employer-sponsored insurance, the attention that is paid to this question is

understandable. However, it is not a question of great economic significance. There is no

efficiency argument for preferring private insurance facilitated by employers to private

insurance facilitated by the state or any other mechanism that could be used to pool risk and

achieve administrative economies of scale. It is also important to remember that relying on

firms as a mechanism for pooling insurance risk generates efficiency costs because of labor

market distortions. A better functioning individual health insurance market has the potential

to improve labor market efficiency by reducing job-lock, eliminating a barrier to

entrepreneurship and making it easier for workers to find a job and an insurance plan that

matches their preferences. If the shift from employer-sponsored insurance to individual

coverage is greater than projected, these labor market gains may be significant.

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Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.

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Exhibit 1. Percent of Private Sector Workers Receiving Offers of Health Insurance, by Firm Size, 2000

and 2011

Source: Medical Expenditure Panel Survey, Insurance Component.

Buchmueller et al. Page 12

Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.

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Exhibit 2. Percent of Private Sector Workers Receiving Offers of Health Insurance, by Firm Size and

Majority Low-Wage Status, 2011

Source: Medical Expenditure Panel Survey, Insurance Component.

Buchmueller et al. Page 13

Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.

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Exhibit 3

Major Affordable Care Act Provisions Affecting Employer Health Insurance Offering

Provisions affecting employers directly: Impact on offering:

Employer penalties: Employers with 50 or more full-time workers face a penalty if any of their full-time workers qualifies for a premium tax credit. If the firm does not offer coverage at all the penalty is $2,000 for each full-time worker beyond the first 30. If the firm offers coverage that is not affordable, the penalty is the lesser of (1) $3,000 for each full-time worker who receives a credit or (2) $2,000 for each full-time worker in the firm beyond the first 30. Originally scheduled to take effect in 2014, HHS recently announced that this penalty will not be implemented until 2015.

Increase offering for large firms

Small business exchanges: Establishes the Small Business Health Options Program (“SHOP exchange”) on which small employers, defined as those with fewer than 50 full-time workers, can get coverage. Between 2014 and 2016, states may choose to allow employers with 50 to 100 workers in the SHOP exchange; in 2017 and later, they may choose to allow employers of any size to offer coverage from the SHOP exchange. As of 2014 in some states and 2015 in others, a small employer may designate a menu of insurance options for employees.

Increase offering for small firms

Small business tax credits: Employers with fewer than 25 employees and average annual wages below $50,000 are eligible for premium tax credits to offset the cost of coverage for up to 2 years. The maximum credit is currently 35 percent, rising to 50 percent in 2014. In 2014 and later, coverage must be purchased through a SHOP exchange.

Increase offering for small, low- wage firms

Provisions affecting worker demand for employer-sponsored insurance:

Health insurance exchanges with community rating and guaranteed issue: Exchanges should, in theory, provide a viable alternative to employer-sponsored insurance since they capture the “economies of scale” and “risk pooling” advantages that employers have. In practice this depends on what the exchange risk pool looks like.

Reduce offering for firms with many low- income workers

Premium tax credits: Premium tax credits are available to workers without access to affordable employer- sponsored coverage, where “affordable” means that the worker’s share of the premium for single coverage does not exceed 9.5 of the worker’s income.

Reduce offering for firms with many low- income workers

Medicaid expansion: In some states, all individuals with incomes below 138% of the Federal poverty threshold will become eligible for Medicaid.

Reduce offering for firms with many low- income workers

Individual mandate: Individuals who lack coverage for more than 3 months in a year face a penalty that is phased in between 2014 and 2016. The penalty is the greater of $285/1% of family income in 2014, $975/2% of family income in 2015, and $2,085/2.5% of family income in 2016 and later. Exemptions apply in the case of hardship, families with incomes below the tax filing threshold, Indians, and certain religious groups.

Increase offering

Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.

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Buchmueller et al. Page 15

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Health Aff (Millwood). Author manuscript; available in PMC 2014 July 31.