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By DICK GOFF, president of the Self-Insurance Institute of America Inc., a national trade association whose members are involved in the self-insurance/alternative risk transfer marketplace

It's safe to say that January 2009 is very different than anyone would have predicted in January 2008. The combination of new political leadership and a foundering economy leaves us in a strange public policy environment.

For members of the Self-Insurance Institute of America Inc., thousands of employers that sponsor employee health benefit plans with millions of members, change must not come abruptly or without concern for their needs. At present, 160 million Americans are covered by employer-sponsored health plans. The security of their coverage must, we believe, be a paramount consideration.

This is so important to get right that we are going to show some restraint in our responses to the forces of change. We will constructively engage with them to make sure the interests of members of employer-sponsored self-insured health plans are served. For us, this means more educational efforts and collaboration rather than combat. However, if the administration and/or members of Congress seek to dismantle the employment-based healthcare system, combat will be required.

Given SIIA's strong reputation on Capitol Hill, we expect to have the opportunity to be part of the discussion and provide technical support in order to refine any legislative proposal that could indirectly lead to the erosion of employment-based health coverage for those 160 million Americans who now count on it.

SIIA has a long history of contributing to the national healthcare debate. Our most recent contribution was the release in 2008 of our Blueprint for Sensible Health Care Reform, which is the backbone of our effort to extend coverage to uninsured people while preserving the employer-based system. The Blueprint, available online at www.siia.org, offers four methods to broaden coverage among uninsured persons: cost containment, reliance on the employer-based healthcare system, small-business pooling arrangements and tax incentives, summarized below.

Cost containment. Controlling healthcare costs would stimulate many additional employers to provide health plans and reduce the number of uninsured persons. America currently spends more on healthcare than any other country in the world. We believe this is because of inefficiencies, lack of competition, overuse or inappropriate use of services, and the lack of modern information technology. SIIA's specific recommendations are:

--Price transparency. Healthcare is the only product that denies consumers the ability to shop by comparing costs, optional treatments and quality.

--Healthcare price data should be compiled by the Department of Health and Human Services. Regional list prices (consistent prices for all customers) and quality assessments would enable consumers to knowledgeably select providers for specific health treatments.

--Creation of lifetime personal electronic medical records controlled by consumers.

--Tax credits and financial grants to help providers and payers develop health IT systems and other components for fully wired healthcare practice and insurance administration.

Rely on the employer-based system. Employer health plans have found great efficiency through the federal preemption provided by the Employee Retirement Income Security Act, which allows an employer with a multistate workforce to maintain a consistent program with all of the cost savings and administrative efficiencies of central management. Erosion of ERISA would lead to a patchwork of state regulations that would burden plans with severe administrative expenses and costs of varying mandatory treatments. Weakening ERISA would actually have the reverse effect on the number of uninsured as many employers would reduce or curtail their health plans.

Small business pooling arrangements. A full 60 percent of the working uninsured work for, or depend on, small employers who lack the financial ability to provide health coverage. The Congressional Budget Office estimates that multistate small business pooling arrangements would save the typical small business owner between 15 percent and 30 percent on employee health insurance.

Legislative solutions would permit small businesses to work together to take advantage of economies of scale to obtain affordable health coverage for their employees. Those arrangements would be regulated by the Department of Labor, which now oversees ERISA plans, and with the understanding that the private sector will continue to create and manage the pooling arrangements.

Tax incentives. Smaller employers should be added to the number of midsize and large employers that now benefit from tax incentives to provide employee health coverage. Small employers and self-employers are now excluded from such tax code advantages.

The current tax code treats big business employee health costs as a deductible business expense, but for certain small businesses, healthcare costs are treated as taxable compensation. Tax incentives to these groups that result in new healthcare coverage will reduce the number of uninsured Americans. Incentives can also help increase the use of less traditional techniques in the fields of preventive care and wellness, which can help lead to lower long-term healthcare costs.

Consumer-driven healthcare is an expanding form that is also incentivized by the tax code. Under current IRS regulations, medical savings accounts such as health savings accounts and flexible spending accounts are restricted and cannot be implemented by companies to their greatest benefit.

SIIA believes that individuals participating in an HSA should be able to deduct the premiums for the high-deductible health insurance policies from their taxable income. Also, the tax code should increase contribution limits to HSAs (with attention to early retirees aged 55 to 64) and allow them to incorporate flexible spending and health reimbursement arrangements.

Finally, the tax code should eliminate the "use it or lose it" rule that states that the money in FSAs must be spent within the "plan year" or be forfeited back to the company.

January 1, 2009

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