The reports last week from two respected surveys that health insurance costs are continuing to run well ahead of both wages and general inflation should be a signal to workers to get ready for higher premiums in the coming year and more "cost-sharing" when they see the doctor.
Employers, who continue to bear the bulk of workers' health care costs across the country, have all but despaired of seeing these expenses brought under control, and thus increasingly are willing to boost the share borne by employees.
A few companies, mostly very small ones, will probably drop employee health insurance altogether, a process that is steadily eroding coverage over time. According to the Kaiser Family Foundation, which conducted one of the surveys, the percentage of employers offering health insurance has slid from 69 percent to 60 since 2000.
But for most workers, the employer response has been simply to require workers to pay more, and the other survey, by Mercer Human Resource Consulting, indicates many are looking hard for ways to do that.
The survey shows -- based on preliminary results; the full study will be out later this fall -- that companies figure they would see a 10 percent rise in their health care costs if they were to take no action. But the rise they are planning for is 6.4 percent, and the difference will come from what benefits people delicately call "plan changes."
Put more bluntly, that means workers will pay more and perhaps get less.
Employers in recent years have tended to set a target for the cost increase they will permit, said Blaine Bos of Mercer. In recent years, that target has been between 6 and 7 percent, he said. "That is what employers are saying [they] need to have in order to be able to compete."
To get there, employers have been implementing a number of tactics. Besides requiring employees to put up more dollars for the coverage, they have been doing such things as boosting the deductibles workers and their families must pay before insurance kicks in; increasing "co-pays" and "coinsurance," which workers must pay for medical services; and increasing "out-of-pocket" limits on the total amount of money that a worker may be required to pay for medical care in a year.
So what can workers and their families do?
This may be the year to go back to the future, or forward into the unknown.
Kaiser's data show that the cheapest common type of plan continues to be the much-maligned health maintenance organization. HMO premiums average about $500 a year less than those of the more-popular preferred provider organizations, which now enroll about three of every five workers who have employer-sponsored health insurance.
At a time of steadily rising costs, one might expect HMOs to be gaining market share, but the opposite is happening, Kaiser found. HMO enrollment has dropped to 21 percent of workers from 25 percent last year.
HMOs employ or contract with doctors and hospitals and generally promise to provide the care you need for a flat fee. A doctor visit might cost you, say, $20, but beyond that, if the HMO finds you need more care, there may be no or very modest further fees.
But the HMO decides what you need -- the essence of what has come to be called managed care -- and many people don't like that.
There would seem to be "reasons to argue why higher health care costs would bring a return to the stricter forms of managed care, but employers have gone in other directions," said Drew E. Altman, president of the Kaiser Family Foundation (which is not associated with Kaiser Permanente, the big health care organization). "I would say that the managed care backlash of the late '90s that did away with the stricter forms of managed care" continues to override the allure of potential savings.
Ironically, efforts to make HMOs attractive to employees have tended to make them less popular with employers, several consultants said.
While "HMOs may be the most cost-effective model, one of the issues is that most HMOs continue to offer very rich benefits compared to PPOs. From a cost perspective, they almost start out with a handicap," said Tom Billett, a senior consultant at Watson Wyatt Worldwide.
Mercer's Bos said this isn't lost on employers.
The HMO "design was created in the '80s to attract people into giving up complete and total choice of provider. The attraction was to know the out-of-pocket amount and [know] that it was very reasonable," Bos said.
Now, some employers "are saying that's not a good thing," because employees may come to assume that it costs only $20 to see a doctor, and therefore may overuse the system. Thus, some are reducing or eliminating HMO options from the plans and/or raising the price on any remaining ones, he said.
But for families on tight budgets, 2006 may be the year to rethink their dislike of HMOs. If one remains available through your employer, check it out carefully, not only by looking at its literature but by asking co-workers who belong what their experience has been. And be aware of limitations. For example, some HMOs are geographically limited and provide no non-emergency benefits outside their home area.
At the other extreme, and in almost complete contrast to HMOs, you may be offered for next year one of the "consumer-driven" health care plans that some theorists believe will greatly help control medical costs.
These combine a high-deductible insurance policy with a savings/investment account funded by you and/or your employer on a deductible or pretax basis. The high-deductible policy covers serious illnesses; the account can be used for other expenses, and if you don't spend it you can keep it.
This arrangement is meant to encourage workers to shop for inexpensive treatment and to avoid unnecessary spending. Whether it will work as an overall restraint on health care costs is as yet unknown -- Kaiser found too few workers so far enrolled to draw any conclusions -- but it has obvious appeal to young, healthy workers.
Those who can go years with minimal health care spending can pile up serious money in one of these accounts.
These two approaches -- the old HMO and the new consumer-driven account -- could hardly be more different in structure and philosophy. And they are likely to appeal to quite different populations. Experts don't expect people who have been in HMOs to shift to consumer-driven accounts. "It's not like moving from Pittsburgh to Philadelphia," Bos said. "It's like moving from Pittsburgh to Mars."
People who go into consumer-driven accounts will likely come mostly from PPOs, he said. "That's like moving from the moon to Mars."