While I do not see a wholesale move away from ESI due to the ACA in the large group market, the economic advantages make it almost impossible for small employers not to drop their coverage, offer a defined contribution through an HRA and have their employees shop its state's health insurance exchange for coverage. This move would save them both money and headaches.
We are going to see the ongoing move to defined contribution and many other changes like HSA etc but the workplace will continue to be a major source of access to coverage even if payment mechanisms and coverage options like Exchanges are now part of the mix. Good overview below:
http://www.huffingtonpost.com/wendell-potter/got-health-insurance-thro_b_878050.html
As for the McKinsey study, as I noted yesterday it has come under major criticism and was called out by the Senate Finance Committee.
http://tpmdc.talkingpointsmemo.com/2011/06/max-baucus-issues-public-call-to-mckinsey-to-come-clean-about-controversial-hcr-survey.php
Also IFEBP's study didn't support their conclusions:
http://www.plansponsor.com/Despite_Anticipated_Costs_Most_Employers_to_Keep_Health_Care_Benefits.aspx
Nor did the Urban Institute study (1/2011) co authored by the head of McKinsey's healthcare practice.
http://www.urban.org/uploadedpdf/412295-Employer-Sponsored-Insurance.pdf
Also the MA experience is indeed relevant as it is the only one to compare to other than UT which also has declined a point or 2 since their limited exchange went into effect. Here is a total review of MA by the BCBS of MA that is quite interesting:
https://c.na7.content.force.com/servlet/servlet.FileDownload?file=015A0000001ZOSL
With nearly 3 years until ACA becomes fully implemented many things will evolve, and I do not believe a SCOTUS strike down will occur of the individual mandate.
The option of doing nothing or simply trying to leave it "to the market" is a non-starter because there is no real market or incentive for the insurers to change and become more consumer friendly and transparent.
It will be interesting to watch this all evolve esp. with the MLR limits and total transparency for health plan exec comp. and for rate increase requests, rebates etc. Aetna and BS of CA are already showing that the MLR's can reduce premiums.
As I have said many times before, health care insurance is a truly dynamic field with more and more changes and shifts to come.
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