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Objective: To determine the sensitivity of employees’ health insurance decisions—including the decision to not choose health maintenance organization or fee-for-service coverage—during periods of rapidly escalating healthcare costs.    Study Design: A retrospective cohort study of employee plan choices at a single large firm with a “cafeteria-style” benefits plan wherein employees paid all the additional cost of purchasing more generous insurance.    Methods: We modeled the probability that an employee would drop coverage or switch plans in response to employee premium increases using data from a single large US company with employees across 47 states during the 3-year period of 1989 through 1991, a time of large premium increases within and across plans.    Results: Premium increases induced substantial plan switching. Single employees were more likely to respond to premium increases by dropping coverage, whereas families tended to switch to another plan. Premium increases of 10% induced 7% of single employees to drop or severely cut back on coverage; 13% to switch to another plan; and 80% to remain in their existing plan. Similar figures for those with family coverage were 11%, 12%, and 77%, respectively. Simulation results that control for known covariates show similar increases. When faced with a dramatic increase in premiums—on the order of 20%—nearly one fifth of the single employees dropped coverage compared with 10% of those with family coverage.    Conclusions: Employee coverage decisions are sensitive to rapidly increasing premiums, and single employees may be likely to drop coverage. This finding suggests that sustained premium increases could induce substantial increases in the number of uninsured individuals.

The Reallocation of Compensation in Response to Health Insurance Premium Increases