[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




 AN UPDATE ON THE SMALL BUSINESS HEALTH OPTIONS PROGRAM: IS IT WORKING 
                         FOR SMALL BUSINESSES?
=======================================================================


                                HEARING

                               before the

                 SUBCOMMITTEE ON HEALTH AND TECHNOLOGY

                                 OF THE

                      COMMITTEE ON SMALL BUSINESS
                             UNITED STATES
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD
                              
                           SEPTEMBER 18, 2014

                               __________

                             [GRAPHIC] [TIFF OMITTED] 
                               

            Small Business Committee Document Number 113-084
            
              Available via the GPO Website: www.fdsys.gov
              

                                 ______
                                       
                      U.S. GOVERNMENT PUBLISHING OFFICE 

89-780 PDF                     WASHINGTON : 2015 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Printing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001
              
              
                  HOUSE COMMITTEE ON SMALL BUSINESS

                     SAM GRAVES, Missouri, Chairman
                           STEVE CHABOT, Ohio
                            STEVE KING, Iowa
                         MIKE COFFMAN, Colorado
                      BLAINE LUETKEMEYER, Missouri
                     MICK MULVANEY, South Carolina
                         SCOTT TIPTON, Colorado
                   JAIME HERRERA BEUTLER, Washington
                        RICHARD HANNA, New York
                         TIM HUELSKAMP, Kansas
                       DAVID SCHWEIKERT, Arizona
                       KERRY BENTIVOLIO, Michigan
                        CHRIS COLLINS, New York
                        TOM RICE, South Carolina
               NYDIA VELAAZQUEZ, New York, Ranking Member
                         KURT SCHRADER, Oregon
                        YVETTE CLARKE, New York
                          JUDY CHU, California
                        JANICE HAHN, California
                     DONALD PAYNE, JR., New Jersey
                          GRACE MENG, New York
                        BRAD SCHNEIDER, Illinois
                          RON BARBER, Arizona
                    ANN McLANE KUSTER, New Hampshire
                        PATRICK MURPHY, Florida

                      Lori Salley, Staff Director
                    Paul Sass Deputy Staff Director
                      Barry Pineles, Chief Counsel
                  Michael Day, Minority Staff Director
                  
                  
                            C O N T E N T S

                           OPENING STATEMENTS

                                                                   Page
Hon. Chris Collins...............................................     1
Hon. Janice Hahn.................................................     2

                               WITNESSES

Ms. Mayra Alvarez, Director, State Exchange Group, Center for 
  Consumer Information and Insurance Oversight, Centers for 
  Medicare and Medicaid Services, Washington, DC.................     4
Dr. Roger Stark, Healthcare Policy Analyst, Washington Policy 
  Center, Seattle, WA............................................     6
Mr. Adam Beck, Assistant Professor of Health Insurance, The 
  American College of Financial Services, Bryn Mawr, PA..........     8
Mr. Jon Gabel, Senior Fellow, National Opinion Research Center, 
  University of Chicago, Bethesda, MD............................    10

                                APPENDIX

Prepared Statements:
    Ms. Mayra Alvarez, Director, State Exchange Group, Center for 
      Consumer Information and Insurance Oversight, Centers for 
      Medicare and Medicaid Services, Washington, DC.............    26
    Dr. Roger Stark, Healthcare Policy Analyst, Washington Policy 
      Center, Seattle, WA........................................    33
    Mr. Adam Beck, Assistant Professor of Health Insurance, The 
      American College of Financial Services, Bryn Mawr, PA......    37
    Mr. Jon Gabel, Senior Fellow, National Opinion Research 
      Center, University of Chicago, Bethesda, MD................    45
Questions for the Record:
    None.
Answers for the Record:
    None.
Additional Material for the Record:
    Heath Affairs................................................    57
    Letter from Lauren Aronson, Director, Office of Legislation, 
      Centers for Medicare & Medicaid Services to Hon. Chris 
      Collins, Chairman, Subcommittee on Health and Technology, 
      Committee on Small Business................................    77

 
 AN UPDATE ON THE SMALL BUSINESS HEALTH OPTIONS PROGRAM: IS IT WORKING 
                         FOR SMALL BUSINESSES?

                              ----------                              

                      THURSDAY, SEPTEMBER 18, 2014

                  House of Representatives,
               Committee on Small Business,
             Subcommittee on Health and Technology,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 1:00 p.m., in 
Room 2360, Rayburn House Office Building. Hon. Chris Collins 
[chairman of the subcommittee] presiding.
    Present: Representatives Collins, Luetkemeyer, Herrera 
Beutler, Hahn, and Schneider.
    Chairman COLLINS. I call this hearing to order.
    I would like to thank our witnesses for appearing today on 
our Committee's second hearing regarding the implementation of 
the health care Small Business Health Options Program, which we 
all know as the SHOP program.
    The SHOPs are marketplaces established by President Obama's 
health care law and are intended to assist certain small 
businesses in shopping for, comparing, and enrolling in health 
insurance plans for their employees. The Administration 
promised that the SHOP Exchanges would simplify the process of 
obtaining insurance, expand health insurance coverage options 
for small businesses, increase small business purchasing power 
to lower costs, and put consumers in charge of their health 
care.
    Unfortunately, the reality of the program is far less than 
promised. Despite spending vast amounts of time and taxpayer 
dollars regarding the SHOPs, the program continues to be beset 
by operational delays and other problems that have undermined 
their utility as a tool for small businesses. These problems 
include the inability to utilize web-based portals, limited 
choice of plans, and a lack of insurance carrier participation 
in the SHOPs.
    The Committee has sent multiple letters to then-Health and 
Human Services Secretary Kathleen Sebelius and Administrator of 
the Centers for Medicare and Medicaid Services Marilyn
    Tavenner to express our ongoing concerns about the 
seemingly endless problems besetting this program and to get 
answers about small business participation rates.
    Unfortunately, the answers have not been provided. 
Specifically, in January of this year, Chairman Graves sent a 
letter to the Department requesting enrollment figures for the 
SHOPs exchanges. This inquiry was followed by another letter in 
June. To date, the responses the Department has provided have 
not included information on the data on SHOPs enrollment.
    In addition, last year, the Committee commissioned the 
Government Accountability Office to undertake an examination of 
the Department's implementation of the SHOP Exchanges. This 
report found a number of challenges the Department would need 
to overcome in order to make the SHOPS operational by the 
Department's original October 1, 2013 deadline. It appears 
these warnings were not heeded and the predictions of problems 
accurate.
    For small businesses, the lack of operational SHOP 
Exchanges is one in a long list of disappointments and 
challenges they face in the wake of the health care law's 
implementation. Small businesses also face cancelled health 
insurance plans, higher premiums, higher deductibles, smaller 
provider networks, more paperwork, and onerous reporting 
requirements--all the result of this misguided health care law.
    Today, I hope we will hear some answers about what small 
businesses can expect of the SHOPs and when the health care law 
will start working for them.
    Ms. Hahn is not here so we will let her make her opening 
statement when she arrives, but we will roll into the testimony 
of our witnesses.
    First of all, to explain the lights, the lights will be 
green as you are speaking. You have five minutes to deliver 
your testimony. You will see them turn yellow and then red. We 
will not adhere completely to that, but that is how the lights 
work.
    So now that Ms. Hahn is here, we will delay your testimony 
just a moment and let her set up and have her deliver her 
opening statement. Sorry that we went without you but with the 
tight time schedule we----
    Ms. HAHN. I heard you went without me without consent.
    Chairman COLLINS. Oh, everyone that was here gave consent.
    Ms. HAHN. Okay.
    Where is my opening statement?
    I am ready.
    Chairman COLLINS. Okay.
    Ms. HAHN. Thank you.
    Chairman COLLINS. I now turn it over to Ms. Hahn for her 
opening statement.
    Ms. HAHN. Thank you, Mr. Chair. It is great to be here.
    My opening statement is in 2010, Congress made history with 
the passage of the Affordable Care Act. And while this law is 
not perfect, it has benefitted families across the country. 
Families no longer find themselves at the mercy of insurance 
companies. People with preexisting conditions can no longer be 
denied coverage. And this year, millions of Americans signed up 
for health coverage through the healthcare.gov website. And the 
uninsured rate has dipped to the lowest level in over a decade.
    But the Affordable Care Act has not just helped families; 
it has helped small businesses also. And while 96 percent of 
small businesses are not required under the ACA to purchase 
coverage, those that choose to are seeing more options and more 
savings. For years, small businesses in every sector have 
struggled with the rising cost of health care. In fact, in a 
study by the National Federation of Independent Business, small 
business owners cited health insurance costs as the number one 
problem facing their business in 2012.
    Because of the Affordable Care Act, we are beginning to 
make some progress. In the period since the enactment of the 
health care law, we have seen the slowest health care price 
growth in almost 50 years. Employer premiums are now growing at 
less than half the rate of the previous decade.
    Small businesses in particular are seeing benefits. Before 
the Affordable Care Act, small businesses paid 18 percent more 
in premiums than their larger competitors for the same 
benefits. They could see their premiums increase dramatically 
if an employee had an accident or was diagnosed with a serious 
illness. Small businesses could be charged more for employing 
women or people with preexisting conditions, or for operating 
in blue collar industries like construction or roofing. Now, 
for the first time, small businesses have an opportunity to 
leverage their buying power with other small businesses in the 
SHOP Marketplace. The businesses enrolled in the new 
marketplaces are finding quality, affordable coverage and many 
qualify for a tax credit that can cut their premiums by as much 
as 50 percent. Three hundred sixty thousand small businesses 
have already used the Small Business Health Care Tax Credit 
available through the SHOP Exchanges to help them afford health 
insurance for two million American workers.
    Take Lorenzo Harris, for example. Lorenzo Harris is the CEO 
of Janico Building Services, a full-service janitorial company 
with 40 employees in California. This year he transferred 
Janico's full-time employees from their existing health plan to 
California's SHOP Exchange and saw his premium costs go down by 
30 percent. He also qualified for a health care tax credit of 
more than $1,000. This is great news, and I expect we are going 
to hear even more success stories like this, particularly from 
California, as the shops enter their second year in business.
    Now, I know the Affordable Care Act is not perfect, and I 
expect today that we are going to hear both about some of the 
successes of ACA, as well as some of the criticism of the 
health care law's implementation. This should prompt us in 
Congress to fix the areas that need improvement. Medicare was 
passed nearly 50 years ago, and we are still making 
improvements and refinements to that law. That does not mean 
Medicare was a bad law; it means the job of Congress is to 
preserve what works and fix what does not.
    I am looking forward to hearing the testimony of our 
witnesses today and the opportunity to learn more about how we 
can work together to ensure that our small businesses have 
access to quality, affordable health care options.
    And I yield back.
    Chairman COLLINS. Thank you, Ms. Hahn.
    I would now like to introduce our first witness, Mayra 
Alvarez, who serves as the Director of the State Exchange Group 
at the Center for Consumer Information and Oversight at the 
Centers for Medicare and Medicaid Services. Prior to assuming 
her current position, Ms. Alvarez also served as associate 
director of the Office of Minority Health at the Department of 
Health and Human Services. She has served on the staffs of 
Senator Richard Durbin, former Congresswoman Hilda Solis, and 
then Senator Barack Obama.
    Ms. Alvarez, thank you for appearing today, and you may now 
deliver your testimony.

 STATEMENTS OF MAYRA ALVAREZ, DIRECTOR, STATE EXCHANGE GROUP, 
CENTER FOR CONSUMER INFORMATION AND INSURANCE OVERSIGHT; ROGER 
 STARK, HEALTH CARE POLICY ANALYST, WASHINGTON POLICY CENTER; 
    ADAM BECK, ASSISTANT PROFESSOR OF HEALTH INSURANCE, THE 
   AMERICAN COLLEGE OF FINANCIAL SERVICES; JON GABEL, SENIOR 
              FELLOW, NORC, UNIVERSITY OF CHICAGO

                   STATEMENT OF MAYRA ALVAREZ

    Ms. ALVAREZ. Good afternoon, Chairman Collins, Ranking 
Member Hahn, and members of the Subcommittee. Thank you for the 
opportunity to discuss the benefits of the Small Business 
Health Options Program (SHOP) for small businesses and their 
employees.
    Since last fall, SHOP has been working to provide small 
employers a new way to shop for health insurance coverage, and 
we look forward to offering even more with the addition of 
online functionality this fall. In the past, although many 
small employers have wanted to offer health benefits to their 
employees, they have faced many challenges. Historically, small 
businesses have been charged 10 to 18 percent more than large 
employers for the same benefits. Small businesses employing 
women or workers with high cost illnesses have faced higher 
premiums. Because small firms have fewer employers to pool than 
larger firms, premiums often vary dramatically from year to 
year due to changes in just one or two workers' health status 
or because of small changes in the ratio of male to female 
employees.
    Because the law limits the factors insurers can use in 
determining the cost of premiums, small businesses can now 
count on more predictable rates, and many qualified small 
employers purchasing coverage through SHOP can receive further 
help keeping costs down through the availability of the Small 
Business Health Care Tax Credit. The SHOP provides a 
streamlined way for small businesses to offer health coverage 
to their employees. Similar to the individual marketplaces, the 
SHOP allows small businesses to easily compare and select plans 
that best meet the needs of their employees.
    In 2014, the SHOP opened to small employers with 50 or 
fewer employees. In 2016, the program will be open to 
businesses with up to 100 employees. Unlike the individual 
marketplace, eligible employers can begin participating in the 
SHOP at any time and may purchase coverage for their employees 
at any time during the year. They are not limited to a single 
open-enrollment period.
    This past year, small employers offered coverage to their 
employees through the SHOP Marketplace by enrolling in coverage 
through an agent, broker, or issuer. During this year, HHS has 
worked to create a seamless, online experience for enrollment 
through SHOP, and we have added key new features for the SHOP 
Marketplace for the 2015 plan year. New features include 
offering many employees a choice of health plans; enabling 
employers to write just one check regardless of the number of 
plans that employees choose, a feature that is generally 
referred to as premium aggregation; and a dedicated online 
system for agents and brokers to assist their SHOP small 
business clients. Starting this fall, the online, federally-
facilitated SHOP Marketplace will offer new health coverage 
options to small employers and make it easier for them to shop 
for, select, and offer employees high-quality health plans. And 
employees will be able to enroll in their employer plan online, 
helping reduce an administrative burden for their employers.
    As we move to make online functionality for the SHOP 
available this November, CMS is committed to acting on lessons 
learned and continuously improving the user experience. One way 
that we are doing this is to give small employers, as well as 
agents and brokers in five states, the opportunity to 
experience key features of the new online SHOP Marketplace in 
advance of the full launch nationwide. During SHOP Early 
Access, small employers in these states will be able to 
establish a marketplace account, assign an agent and broker to 
their account, fill out an application, obtain an eligibility 
determination, upload their employee roster, and then when 
available in early November, browse available plans and pricing 
and complete the enrollment process. Early Access will also 
allow for targeted consumer testing before the SHOP functions 
are made available online in all federally-facilitated SHOP 
Marketplace states. This consumer testing will add to the 
rigorous performance and security testing completed prior to 
going live.
    Beyond the opportunity for online enrollment, we are also 
making important progress in offering small business employees 
additional choices for their health coverage. In the past, most 
small employers were only able to offer a single health and 
dental plan for all of their employees. Now, through the 
Employee Choice option, small businesses in most states will 
have the option to allow employees to choose any health plan 
available at the coverage level selected by the employer. This 
provides significant benefits to both employers and employees, 
including lessening the administrative burden on employers, 
while allowing employees to select the plan that best fits 
their needs.
    In addition to choice, we know how important affordability 
is to small businesses. The law created the tax credit to help 
small employers of lower wage workers afford a significant 
contribution towards workers' premiums. Qualified small 
employers can receive a tax credit worth up to 50 percent of 
their contribution towards employees' premium costs, and since 
the tax credit first became available in 2010, it has provided 
hundreds of thousands of small businesses more than $1.5 
billion in tax credits. For too long, small business owners 
have struggled to keep up with the ever-rising costs of 
providing health insurance for their employees. The SHOP, 
combined with new insurance reforms and tax credits, enables 
more employers to provide their employees with high quality, 
affordable health coverage.
    I look forward to continuing to work with you to improve 
the health care options for America's small businesses, 
families, and communities, and I am happy to answer your 
questions.
    Chairman COLLINS. Thank you, Director Alvarez.
    At this point, I would like to yield to my colleague, 
Congresswoman Herrera Beutler so she may introduce our next 
witness.
    Ms. HERRERA BEUTLER. Thank you, Chairman and Ranking Member 
Hahn. I would like to thank you for the work the Subcommittee 
is doing.
    I am excited to highlight what is happening with the SHOP 
and to see whether or not we are meeting the needs of small 
businesses and to see what we can do about that.
    It is my pleasure to introduce a retired physician and 
accomplished health care policy analyst from Washington State, 
Dr. Roger Stark. Dr. Stark practiced thoracic surgery in 
Washington State for 20 years and was one of the cofounders of 
the Open Heart Surgery Program at Overlake Hospital in 
Bellevue, Washington. He graduated from the University of 
Nebraska, College of Medicine, and completed his general 
surgery residency in Seattle and his cardiothoracic residency 
at the University of Utah. Currently, Dr. Stark is a health 
care policy analyst for the Washington Policy Center. He is the 
author of two books and numerous in-depth studies on health 
care policy. We are lucky to have Dr. Stark here as a valuable 
resource, who understands the intricacies of the medical system 
as a physician, as well as the intricacies of the Affordable 
Care Act as an analyst, specifically the workings of SHOP in 
Washington State and the exchanges intended for small business 
owners.
    So Dr. Stark, welcome. Thank you for being here. Thank you 
for making the very long trip across the country. We appreciate 
it.

                    STATEMENT OF ROGER STARK

    Dr. STARK. Thank you very much, Chairman Collins, Ranking 
Member Hahn. Thank you very much, Representative Herrera 
Beutler.
    Officials in Washington State chose to establish a state-
run health insurance exchange, including a SHOP Marketplace. 
Coverage began in 2014. Only one carrier, Kaiser Permanente 
offered plans, and only offered those five plans in two 
counties in southwest Washington. Although 4,300 small 
businesses created online accounts, only 11 companies with a 
total of 40 people actually purchased insurance on the SHOP 
Exchange this year.
    A second insurance company, Moda, has applied to offer 14 
plans statewide starting in 2015.
    The director of the Washington State SHOP Marketplace, 
Catherine Bailey, stated that many of the carriers were not 
interested in expending additional resources to be in the Small 
Business Exchange right away.
    The Government Accountability Office has speculated that 
the use of tax credits and the SHOP enrollment are so low 
nationally for several reasons. The first reason is the 
complexity of doing all the paperwork.
    The second reason that GAO reports is the tax credit is not 
a large enough incentive for many small employers.
    And third, the majority of small businesses have never 
offered health benefits to employees.
    In addition, insurance companies are seeing a drop off in 
employer-sponsored health insurance for small businesses. The 
CEO of Well Point, Joseph Swedish, is on record earlier this 
month stating that small employers are shifting employees to 
the individual exchange or are dropping coverage completely.
    From a policy standpoint, although the employer mandate is 
a critical part of the ACA, the SHOP Marketplace for small 
businesses seems to be almost an afterthought in the law. There 
is no clear evidence of interest on the part of small companies 
to provide health insurance through a marketplace with tax 
credits. Small businesses are typically startup or low margin 
companies where the added costs of employee health insurance 
can mean the difference between success and failure. The 
paperwork and regulatory burden in the SHOP Exchange are 
definite hurdles for small business employers.
    There is no real free market in the individual exchanges or 
in SHOP. Proponents will claim that competition exists.
    Yet, all insurance plans offered in the exchanges must 
contain the 10 government-mandated essential benefits. 
Insurance premium prices must be approved by the government. 
Consequently, individuals and employers only have government-
approved plans and not meaningful choices or real competition. 
Narrow provider networks further limit choices.
    The incentive of tax credits has not been significant 
enough to encourage employers to use SHOP. Obtaining the credit 
is so complicated that small businesses are unwilling or unable 
to spend the time and effort to complete the necessary forms.
    The SHOP Marketplace duplicates the private insurance 
marketplace with an added burden to taxpayers. Private 
association health plans, for example, have flourished for 
years without government financial support. Since employer 
interest and utilization of the tax credit is so small, the 
benefits of the SHOP Marketplace are unclear.
    So where to go from here? Designing an insurance exchange, 
whether it is private or government run, offers each state, 
like Washington State, the opportunity to reform health care 
delivery by starting with a clean slate and moving toward a 
patient-oriented consumer-driven system. The exchange can be a 
transparent, information-based market where individuals and 
small businesses can select the plan most appropriate to their 
needs. Done right, the exchange should be easy to use and 
should promote decreased health care costs. Insurance rates and 
benefit levels should be set by the insurance market and not by 
government regulations.
    Washington State has 57 benefit and provider mandates that 
overlap the federal benefits. Ideally, an exchange should be 
able to offer an array of mandate-free or mandate-light 
insurance plans that satisfy market needs. Exchanges should not 
replace existing programs that work, such as association health 
plans.
    Any subsidies in the exchange should flow to and be 
controlled by the patient. Tax credits or premium supports to 
purchase health insurance could also be offered in an exchange.
    Each state should be able to function as a laboratory to 
design the most efficient, cost-effective exchange for small 
businesses and individuals with real choices and competition.
    Thank you very much. I look forward to your questions.
    Chairman COLLINS. Thank you, Dr. Stark.
    Our next witness is Adam Beck. Mr. Beck serves as assistant 
professor of Health Insurance at the American College of 
Financial Services. Prior to his current position, he practiced 
law in Philadelphia, Pennsylvania.
    Mr. Beck, thank you for appearing today, and you may now 
deliver your testimony.

                     STATEMENT OF ADAM BECK

    Mr. BECK. Thank you, Mr. Chairman, Ranking Member Hahn, 
Members of the Subcommittee, for the opportunity to appear 
before the Subcommittee today.
    Small businesses and the people who work for them, they 
combine together to constitute the backbone of the American 
economy. Health insurance is a tremendously valuable and often 
lifesaving financial product, which our tax code affords 
special status. And therefore, it is an important and essential 
goal to allow small business owners the opportunity to offer 
quality, affordable health insurance coverage to their 
employees.
    The Small Business Health Options Program, or SHOP 
Marketplace, was designed by the 111th Congress to lower costs 
for small business, increase competition, and therefore, choice 
for business owners, and simplify the process of offering 
health coverage. These are laudable goals. However, it is my 
opinion that the SHOP Marketplace as it is currently structured 
and presented, falls short of these goals.
    I believe that the SHOP Marketplace will remain inadequate 
and continue to enroll relatively few companies so long as 
three factors remain--the existing tax incentives, the lack of 
engagement of agents and brokers, and shortcomings in 
information technology infrastructure.
    First, the tax incentives are too small, or indeed for most 
small employers, nonexistent. Without substantial and long-term 
tax credits, the cost of plans through the SHOP Exchange has 
been for most employers similar to the cost outside of SHOP and 
prior to the implementation of the Affordable Care Act. While 
most small employers have the desire to offer health coverage, 
the costs, both direct and opportunity, have been prohibitive 
for many. The Small Business Health Care Tax Credit created by 
the ACA does nothing to alleviate the cost burden for most 
employers. It is a complicated tax credit that is available 
only to a select number of very small businesses with few 
qualifying for the full 50 percent credit, and even then, they 
are only able to claim it for two years.
    The Government Accountability Office estimates that up to 
four million small businesses could qualify for the credit, but 
this requires that the small business know about the credit and 
go through the difficult process of determining eligibility. 
Further, even by the GAO's own admission, advocacy groups 
identify that four million figure as the likely high point of 
potentially eligible businesses, with some estimating that as 
few as 1.4 million employers would qualify.
    Data from the first year of the tax credit in 2010 indicate 
that the overwhelming majority of employees who are eligible 
for any credit were not eligible for the full credit. Only 17 
percent, in fact, were eligible for that full credit. The 
greatest obstacle, according to the GAO analysis, was the 
annual wage requirement. In the first year, 68 percent of 
businesses who received less than the full credit would have 
qualified for the maximum percentage based on the number of 
full-time equivalent employees but failed to qualify based on 
their wages.
    Second, the SHOP Marketplace has not sufficiently engaged 
or compensated the agents or brokers who are so often the 
conduit to the small business community. Many brokers have 
encouraged their small group clients to consider purchasing 
plans off the SHOP Exchange because it requires about half the 
time of the broker and the compensation structure is the same 
whether the plan is on or off shop. States have required 
training of brokers to be SHOP certified, that many brokers 
have reported to be unhelpful and inaccurate. Overall, the SHOP 
Exchange has been very poorly marketed to both businesses and 
brokers alike.
    Third, and hopefully most obviously, the delay by the 
administration of the federal-facilitated SHOP Marketplace and 
the accompanying website limited the ability of small 
businesses and the 32 states relying on the federal 
marketplace, but it also created confusion for business owners, 
brokers, and navigators in the states that had functioning 
shops. Additionally, states that were operating their own SHOP 
Exchange in 2014 experienced IT problems of their own that 
hindered enrollment.
    I would compare the existing SHOP Marketplace to a new 
restaurant that despite offering some very good entrees, is 
struggling because of a poor location, minimal advertising, and 
prices that for many are simply too high. It has much potential 
but it needs much to change in order for that potential to be 
realized.
    Small businesses want to offer health coverage. It simply 
needs to be more affordable, simpler, and facilitated by an 
experienced insurance broker. The Small Business Health Options 
Program has the potential to offer just that, but marketing, 
tax credits, information technology, and the agent-broker 
involvement need to be dramatically increased in order for the 
program to achieve wider popularity and demonstrate markers of 
success.
    I thank you for the opportunity to testify, and I look 
forward to your questions.
    Chairman COLLINS. Thank you, Mr. Beck.
    I will now yield to Ranking Member Hahn so she can 
introduce our next witness.
    Ms. HAHN. Thank you, Mr. Chairman.
    It is my pleasure to introduce Jon Gable, the Senior Fellow 
at the National Opinion Research Center at the University of 
Chicago. He has more than 35 years of experience and is a 
nationally-recognized expert on the private health insurance 
and has authored more than 135 articles in scholarly journals. 
He is also an adjunct professor at the George Washington 
University in the Health Policy Department. He received an M.A. 
in Economics from Arizona State University and an A.B. in 
Economics from the College of William and Mary.
    Welcome, Mr. Gabel.

                     STATEMENT OF JON GABEL

    Mr. GABEL. Thank you. Thank you, Chairman Graves, Ranking 
Member Hahn, Members of the Committee. Thank you for the 
opportunity to discuss the promise and challenges of Small 
Business Health Options Program or SHOP. I am John Gabel, 
senior fellow at NORC at the University of Chicago.
    NORC is an independent, nonprofit, nonpartisan research 
organization, whose mission is to conduct objective research in 
the public interests. The views I express are mine and not 
those of NORC.
    Today, I will discuss factors promoting and inhibiting the 
success of SHOPs. Now, let me, given the time, I want to start 
off going through some graphics. So first, if you can turn to 
page four. What I want to point out--this is data from the 
Kaiser Family Foundation--that we are going through a period of 
price stability according to the Kaiser Foundation Survey. In 
fact, last year there was actually a decline in premiums.
    Just a brief history of SHOPs and purchasing pools. 
Exchanges are not a new idea. Over the last 25 years, states 
attempted to build what was termed ``health insurance 
purchasing co-ops'' (HIPCs), but none enjoyed widespread 
success. Among the states to build HIPCs were California, 
Connecticut, Washington, Florida, Kansas, Colorado, and 
Kentucky. Connecticut got an 8 percent market share and that 
was considered successful. Massachusetts invested more than a 
million dollars in research and marketing in 2012-2013 and 
enrollment is less than 10,000.
    I am going to allude later to the lessons learned of these 
earlier HIPCs, but just note that the authors of the ACA 
addressed many of these earlier shortcomings of the HIPCs.
    Now, if you will turn now to number four, which is on page 
nine, this is a study we did for CCIIO. Here we compare the 
price of plans sold on the SHOP compared to those sold off the 
SHOP by the same metal tier. And what you see is the plans on 
the SHOP are lower cost than those off the SHOP. This may be 
due to narrow networks. This could be due to more nonessential 
benefits. But in any case, the costs are lower on the SHOP.
    If SHOPs are to succeed where HIPCs fail, they must 
demonstrate added value over the traditional market. Shops can 
offer lower prices, tax credits not available off the SHOPs, 
wider employee choice, and a defined contribution that reduces 
the risk of future price increases. The authors of the ACA 
wrote into legislation provisions that would address major 
problems of earlier HIPCs.
    Specifically, they made inside and outside the market 
played by the same underwriting rules. Administratively, CCIIO 
has tied large carriers to participate in the SHOPs. The 
promise of SHOPs is they operate under fair market rules. 
Prices on the SHOPs are lower than off the SHOPs. Lower prices 
are attributed to maybe narrow networks, but for employers 
seeking lower premiums, SHOPs are the place to shop.
    Multiple carriers are participating in the SHOPs in all but 
one state. With the Employee Choice Model, employees can choose 
from multiple carriers and in some multiple tiers. Carriers on 
the competitive fringe of the small employer market, as well as 
nonprofit, vertical, integrated organizations such as Kaiser 
Permanente see SHOPs as a way to build their market share.
    If SHOPs and fully ensured plans are to survive, they must 
stand off threats by other insurance systems, such as self-
insurance. To paraphrase Lincoln, a house divided cannot stand. 
Two insurance systems, one risk rated and the other not, will 
lead to a system with disproportionate share of bad risk and 
one with favorable risk. Such a system will live to the demise 
of the non-risk rated system.
    I want to close with an observation from nearly 40 years of 
research. Many times I have written why are we making--may I 
proceed?
    Many times I have written, why are we making such a big 
deal out of HMOs, PBOs, HRAs, and HSAs? They have only X 
percent enrollment. Why are we giving them so much attention?
    All in due time became prominent insurance products, but it 
required many years of growth. So to paraphrase John Lennon, 
give SHOPs a chance.
    I would be delighted to answer your questions.
    Chairman COLLINS. Thank you very much.
    Here is what we are going to do because our first vote 
series really does not end in nine minutes like that says. We 
have an extra 10, and I would like, in deference to 
Congresswoman Herrera Beutler, allow her to ask her questions, 
at which point we will adjourn for about 20 minutes. It is only 
two votes. And then Ms. Hahn and I will come back and continue.
    So, I yield to Ms. Herrera Beutler.
    Ms. HERRERA BEUTLER. Thank you, Mr. Chairman.
    I have a few different questions and thoughts.
    I understand, Mr. Gabel, what you were talking about in 
terms of giving things a chance. I think some of the challenges 
that we are seeing in Washington State may allude to a bigger 
problem.
    A little bit of background for folks. Washington State has 
called successful its implementation of ACA based on the number 
of individuals it has added to the Medicaid state roles. And 
regardless of whether or not you believe shifting from the 
private market to the Medicaid market is success or not, that 
is a separate issue.
    On the SHOP-specific exchange, I am gravely concerned 
because we do have association health plans. We do have some 
other options for the small businesses who want to offer 
insurance, but those are being--I think the screws are being 
tightened on those in favor of the shops; yet, there is only 
one insurance provider in Washington State that partakes of the 
SHOP. And actually, it is only in two of the 39 counties. Next 
year, there will be one for all of the counties, and then those 
two counties may have a second option, but still that is a 
major, major challenge because, as you noted, premiums 
increasing, these small business owners do not have a lot of 
options except for push people into the individual market.
    So I guess my first question I would like Dr. Stark to 
speak to, as you mentioned, the SHOP Exchanges were supposed to 
provide these business owners with choice and that was going to 
push down the prices. In my view, this has failed. The SHOP has 
failed. But what are you hearing from small businesses? Are you 
hearing hopefulness? Am I being too critical? You are working 
with a lot of these folks.
    Dr. STARK. Yeah, I do not believe you are being too 
critical, Congresswoman. Our two big business associations in 
the state of Washington are the Association of Washington 
Businesses (AWB) and the NFIB chapter there in Washington. And 
both of those organizations are in a watch-and-wait mode. I 
think the individual employers are looking to see will SHOP 
expand? Will there be choices? Will there be competition in the 
SHOP in the state of Washington? As it is now, as you alluded 
to, the association health plans are very popular in the state 
of Washington. The screws are being tightened on those. The 
qualifications are being tightened and a lot of business owners 
are very fearful that those are going to go away and they will 
be left with either putting their employees in SHOP or in the 
individual market. So there is a lot of concern on the part of 
small employers in the state.
    Ms. HERRERA BEUTLER. What do you think if the association 
plans are on their way out and even for next year we do not 
really have much choice for the small businesses, what do you 
think is going to start to happen? What have you seen numbers-
wise in terms of whether they are offering coverage, not 
offering coverage, or just closing down? Where are they 
supposed to go?
    Dr. STARK. Well, we have three major employers in the 
individual market, or three major carriers in the individual 
market in the state of Washington, and so far none of those 
three have opted or elected to participate in SHOP, and we do 
not see them participating. Certainly, in 2015, it is doubtful; 
2016 and 2017, they are going to have a product available for 
SHOP. So I think employers are going to be looking at either 
doing away with coverage and putting individuals--their 
employees in the individual exchange or the individual market, 
and I think that is probably the biggest option that they are 
going to--or getting out of the health insurance business 
completely.
    Ms. HERRERA BEUTLER. Do you think that this is going to 
make it--so one of the things I heard I think from Mr. Gabel 
and from Ranking Member Hahn--I cannot remember everybody's 
titles--is that marketing could be a piece of this. It is my 
understanding that for the SHOP Exchange that the state has had 
about $1.4 million to market, and I think your numbers were 11 
employers with 40 employees?
    Dr. STARK. Yes.
    Ms. HERRERA BEUTLER. How much would it take?
    Dr. STARK. Yeah, I do not know. I am not a marketing 
person, so I really do not understand. I know our state 
exchange has been marketed fairly heavily, especially in the 
Medicaid population. We have been very successful at signing up 
Medicaid patients, but I am not aware of any big organized 
campaign on the shop aspect of the exchange.
    Ms. HERRERA BEUTLER. So I wonder if that means that part of 
the goal is just to get folks--and my time is up--to get them 
out of group markets all together. But that is just for 
thought.
    With that I will yield back. Thank you.
    Chairman COLLINS. Thank you very much.
    What we are going to do is adjourn for about 15-ish 
minutes, maybe 20. We will go and cast this vote and then when 
the second vote comes up, Ms. Hahn and I could quickly vote and 
be back up here. I apologize for that but it happens more than 
not and it is outside of our control.
    So with that we will adjourn for about 15 or 20 minutes and 
then we will be back.
    [Recess]
    Chairman COLLINS. I call the hearing back to order.
    So we will kind of jump into questions and I will ask some 
and then leave it to Ms. Hahn to ask a few, and then I may have 
some follow up, and she may have some follow up. So since this 
is a crazy day, I think we will take it from there.
    So I guess, let me start with you, Director Alvarez. We 
have been trying very hard to get the hard data numbers from 
your group on how many businesses have signed up for the SHOP. 
Maybe the state exchanges and the federal, and how many--and we 
have not been successful. Is that data available yet? Do you 
have those numbers? And if not, when might we see it?
    Ms. ALVAREZ. So just to provide some context, in 2014, 
small businesses had the opportunity to apply for coverage 
through the SHOP program, the paper application utilizing an 
agent and broker or directly through issuers. As a result of 
that, we are not the source of information as far as SHOP 
enrollment. CMS is not. We are working with issuers to get that 
information so that we can better understand the number of 
small businesses that enrolled in coverage through SHOP. And as 
soon as we get that information we will share it with you, as 
well as with the American public.
    Chairman COLLINS. Is the same true of the state exchanges? 
Were they all paper-based or do we have data from the--what is 
it, is it 18 states that are providing their own? Do we have 
data from them?
    Ms. ALVAREZ. It really does vary depending on the state. 
Some of them are working directly with issuers because they had 
a more manual process, while others are able to send numbers. 
As soon as we have a more accurate picture of what the 
enrollment in SHOP looks like, we will definitely give you that 
information.
    Chairman COLLINS. There is a sign in my office. People 
actually take pictures of it, ``In God we trust. All others 
bring data.'' It is the data that will tell the story. So to 
some extent now we are all supposing in doing that there is 
always a bias. The data takes the bias out of it, so I would 
encourage, certainly as you now move into the electronic piece 
and you are going to be rolling out your, across, what is it, 
five states, kind of an early enrollment piece?
    Ms. ALVAREZ. Yes.
    Chairman COLLINS. My concern has been, and I own a number 
of small businesses, is I sometimes think of the SHOP Exchange 
as a solution looking for a problem because the Chambers of 
Commerce across the United States did a marvelous job providing 
small businesses with health insurance--sole proprietorships 
and others. In fact, some would argue half the memberships at 
Chambers of Commerce signed up for the health insurance. And 
now that they are no longer in that, Ms. Alvarez, what would 
you say to those like me who would say we had an opportunity 
through the Chambers of Commerce. It was working well and now 
we are into the SHOP Exchanges. Any comments there?
    Ms. ALVAREZ. Definitely. It is important to consider that 
when we speak to small business owners, when I have talked to 
folks across the country, they want to provide coverage to 
their employees. They want the opportunity to give this as a 
benefit. And what we know is that we want to provide that 
opportunity through the SHOP program.
    And when we talk about previous plans that were available 
to small businesses, we have to really talk about the quality 
of the coverage that the small businesses had access to and the 
risky environment that they were operating in. If one person 
got sick, premiums would go up. Sometimes if they needed 
hospitalization or treatment, it was not covered because it was 
not part of the defined package of services. What the 
Affordable Care Act is doing is providing access to health 
insurance coverage that is high quality, that provides a 
package of essential health benefits, that is going to be there 
when you need insurance the most. That is the reasoning behind 
ensuring that small businesses have access to these types of 
plans so that they know that their coverage will be there when 
they need it the most. Services like preventive care, 
hospitalization, emergency room care, cancer treatment. 
Services that we want and expect insurance to cover.
    Chairman COLLINS. Sure. So what do you say to the patient 
who had a policy where their drug treatment for cancer was 
provided and now they have signed on to an exchange and it is 
not covered anymore and their formulary took it out? Or how 
about the person who was going to this hospital and all of a 
sudden under the restrictions of the insurance and the 
exchange, that hospital, they cannot go there anymore. Or their 
doctor is not in there. So I am just curious. Because I think 
you would agree there are cases where cancer coverage has been 
dropped from the formularies, hospitals have been dropped, and 
doctors have been dropped. Is that not an accurate statement?
    Ms. ALVAREZ. I do not know the specifics of what cases you 
are referring to, Chairman, but what I can tell you is that 
what the marketplace has intended to offer is options for 
people.
    Chairman COLLINS. Intended.
    Ms. ALVAREZ. It does offer.
    Chairman COLLINS. Okay. But you stated that they get all 
this coverage and I am saying that is just not so. I have had 
people call up and say, ``I had my cancer drugs covered but now 
under Obamacare they have to provide prescription drugs but 
subject to their formulary.'' Am I wrong? I mean, does 
Obamacare require that every drug be covered under all the 
formularies?
    Ms. ALVAREZ. Not every drug.
    Chairman COLLINS. Right. So they dropped the most expensive 
ones.
    Does Obamacare require that people can go to any hospital?
    Ms. ALVAREZ. No, the networks vary.
    Chairman COLLINS. Yeah. Sometimes so restrictive.
    How about if you had your doctor you can keep it. Are all 
doctors in these plans?
    Ms. ALVAREZ. The networks vary.
    Chairman COLLINS. Yeah. In other words, it is, in many 
cases, a very bad day at the office when somebody comes home 
and says to their spouse, ``We lost our hospital, we lost our 
doctor, and by the way, I just lost my cancer coverage.''
    So I think it is, again, the facts mean a lot, and I know 
you are sugar-coating it, but these have been very painful 
times for a lot of folks. As was pointed out, small businesses 
that had insurance, and you are right in saying in many cases 
without prescription drug coverage. What I have seen is prior 
to Obamacare, a lot of small companies with younger employees 
were able to provide that Affordable Health Care, and they did 
not offer prescription drug coverage. But in the younger 
populations, if most of your employees are under age 40, to a 
large extent that insurance was very affordable. Now all of a 
sudden, they have to provide prescription drug coverage so they 
lost all their insurance. So I would beg to differ with you 
when you again put this happy face on it.
    If I am 35 years old with a young family and I have health 
insurance and now because the new policy I have to have has 
prescription drug coverage, which my family does not need 
because antibiotics are generic, a lot of pharmacies give them 
away for free. Most high blood pressure is generic now. Lipitor 
equivalents are generic now. That was not a good day for folks 
to come home and say I now have no insurance.
    I guess maybe, Dr. Stark, I would ask you to comment on 
my--that is my bias but I have had it come firsthand--if you 
have heard similar things.
    Dr. STARK. In the state of Washington, for example, we know 
at least 290,000 people lost the insurance plan they were on. 
We have no idea how many of those people then went into the 
individual exchange or how many people signed up on the 
individual market or went without insurance. So no, it is a 
significant issue, at least in the state of Washington; 
certainly nationally as well.
    Chairman COLLINS. The other thing I have seen is higher 
deductibles. I have seen deductibles go up. So I guess, 
Director, when you talked earlier about small businesses now 
are comfortable now that they are not going to be penalized for 
having more women than men, they are not going to be penalized 
for having an older workforce, is that really true? Are you 
telling me that any company anywhere with a bunch of 65-year-
old employees is going to pay the same insurance as somebody 
with 22-year-olds?
    Ms. ALVAREZ. So premiums may vary, but they may vary only 
on a set number of factors. Age is one of them, but it is 
limited to three to one. Prior to the Affordable Care Act, 
older adults could pay 10 times more than a younger adult, so 
now we are limiting what that difference can be, as well as 
geographic area, and tobacco.
    Chairman COLLINS. So men-women is not part of that anymore?
    Ms. ALVAREZ. That is correct.
    Chairman COLLINS. All right. But I know I have seen and 
heard where three to one is fine until they increase the 
individual, the younger. They increase the younger so that they 
are still getting the same on the older as opposed to keeping 
the younger the same. I mean, have you heard or seen of folks 
where the young are being penalized now? Their premiums are 
going up more than ever?
    Ms. ALVAREZ. I think it is important to consider what the 
health insurance market looked like before the Affordable Care 
Act. You saw health insurance premiums going up by double-digit 
increases, and no one had an understanding of why. What the 
Affordable Care Act does now is yes, insurance premiums can go 
up, but they are going up at a slower rate. In some states they 
are going down.
    Chairman COLLINS. So is 20 percent a low rate?
    Ms. ALVAREZ. It varies. Congressman, it varies.
    Chairman COLLINS. There are 20 percent increases being 
announced all over because--well, let me again, what you know 
or may not know, is it not true that a lot of small businesses 
last year renewed their policies in October to lock in premiums 
last October where they were not subject to many of the 
mandates but now this October, as in a couple of weeks, they 
are getting their renewals and their renewals now compared to 
what they had are up 20 percent, 28 percent?
    Ms. ALVAREZ. And the opportunity exists to have additional 
options in the marketplace. That is what the marketplace has 
intended to do, provide small businesses a choice. We have some 
preliminary information on 2015 rates for small businesses, and 
what we are finding is that there is going to be a decrease or 
only a modest increase in those premiums.
    Chairman COLLINS. That is not so. That is just not so.
    Ms. ALVAREZ. That is based on the preliminary information 
that we have, so we are happy to share that once it is 
available.
    Chairman COLLINS. Once it is available.
    Again, I mean, you are providing this without any data to 
support it. The data that we have supported is in New York 
State. Now, New York State is running its own exchange. All 
over the place, there is 18, 22, 24 percent increase for these 
companies all over the place. That is hard data. That is 
published data.
    So again, I am just pointing out in my opinion, and we can 
agree to disagree, this whole SHOP experience is a solution 
looking for a problem. Small businesses that wanted to provide 
coverage, we are providing it. And granted, in many cases, 
perhaps not with prescription drug coverage, but that made it 
affordable. Now the easy thing for a lot of small businesses is 
just push people out, cancel it, and to some extent say, you 
know, go into the individual exchange.
    Mr. Beck, I just wonder what experience--I am sharing some 
of mine. I am just wondering if you have any similar----
    Mr. BECK. Well, the experience that I have seen speaking 
with independent agents and brokers from across the country is 
that a lot of them are concerned that they will lose their 
small group clients. I think from a policy perspective, the 
question then becomes is that such a bad thing for the 
marketplace or for the employees if they had previously had 
small group coverage and now are encouraged or even 
incentivized through their payroll to then go on to the 
individual exchange where they can--statistically they would 
have a likelihood of qualifying for tax credits. But I do 
definitely hear from agents and brokers that small group 
clients are nervous. I think a lot of the early renewals had to 
do with uncertainty as much as they had to do with concerns 
about having to cover the 10 essential health benefits, but 
whether it is because of the SHOP Exchange or simply despite 
the SHOP Exchange, I think the nature of the small group market 
is going to change, and that probably has more to do with the 
availability of the individual marketplace with the tax 
incentives than it does anything else.
    Chairman COLLINS. Thank you. I think I will reserve 
additional questions so we can hear from Ms. Hahn. And also, I 
think I saw Mr. Luetkemeyer get here, so Ms. Hahn.
    Ms. HAHN. Thank you, Mr. Chairman.
    Again, I think it is important to remember what our health 
care system was like before Congress passed the Affordable Care 
Act. It was a broken system. And fortunately, many of those 
folk were offering insurance plans that were bad plans. They 
did not cover what was needed. Many times you think you are 
young and you do not need certain prescription drugs or certain 
coverage, and you do not know what is going to happen. That is 
why it is an insurance plan. I do not think any of us can 
foretell what is going to happen to us, but we know a lot of 
people were wiped out financially in this country, many small 
businesses, because of a couple of catastrophic illnesses, bad 
accidents, unforeseen health challenges, and that is what 
Congress was attempting to fix with the Affordable Care Act. 
And we know that now a lot of individuals, even who work for 
small businesses, have the choice to get insurance. Your 
insurance does not matter who your employer is.
    I was one of those whose insurance was tied to my employer 
and when I was laid off by a financial investment banking 
company, my only option was COBRA. And you want to talk about 
high premiums. I was a single mother at the time with three 
kids. It was impossible for me to pay that. So, and being a 
woman was a preexisting condition. And I know the communities I 
represent, you know, children have a higher instance of asthma 
because we live near big polluters in southern California, and 
many of those families could not get insurance because their 
kids already had a preexisting condition. So let us try to 
remember how bad our health care system was in this country. It 
was very much broken. And the Affordable Care Act is an attempt 
to remedy that.
    Now, if there are places where we can do better, we should 
work together, you know, we should work together and try to do 
that. But certainly, wiping it away and going back to what we 
had is really not an option. And many people who have plans now 
that do not cover certain things, you know, those are plans 
that they chose. So these are plans people actually make the 
choice for, and you can look at all your options. You can line 
them all up, see what is available, see what the cost is going 
to be, and know. You never knew that before with insurance 
plans. You did not really know until you needed it whether or 
not it was going to be there for you.
    So one of the things, Ms. Alvarez, I was going to ask, it 
was disturbing, Dr. Stark, to hear, you know, that a lot of 
insurance companies are not participating in the SHOP, and that 
is not good for consumers. We know that competition does drive 
down cost, and we know that is better. So I was going to ask 
you, what are you doing to ensure that insurance carriers do 
participate? How can we do a better job? Is there something we 
can do here in Congress to encourage insurance companies to 
participate in the various SHOPs and exchanges?
    Ms. ALVAREZ. We completely agree. We think competition does 
drive down cost for small businesses and individuals alike. And 
we are encouraged by some of the preliminary information we are 
seeing and participation in the SHOPs for 2015. Based on this 
preliminary information, we do anticipate that every state will 
have coverage in their SHOP market. And I do think it is a 
continual improvement process. The first year had some issues. 
The second year we are working on those issues and improving 
them, such as adding online functionality come November 15th, 
and that is the process of setting up this program, ensuring 
that we are learning from the lessons that we experience and 
improving for the next year. So 2015 is going to have online 
functionality come November 15th. We will learn valuable 
lessons this year and we will make it even better in 2016 and 
2017. But yes, I agree that we are looking at better 
competition for small businesses across the country with 
greater participation by issuers.
    Ms. HAHN. And just to follow up on that, do you think that 
is a long enough period to launch in October in five states and 
then in November a full launch? Is that enough time for us to 
look at this pilot launch and learn and make enough changes if 
need be? Is that a long enough time?
    Ms. ALVAREZ. So just to clarify, we have done all of the 
necessary security testing and end-to-end testing in order to 
have a nationwide launch come November 15th for online 
functionality of the SHOP program. What we are doing at the end 
of October is providing early access to five states and, based 
on their market, based on on-the-ground agent and broker 
participation and a network of small businesses to give us 
their feedback of what the SHOP online marketplace looks like. 
They will be able to upload their employee roster, fill out an 
application, get an eligibility determination, and be able to 
access that website and identify any glitches or issues that we 
can then turn around and address for November 15th.
    And, coupled with that, we are reaching out to agents and 
brokers to ensure that they have the opportunity to access a 
new portal that is established for agents and brokers to, 
again, be able to fill out their information so small 
businesses can assign themselves to this agent and broker, and 
be able to monitor activity once open enrollment begins. It is 
intended to identify any last minute glitches or issues so that 
we can be ready when we launch nationwide on November 15th.
    Ms. HAHN. Right. Because we cannot afford another bad 
rollout of this.
    Mr. Gabel, I was just was going to--it looked like you 
wanted to respond earlier, which you are welcome to do. But I 
know you sort of talked about some of the features, like 
getting one bill, writing one monthly insurance check, 
comparing plans that were positive benefits. Did not know if 
you could give us some more of your findings that you are 
hearing that are positive benefits from SHOP Exchanges.
    Mr. GABEL. Okay. Just for the record----
    Ms. HAHN. Is your mic on?
    Mr. GABEL. Just for the record, we studied 26 states. 
Washington is the only state with one carrier. Some states, 
like Maryland, have 10 carriers. There are too many--it is in 
my testimony--too many have two carriers, but Washington is not 
typical.
    And also, for the record, about 45 percent of small 
employers do not offer coverage, but that number is not 
declining. That number stayed relatively constant over the last 
couple of years. So, so far we do not see a movement towards 
individual exchanges.
    What we can say, we did a survey for the Commonwealth Fund, 
and it is in my testimony. We asked small employers what you 
are looking for, and what we found was many of the attributes 
of SHOPs are what small employers are looking for. For example, 
if you will go to page seven, you have about 41 percent say it 
is very important to have more plans choices, and 34 percent 
say somewhat important. Ability to compare plans, 68 and 23 
percent. That is very important. These are firms offering 
coverage. Having a third-party payer as a go-to or to answer 
questions, that is very important to about 40 percent roughly. 
And even for firms that do not offer coverage, the most 
important item basically is--well, two items--costs less than 
it does today. And as I showed you, the SHOP plans cost less 
than the plans off the marketplace. And another one is sick 
employee will not increase the cost.
    Being a small employer in the pre-ACA days was a risky 
business because you never knew if you are offering coverage 
now and all of a sudden one of your employees gets cancer and 
then the next thing you know nobody wants to ensure your group. 
Or they will give you a prohibitively high premium. So I think 
those are aspects that will appeal to small employers.
    Now, let me just also say the history of--this is not a new 
concept. Health insurance purchasing pools were really thought 
of as the solution back in the late `80s and the `90s, and a 
number of states sponsored them. But nobody had succeeded. But 
the way the SHOPs are organized, they have addressed some of 
the problems that the previous health insurance exchanges faced 
and could not overcome.
    Ms. HAHN. Thank you.
    Chairman COLLINS. Thank you, Ms. Hahn.
    I would like to yield to Mr. Luetkemeyer.
    Mr. LUETKEMEYER. Thank you, Mr. Chairman.
    I would like to read to you a little statement from the 
folks that own and operate an animal hospital close to where I 
live. This particular business has nine employees and they say, 
``I am skeptical about whether the Affordable Care Act will 
help my employees in the long run, but the rollout is such a 
mess it may cost me thousands of dollars extra in the first 
couple of years. I am required to enroll in the SHOP program, 
not just an ACA-compliant program, which I already am enrolled 
in. Or I may stand to lose the tax credit. The problem is the 
laws change on a weekly basis so even the insurance companies 
cannot tell me what to do in advance to ensure I will make the 
correct decisions. The worst case scenario is I will lose the 
tax credit and my employees will lose their employer-provided 
health care. I am spending hours and days trying to figure out 
what the best route is to take, but as mentioned above, no one 
has the answers to what I need to do to make the best business 
decision. At this point, I am planning on sticking with the 
plan I recently enrolled in after hours of research by myself 
and my financial advisors and let the government tell me later 
whether this is the correct plan or not.''
    This is the dilemma that many of my small business folk 
have. And so the question I have for you, Ms. Alvarez, is will 
the temporary or limited tax credit be available to businesses 
outside the SHOP Exchanges in a situation like this gentleman 
due to the delay online and/or when the administration starts 
allowing or continues to allow certain individuals to obtain 
the taxpayer subsidies outside the individual exchange?
    Ms. ALVAREZ. The tax credit is available for SHOP plans 
that are available through the SHOP Marketplace.
    Mr. LUETKEMEYER. So if he shops outside it, he does not get 
it?
    Ms. ALVAREZ. It depends, honestly. For the state of 
Washington, in the first year of enrollment in the SHOP 
program, we actually worked with Treasury to ensure that small 
businesses in the state of Washington still had access to the 
tax credit.
    But one important point of clarification is that no small 
business with less than 50 employees is required to offer 
coverage to their employees. The SHOP program is intended to 
provide options for small businesses if they want to provide 
their employees coverage.
    So for this veterinary hospital, while I do not know the 
specifics, I would want to clarify to them that they are not 
required. But I would expect that, like many small business 
owners, they want to offer this coverage and we want to get 
them answers to the information that they need. So we have a 
dedicated SHOP call center to provide answers. We have many 
partners on the ground willing and able to answer those 
questions, and we are more than happy to work with you, 
Congressman, to get them that information.
    Mr. LUETKEMEYER. Okay. Next question, HHS and IRS decided 
last year that employees could no longer provide tax-free 
contributions to standalone reimbursement arrangements so that 
employees could purchase their own individual coverage. There 
are a lot of employers that use this that cannot afford to pay 
full insurance but they will pay $100, $200, $300 per employee 
per month or per week, whatever their pay period is, to be able 
to do that. The continuous arrangement will result in $100 per 
employee per day penalty, and many folks are not aware of this 
strict fine. Do you not think that the SHOP program should be 
encouraging innovation like this to be able to make and support 
the employers to be able to help their employees afford health 
insurance rather than penalize them?
    Ms. ALVAREZ. What the SHOP program is doing is giving 
options to small businesses to have access to quality, 
affordable coverage. What I think you are referencing is the 
Department of Treasury rule.
    Mr. LUETKEMEYER. Right. HHS and IRS----
    Ms. ALVAREZ. Right.
    Mr. LUETKEMEYER.--together made the decision.
    Ms. ALVAREZ. And the understanding for the SHOP program is 
intended to provide those options for small businesses. Before 
the Affordable Care Act, whatever available health plan----
    Mr. LUETKEMEYER. So with the SHOP program they can pay only 
part of the premium?
    Ms. ALVAREZ. They have to be willing to pay at least 50 
percent of the cost of coverage.
    Mr. LUETKEMEYER. Okay. So if they have 10 employees and 
they pay the cost per employee is $300 a month and they pay 
$150, they are okay is what you are telling me?
    Ms. ALVAREZ. I am sorry. Say that one more time.
    Mr. LUETKEMEYER. Okay. If the cost of the program is $300 
per month per employee, and they then pay $150 towards that, 
that is okay? The employee picks up the rest?
    Ms. ALVAREZ. If you are using ``program'' as the key word 
for health insurance available through the SHOP program, yes. 
What we are trying to do is incentivize small businesses who 
are offering coverage to their employees, and that is done so 
through this tax credit. It is worth up to 50 percent of the 
cost of coverage for these employers that are contributing to 
employees' coverage. And that is available. It has been 
available since 2010 at 35 percent. It is going up to 50 
percent, and we will know more information about how many small 
businesses took advantage of this opportunity soon.
    Mr. LUETKEMEYER. Published reports have got that the 
president has waived a lot of different businesses from having 
to have business coverage for their employees. Can you tell me 
the basis for those waivers?
    Ms. ALVAREZ. What we have been able to do is provide 
flexibility to employers that may not have been ready to 
transition into this market. And that is what we have been 
doing based on feedback from businesses. That is what we are 
trying to do with implementation, is be able to better 
understand and reflect the needs of Americans where possible 
with implementation of the law. Through the health insurance 
marketplace, it was up and running in 2014, and millions of 
people were able to have coverage as a result of it. Today, we 
announced that 7.3 million people were enrolled in coverage and 
paid their premiums.
    Mr. LUETKEMEYER. Can I ask that question again? Because I 
am not getting an answer for it.
    I asked the question, on what basis were the waivers given 
by the president for certain businesses?
    Ms. ALVAREZ. It was based on our authority as the assigned 
departments to implement the law.
    Mr. LUETKEMEYER. Okay. You were able to do it based on the 
authority, but what was the basis for the decision on why 
certain businesses got the waiver and other businesses do not 
get the waiver?
    Ms. ALVAREZ. Implementation of this complex law requires a 
lot of stakeholder engagement and feedback and that is what we 
listened to. And looking at the different provisions, where we 
had flexibility, based on our authority, we were able to do so.
    Mr. LUETKEMEYER. So the business had to come in to you and 
make a case that we cannot afford this? Or it is going to 
bankrupt us? Or I cannot compete anymore with my competitor? 
What was the basis for the decision?
    Ms. ALVAREZ. Sir, the conversations with the secretary and 
leadership are not ones that I am privy to.
    Mr. LUETKEMEYER. Yeah, but you are administering the 
program; right?
    Ms. ALVAREZ. I can tell you that the changes that were made 
to the program----
    Mr. LUETKEMEYER. So what were some of the businesses that 
were waived and why did they get those--you do not know why 
they were given the waivers?
    Ms. ALVAREZ. It was done in order to be flexible with 
implementation and to be responsive to the needs of the market.
    Mr. LUETKEMEYER. But you do not know the basis of the 
waiver?
    Maybe she knows the basis of the waiver.
    Ms. ALVAREZ. I can definitely get back to you with that 
information.
    Mr. LUETKEMEYER. Oh, Mr. Chairman, Mr. Chairman, another 
day at the capital.
    I yield back.
    Chairman COLLINS. Thank you, Mr. Luetkemeyer.
    We will now yield to Mr. Schneider. Five minutes.
    Mr. SCHNEIDER. Thank you. Brad Schneider from Illinois.
    I want to thank the witnesses for being here. I appreciate 
your input and time.
    The Affordable Care Act is often a contentious issue, but I 
think many of us on the Committee can at least agree that the 
issues small businesses are facing, have been facing in the 
marketplace, are difficult. Cost was not the only rising--was 
not only rising at unsustainable rates for small businesses and 
employees, but it was also proving to be an efficient and 
effective coverage that many businesses and individuals working 
in those businesses were receiving.
    Both of these problems have the effect of ultimately 
stifling economic growth and putting businesses and individuals 
unnecessarily at undue risk. I know that in the early `90s we 
were seeing double-digit increases routinely in my insurance 
agency. The SHOPs take steps to address these issues, but 
clearly the implementation has not been perfect.
    I guess Director Alvarez or Dr. Stark, maybe to one of you, 
Dr. Stark, in your testimony you indicated that when the plan 
was introduced, when SHOP plans came online, there were upwards 
of a million potential businesses, but so far only 170,000 
recipients took the tax credit in 2011. Delivery has been 
inefficient. With an estimate so much higher, what can we do to 
streamline the process to make it more efficient to help these 
small businesses take advantage of the SHOP?
    Dr. STARK. I think there is a broader answer to your 
question, or maybe it should be a broader question, and that is 
what should the employer-employee model really look like? Is 
the SHOP an effective way really to provide the sort of health 
insurance that employees need?
    First of all, it is unclear that employers should be in the 
health insurance market. Traditionally, they are. They have 
been since the mid-1940s. Should that be the model for the 
country? And quite frankly, I do not think it should be.
    So then the second part to your question is, well, what can 
we do with SHOP? Well, again, if you really want to help 
employers, then you have to increase the competition and you 
have to increase choices that they are going to have in SHOP, 
and you have to get away from the 10 essential benefit mandates 
that really make every product sold in SHOP exactly the same. 
You have to get away from government pricing, which really 
limits what insurance carriers can charge, and I think that is 
the answer to it. Set up an exchange that is transparent, that 
offers people an array of products that they can use.
    Mr. SCHNEIDER. Dr. Alvarez? Or Director Alvarez? I am 
sorry.
    Ms. ALVAREZ. The biggest problem, I think, with that 
approach would be adverse selection and the fact that people 
that need more services are going to select the plans that have 
more services, and it will be more expensive for them. And that 
is not leveling the playing field for Americans across the 
country. What the Affordable Care Act does, with the essential 
health benefits package, is just that. Insurance has to pool 
risk. There have to be people who are sick and people that are 
healthy coming together in a pool in order to balance it out 
and have better access to competition which drives down cost. 
But that is the expectation because no one knows what is going 
to happen in their life, if there is going to be a car accident 
or a serious diagnosis or if we are going to need prescription 
drug coverage sometime. We do not know. We do not know what 
tomorrow holds for us, and insurance should be there when we 
need it the most. That is the premise.
    Mr. SCHNEIDER. So, Mr. Gabel, I think you touched on this. 
By definition, small businesses do not have the numbers to pool 
risk to get the benefit of the law of large numbers. What are 
your thoughts?
    Mr. GABEL. Most definitely, they do not. And I believe that 
you have to have a minimum benefit package because without a 
minimum benefit package, let us say all the people who do not 
think they have mental health problems will not have mental 
health benefits, and they will not cover it. And they will not 
cover it. Whereas, those with mental health benefits, people 
with mental health benefits will go in. This has happened 
historically. This will most definitely occur.
    I do want to say this. The average plan before the ACA of a 
small employer was a little bit less than .80 or .79, something 
like that. So this is not like the individual market. Before 
the ACA, the individual market, 50 percent of the plans did not 
meet the actuarial .6 threshold.
    Mr. SCHNEIDER. Okay.
    Mr. GABEL. Most, almost all the small employer plans in the 
country had a .6 actuarial value before.
    Mr. SCHNEIDER. Great. Well, thank you. I am out of time so 
I will yield back.
    Chairman COLLINS. Okay. I guess to finalize where we are, 
maybe a couple of questions then, I guess.
    Dr., or Director Alvarez, I am assuming the government has 
provided funding to the states, however many that is, the 18 or 
so states that are creating SHOP Exchanges. I am assuming that 
is correct. Can you tell us how much has been spent towards the 
SHOP Exchanges in those 18 states?
    Ms. ALVAREZ. I do not have the specific figures in front of 
me, but just one point of clarification, Congressman. What we 
have done is give establishment grants to state-based 
marketplaces. We have not given specific money for the 
establishment of a SHOP Marketplace. It is related to the 
establishment of the state-based marketplace. And as one of 
their requirements of operating a state-based marketplace, it 
is also operating a SHOP.
    Chairman COLLINS. So let us go back to the data piece. Now, 
today, Administrator Tavenner did say 7.3 million folks, 
individuals have enrolled in health plans. Are any of those 
SHOP enrollments or are they all on the individual side?
    Ms. ALVAREZ. They are all on the individual market.
    Chairman COLLINS. So we still do not have any numbers on 
the SHOP?
    Ms. ALVAREZ. We are working to get that information for 
you.
    Chairman COLLINS. Well, and so let me just conclude by 
encouraging anyone and everyone in your arena to get the data 
because I know as a business guy, I cannot even imagine flying 
blind the way we are. We would like to answer the question, how 
many businesses are taking advantage of it? How many employees 
are taking advantage of it? What is the cost? And then once you 
have got that benchmark, you can go quarter-to-quarter, month-
to-month, because on the SHOPs they can sign up every month, so 
it is not like a snapshot which we may have on the individual, 
that anything we could do to have that data will let the 
taxpayers understand how their money has been spent. And 
without it there is a frustration that I have and others where 
we are supposing things. And I think you understand that 
frustration. So if you could just let us know, and sooner than 
later where we are.
    So I was just wrapping up. I did not know if you had 
anything else to add or not, Ms. Hahn?
    Ms. HAHN. No. Just thank you to all of you for coming and 
expressing your concerns. Director Alvarez, I really 
appreciated and was impressed by your knowledge of the 
situation and your ability to clarify and illuminate for us 
what the intended purposes are of the Small Business SHOP 
Exchange. And again, I would reiterate my opening comments that 
certainly we have already found out things are not perfect, but 
I am dedicated to and committed to, and I hope my friends 
across the aisle are as well, to fixing what we think needs to 
be fixed because ultimately I think this is a good law and a 
lot of it I think has helped we already know millions of 
Americans. So thank you for being here today.
    Chairman COLLINS. I also would like to thank everyone for 
appearing and just concur that this health care debate is going 
to be continuing for some time to come. And the more data we 
have, the better the context can be. We do not have to talk 
over each other. The debate should be on the data, which then 
will lead us to see where we are going.
    And I would like to point out though, I am a small business 
owner, and I probably visit in any given week when I am back in 
the district, 15 or 20 small businesses. And I can tell you 
universally that the biggest problem they bring up is 
Obamacare. The mandates on hours and the fact that they are 
cutting workers' hours to 28 hours, and I hear this 
prescription benefit cost which can be 25-30 percent, the cost 
of insurance, and some of these folks with young employees do 
not have any need for it. So what we are doing is penalizing 
the young and the healthy in order to provide for the old and 
the sick, and I understand that balance, but let us face it, 
the young and the healthy are not signing up at anywhere near 
the percentage that was put out, and partly as a result we are 
now seeing some of the costs go up because they have got a year 
of data and the young and the healthy were not there for it.
    Ms. HAHN. May I just add one thing?
    Chairman COLLINS. Sure.
    Ms. HAHN. I also visit lots of small businesses in my 
district in Los Angeles. I have business roundtables all the 
time I make it a point to walk into, and universally, the 
biggest concern that my small businesses have are not with 
health care but with the economy. They want more customers, and 
their access to capital. Many of my small businesses, 
particularly my women-owned and minority-owned businesses, want 
to find out how they can access small business loans so that 
they can grow, expand, and hire people. That is what I hear 
universally.
    Chairman COLLINS. We could have a whole discussion about 
Dodd-Frank and what that has done to the economy, but we will 
not be there today.
    So again, you have all provided valuable insight and I 
appreciate your attendance.
    I will ask unanimous consent that members and the public 
have five legislative days to submit supporting material into 
the record. And hearing no objections, so ordered.
    The hearing is now adjourned.
    [Whereupon, at 2:51 p.m., the Subcommittee was adjourned.]
                            A P P E N D I X

[GRAPHIC] [TIFF OMITTED] T9780.001

                    Statement of Mayra E. Alvarez on


   ``An Update on the Small Business Health Opti8ons Program: Is It 
                    Working for Small Businesses?''


   U.S. House Committee on Small Business Subcommittee on Health and 
                               Technology


                           September 18, 2014


    Chairman Collins, Ranking Member Hahn, thank you for the 
opportunity to discuss the many benefits that the Affordable 
Care Act is providing for small businesses. The Affordable Care 
Act has improved the insurance market for small employers, 
making it easier for them to find and purchase employee health 
coverage. Qualified small employers can now purchase coverage 
for their employees using the Small Business Health Options 
Program (SHOP), and small businesses are receiving a more 
generous tax credit in 2014 for offering their employees a 
qualified health plan through the SHOP in their states. Small 
employers will see even greater options this fall when the 
online functions of the Federally-facilitated SHOP Marketplace, 
and those of many state-based SHOPs, become available on 
November 15.

    In the past, although many small employers have wanted to 
offer health benefits to their employees, they have faced many 
challenges. Historically, small businesses have been charged 10 
to 18 percent more for the same benefits compared to large 
employers.\1\ Small businesses employing women or workers with 
chronic or high-cost illnesses, or with pre-existing 
conditions, have faced higher insurance rates in most states. 
Because small firms have fewer employees to pool than larger 
firms, premiums varied dramatically from year to year due to 
changes in just one or two workers' health status or because of 
small changes in the ratio of male to female employees. The 
Affordable Care Act limits the factors insurers can use in 
determining what they charge small business and thus helps 
provide small businesses more predictable rates. In doing so, 
the law helps small employers provide their employees with 
high-quality, affordable health care coverage that cannot be 
priced so high that it's out of reach for businesses just 
because someone gets sick.
---------------------------------------------------------------------------
    \1\ http://www.commonwealthfund.org//media/Files/Publications/
In%20the%20Literature/2006/May/
Benefits%20and%20Premiums%20in%20Job%20Based%20Insurance/
Gabel--benefitspremiumsjobbased--925--i
tl%20pdf.pdf

    Affordable Care Act Implementation: Building on Progress in 
---------------------------------------------------------------------------
Affordability, Access and Quality

    A new wave of evidence shows that the Affordable Care Act 
is working to make health care more affordable, accessible and 
of a higher quality, for families, seniors, businesses, and 
taxpayers alike. Thanks to the Affordable Care Act, consumers 
today enjoy better access to affordable health coverage, 
stronger protections in the case of illness or changes in 
employment, and a competitive Marketplace that allows them to 
choose from and enroll in insurance coverage that is right for 
them. Millions of people--including many of the self-employed--
have obtained private insurance coverage in the Marketplace, 
over seven million children, families, and individuals have 
gained coverage through Medicaid and CHIP, and more than three 
million young adults gained or retained insurance under the 
Affordable Care Act by staying on their parents' plan.

    Recent years have seen historically low growth in overall 
health spending, and a variety of recent data show that very 
slow growth in health care costs is continuing.\2\,\3\ In fact, 
just last week, the Kaiser Family Foundation and Health 
Research and Education Trust reported the premiums for small 
businesses rose by just 1.7 percent from 2013 to 2014, the 
smallest increase since the organizations' survey began in 
1999.\4\ These increases are far below the double-digit 
increases small businesses experienced in the decade before the 
Affordable Care Act was enacted.
---------------------------------------------------------------------------
    \2\ Council of Economic Advisers. 2014. ``Recent Trends in Health 
Care Costs, Their Impact on the Economy, and the Role of the Affordable 
Care Act.'' Economic Report of the President, http://
www.whitehouse.gov/sites/default/files/docs/
erp--2014--chapter--4.pdf
    \3\ Jason Furman. ``Good News on Employer Premiums Is More Evidence 
of a Dramatic Change Economic Change for the Better,'' http://
www.huffingtonpost.com/jason-furman/good-news-on-employer-
pre--b--5798244.html
    \4\ http://kff.org/report-section/ehbs-2014-section-one-cost-of-
health-insurance/

    Several recent reports make clear that the Affordable Care 
Act is reducing the uninsured rate. A study published in the 
New England Journal of Medicine found that, as compared with 
the baseline trend, the non-elderly uninsured rate declined by 
5.2 percentage points by the second quarter of 2014, a 26 
percent relative decline from the 2012-2013 period, 
corresponding to 10.3 million adults gaining coverage.\5\ These 
independent surveys point to the same overarching trend--the 
success of the Affordable Care Act in lowering the number of 
uninsured Americans.
---------------------------------------------------------------------------
    \5\ New England Journal of Medicine, Health Reform and Changes in 
Health Insurance Coverage in 2014.

    The Affordable Care Act benefits Americans broadly, not 
simply those who are newly insured. Over the past three years, 
Americans have benefitted from insurance reforms that have 
already gone into effect, such as allowing adult children up to 
age 16 to stay on their parents' insurance, eliminating 
lifetime dollar limits on essential health benefits, and 
prohibiting rescissions of insurance when someone gets sick. 
Preventive benefits, including wellness visits and certain 
cancer screenings with no cost sharing, as well as new 
incentives to pay doctors and hospitals for improving outcomes, 
are aimed at improving the quality of the health care that 
Americans receive. Now pre-existing conditions no longer 
preclude individuals from gaining health insurance, and 
consumers have better access to comprehensive, affordable 
coverage. Consumers now have the comfort of knowing that if 
their employment changes or they lose their current coverage, 
they can purchase affordable coverage through the Marketplace--
regardless of their personal health history--or have access to 
Medicaid in many states. Small business owners can be assured 
that they will not face wide variations and high volatility in 
premiums based on the type of work they do or the health status 
---------------------------------------------------------------------------
of their workers.

    The Affordable Care Act's reforms are effective because 
they have benefits across the health care system. Reductions in 
the uninsured rate should mean doctors and hospitals provide 
less uncompensated care, a cost that is often passed along to 
taxpayers, as well as consumers and employers who pay premiums 
for health coverage. And new pools of people buying insurance 
means insurers have an opportunity to grow by competing to 
provide better access to quality, affordable choices--the same 
advantages that consumers are used to in any competitive 
marketplace. The creation of a viable health insurance market 
benefits all Americans, no matter where they get their health 
insurance.

    Small Business Health Options Program (SHOP)

    The Affordable Care Act established the Small Business 
Health Options Program (SHOP) to make it easier for small 
businesses to obtain health coverage for their employees. Just 
as in the individual Marketplaces, the SHOP allows small 
businesses to easily compare and select plans that meet the 
needs of their employees. In 2014, the SHOP opened to small 
employers with 50 or fewer full-time equivalent employees. In 
2016, the program will be open to businesses with 100 or fewer 
full-time equivalent employees. It is important to remember 
that unlike the individual Marketplace, eligible employers can 
begin participating in the SHOP at any time, and are not 
limited to a single open enrollment period. Just as they always 
have, small employers may purchase coverage for their employees 
throughout the year.

    This past year, small employers have offered coverage to 
their employees through the Federally-facilitated SHOP 
Marketplace by receiving an eligibility determination from the 
SHOP, and enrolling in coverage through an agent, broker, or 
issuer. Some of these employers have also been able to claim 
the small business health care tax credit, which can cut their 
premiums by as much as 50 percent. Since August 2013, small 
employers have been able to contact a dedicated call center 
with questions about the Affordable Care Act and Federally-
facilitated SHOP enrollment. HHS also added new small business 
online tools to HealthCare.gov earlier this year, including a 
consumer-friendly small business health care tax credit 
estimator that helps small employers determine if they qualify 
for the small business health care tax credit and how much it 
could be worth for a small employer.

    Consistent with state law, agents and brokers are playing a 
vital role in the SHOPs, as they do in the small group market 
today. Agents and brokers act as trusted counselors, providing 
service at the time of plan selection and enrollment and 
customer service throughout the year. For the 2014 plan year, 
more than 79,000 agents and brokers trained to assist consumers 
in the Federally-facilitated Marketplace--including many who 
completed the SHOP-specific course. The SHOP Call Center is 
also available to help agents, brokers, Navigators, and other 
Marketplace approved assisters specifically working on behalf 
of small employers in states participating in the Federally-
facilitated Marketplace.

    HHS has worked to create a seamless online experience and 
add key new features for the Federally-facilitated SHOP 
Marketplace in 2015. New features include offering employees a 
choice of health plans, premium aggregation services, and a 
dedicated online system for licensed agents and brokers to 
assist their SHOP small business clients. Starting November 15, 
the online Federally-facilitated SHOP Marketplace on 
HealthCare.gov will offer new health coverage options to small 
employers with one to 50 employees, and make it easier for them 
to shop for, select and offer employees high quality health 
plans and dental plans, and allow employees to enroll online.

    SHOP Early Access

    As we move to expand online functionality for the SHOP this 
November, CMS is committed to acting on lessons learned and 
continuously improving the user experience. Thus, small 
employers, agents and brokers in five states--Delaware, 
Illinois, New Jersey, Missouri, and Ohio--will have the 
opportunity to experience key features of the new online SHOP 
Marketplace on HealthCare.gov, in advance of the full SHOP 
Marketplace launch nationwide on November 15. During ``SHOP 
Early Access'', small employers in these states will be able to 
establish a Marketplace account, assign an agent/broker to 
their account, complete an application, obtain an eligibility 
determination, upload their employee roster, and--when 
available in early November--browse available plans and 
pricing. Beginning on November 15th, small employers in these 
states and others participating in the Federally-facilitated 
SHOP will be able to complete their plan selection and 
enrollment and offer coverage to their employees that takes 
effect as soon as January 1, 2015.

    Early Access will also allow for targeted consumer testing 
with small businesses, agents, brokers, and assisters before 
the SHOP functions are made available online in all Federally-
facilitated SHOP Marketplace states. This consumer testing will 
add to the rigorous performance testing completed on the core 
software product and interfaces prior to Early Access and go-
live.

    SHOP Employee Choice

    We are also making important progress in offering small 
business employees additional choices for their health 
coverage. In the past, most small employers were only able to 
offer a single health and dental plan for all of their 
employees. Now, through the ``employee choice'' option, small 
businesses in many states will have the option to allow 
employees to choose any health plan and dental plan available 
at the coverage level selected by the employer. Employee choice 
provides significant benefits to both employers and employees. 
It can lessen the administrative burden on employers and allow 
employees to select the plan that best fits their individual 
and family circumstances. Additionally, in 2015, all employers 
participating in the Federally-facilitated SHOP Marketplace 
will make their monthly premium payments directly to the SHOP 
Marketplace, which will disburse payments to all of the 
different plans selected by employees when employee choice is 
offered, thus further reducing administrative hassle for 
employers.

    In addition to expanding choices for consumers, employee 
choice has the potential to facilitate greater market 
competition in states--making it possible for smaller, less 
established issuers to break into small group markets and 
encourage all small group market issuers to compete based on 
price, customer satisfaction, and other quality measures.

    HHS is aware that small business markets differ from state-
to-state. To help smooth the transition to employee choice, HHS 
has allowed State Insurance Commissioners to request that the 
SHOP in their state defer implementation of the employee choice 
provision in 2015 if, in the Insurance Commissioner's expert 
judgment, doing so would be in the est interests of small 
employers and their employees and dependents. HHS is committed 
to implementing employee choice in a way that learns from early 
experience and ensures success. In total, 14 states with a 
Federally-facilitated SHOP Marketplace plus most State-based 
SHOPs will make employee choice available to small businesses 
in 2015, doubling the number of states offering this option. In 
2015, nearly two-thirds of Americans will live in states where 
small business employees could be offered the option to choose 
a health plan rather than have their employer do it for them.

    Small Business Health Care Tax Credit

    In addition to choice, we know how important affordability 
is. The Affordable Care Act created the Small Business Health 
Care Tax Credit to help small employers of lower wage workers 
afford a significant contribution towards workers' premiums. An 
employer may qualify for a tax credit if it has fewer than 25 
full-time-equivalent employees making an average of less than 
$50,000 a year (as adjusted for inflation beginning in 2014). 
To qualify for the Small Business Health Care Tax Credit, an 
employer must also pay at least 50 percent of the premium cost 
of employee-only coverage for each of its employees. For tax 
years starting in 2014, the tax credit can be worth up to 50 
percent of for-profit employer's contribution towards 
employees' premium costs and 35 percent for non-profit 
employers, and is generally available only when employees are 
enrolled in SHOP coverage. The 2014 maximum credit amount for 
the Small Business Health Care Tax Credit is a significant 
increase over the maximum amount for the credit from 2010-2013, 
when it should be worth up to 35 percent of employer-paid 
premium costs, or 25 percent for tax-exempt employers. Since 
the Small Business Health Care tax credit first became 
available in 2010, it has provided hundreds of thousands of 
small businesses more than $1.5 billion in tax credits.

    Conclusion

    In conclusion, for too long, small business owners have 
struggled to keep up with the ever-rising cost of health 
insurance for their employees. The Affordable Care Act makes it 
easier for businesses to find better coverage options and 
builds on the current employer-based insurance market. The 
SHOP, combined with new insurance reforms and tax credits 
provided by the Affordable Care Act, gives employers new 
options to provide their employees with high quality, 
affordable health care coverage. I look forward to continuing 
to work with you to improve the health care options for 
America's small businesses, families, and communities, and am 
happy to answer any questions you may have.
                   Testimony of Roger Stark, MD, FACS


       House Small Business Subcommittee on Health and Technology


                           September 18, 2014


               The Small Business Health Options Program


    Background

    The Patient Protection and Affordable Care Act (ACA) became 
law in 2010. The law is based on an individual mandate that 
requires every adult to own health insurance and an employer 
mandate that requires every employer with 50 or more full-time 
employees (FTEs) to provide health insurance to their 
employees.\1\
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services @ http://
www.hhs.gov/healthcare/rights/law/

    Under the ACA, states are allowed to expand their Medicaid 
entitlement program for the poor and are required to establish 
health insurance exchanges or utilize the federal exchange. 
These exchanges function as insurance brokerages where 
individuals can access insurance plans and potentially receive 
taxpayer subsidies to help them pay the insurance premium. Each 
exchange must offer at least four plans which must include t he 
ten essential benefits mandated in the ACA. Pricing must be 
---------------------------------------------------------------------------
approved by the government.

    The ACA also attempts to establish an exchange marketplace 
for employers with less than 50 FTEs. The Small Business Health 
Options Program (SHOP) is designed to help ``businesses provide 
health coverage to their employees.'' \2\
---------------------------------------------------------------------------
    \2\ What is the SHOP Marketplace @ https://www.healthcare.gov/what-
is-the-shop-marketplace

    Small businesses with less than 25 FTEs may qualify for tax 
credits if they pay at least 50 percent of the total health 
insurance premium cost for employees and the average wage of 
their employees is below $50,000, The tax credit is determined 
by the number of employees and by average wages. Basically, the 
smaller a business is, the larger the tax credit it could 
---------------------------------------------------------------------------
receive.

    Phase I of the employer tax credit began in 2010. Eligible 
employers may qualify for a tax credit of up to 35 percent of 
their contribution toward employees' insurance premiums. The 
employer must pay at least 50 percent of the employee-premium.

    Phase II of the employer tax credit began in 2014. Eligible 
employers may receive a credit of up to 50 percent of their 
portion of premium costs. However, these employers must 
purchase coverage through a SHOP Marketplace, or qualify for an 
exception to this requirement, to be eligible for the credit. 
The credit is only good for two consecutive tax years.\3\
---------------------------------------------------------------------------
    \3\ What You Need to Know About the Small Business Health Care Tax 
Credit @ http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-
for-Small-Employers

    At least 70 percent of employers must be enrolled in the 
SHOP Marketplace for the employer to qualify for tax credits. 
Employees who purchase their own health insurance count toward 
the 70 percent. Employees who have insurance through their 
spouse or who have government insurance, such as Medicare or 
Medicaid, do not count toward the total.\4\
---------------------------------------------------------------------------
    \4\ It's Still Hard for Small Businesses to Shop Around for Health 
Coverage by Meir Rinde @ http://www.njspotlight.com/stories/14/04/29/
it-s-still-hard-for-small-businesses-to-shop-around-for-health-
coverage/

    Some state exchanges started accepting enrollees through a 
SHOP Marketplace this year. The federal exchange will start 
accepting online applications this November for coverage in 
---------------------------------------------------------------------------
2015.

    Employers with more than 50 FTEs will be able to access 
SHOP on November 1, 2015 and employers with more than 100 FTEs 
will be able to access the program in 2016.\5\
---------------------------------------------------------------------------
    \5\ Obamacare Small Business Facts @ http://obamacarefacts.com/
obamacare-smallbusiness.php

    The demand and interest level of employers in an exchange 
such as SHOP was never determined. There is speculation and 
anecdotal evidence that SHOP was placed in the ACA for 
political reasons and convenience, rather than at the 
insistence of the law's architects.\6\
---------------------------------------------------------------------------
    \6\ SHOP Flop: Obamacare for Small Businesses, by Brett Norman @ 
http://www.politico.com/story/2014/06/shop-sdmall-business-health-
options-program-delay-107649.html

---------------------------------------------------------------------------
    Enrollment in SHOP to Date

    When the ACA became law in 2010, estimates showed that 1.4 
million to 4 million employers were eligible for tax credits. 
Only 170,00, or 4 to 12 percent of employers, filed for credits 
that year.\7\
---------------------------------------------------------------------------
    \7\ Small Employer Health Tax Credit: Factors Contributing to Low 
Use and Complexity @ http://kstp.com/kstplmages/repository/cs/files/
SMALL%20EMPLOYER%20HEALTH%20TAX%20CREDIT.pdf

    Individual state exchanges have had varying success at SHOP 
enrollment. New York state had nearly 1 million enrollees in 
its exchange, but only one percent were in the small employer 
market. California had a similar experience with 1.4 million 
enrollees overall, but less than 1 percent enrolled in SHOP.\8\
---------------------------------------------------------------------------
    \8\ Why We Still Don't Know How Many Small Businesses Signed Up 
Through Obamacare by J.D. Harrison @ http://www.washingtonpost.com/
business/on-small-business/why-we-still-dont-know-how-many-small-
businesses-signed-up-through-obamacare/2014/07/10/773d0cb6-0859-11e4-
a0dd-f2b22a257353--story.html

    The federal exchange has delayed online enrollment until 
November, 2014.\9\
---------------------------------------------------------------------------
    \9\ Obamacare's Online SHOP Enrollment Delayed by One Year by Sarah 
Kliff @ http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/27/
obamacares-online-exchange-for-small-businesses-is-delayed-by-one-year/

    Officials in Washington state chose to establish a state-
run health insurance exchange, including a SHOP. Coverage began 
in 2014, with SHOP having an open enrollment period. Only one 
carrier, Kaiser Permanente, offered plans and only offered 
those five plans in two counties in Southwest Washington. 
Although 4,300 small businesses created online accounts, only 
11 companies, with a total of 40 people, actually purchased 
insurance on the SHOP exchange this year.\10\
---------------------------------------------------------------------------
    \10\ With Statewide Insurance Options, Washington's Business Health 
Exchange Readies For Close-up by Gregg Lamm @ http://
www.bizjournals.com/seattle/blog/health-care-inc/2014/09/with-
statewide-insurance-options-washington-s.html

    A second insurance company, Moda, has applied to offer 14 
---------------------------------------------------------------------------
plans state-wide starting in 2015.

    The Director of the Washington State SHOP Marketplace, 
Catherine Bailey, stated that ``many of the carriers were not 
interested in expending additional resources to be in the small 
business exchange right away.'' \11\
---------------------------------------------------------------------------
    \11\ Ibid.

    The Government Accountability Office (GAO) has speculated 
that the use of tax credits and the SHOP enrollment are so low 
for several reasons. The first reason is the complexity in 
doing all the paperwork.\12\ Conversations the GAO has had with 
tax preparers reveal that employers must spend from two to 
eight hours or possibly longer collecting employee data and tax 
preparers must spend an additional three to five hours 
calculating the credit.
---------------------------------------------------------------------------
    \12\ See ref 5.

    Second, the GAO reports the tax credit is not a large 
---------------------------------------------------------------------------
enough incentive for many small employers.

    Third, the majority of small businesses have never offered 
health benefits to employees. The Medical Expenditure Panel 
Survey (MEPS) estimated that 83 percent of small companies did 
not offer health insurance in 2010 when the ACA became law.

    In addition, insurance companies are seeing a drop-off in 
employer-sponsored health insurance for small businesses. The 
CEO of Well Point, Joseph Swedish, is on record earlier this 
month stating that ``small employers (are) shifting employees 
to the individual exchange or (are) dropping coverage 
completely.'' He goes on to say small employers are making ``a 
very radical, fast shift to walking away from the so-called 
moral imperative'' of providing health insurance.\13\
---------------------------------------------------------------------------
    \13\ But Small Employers are Walking Away From Coverage by Sarah 
Wheaton @ http://www.politico.com/politicopulse/0914/
politicopulse15173.html

---------------------------------------------------------------------------
    Policy Analysis

    Although the employer mandate is a critical part of the 
ACA, the SHOP marketplace for small businesses seems to be 
almost an afterthought in the law. There is no clear evidence 
of interest on the part of small companies to provide health 
insurance through a marketplace with tax credits.

    Small businesses are typically start-up or low-margin 
companies where the added cost of employee health insurance can 
mean the difference between success and failure. The paperwork 
and regulatory burden in the SHOP exchange are definite hurdles 
for a small business employer.

    There is no real free market in the individual exchanges or 
in SHOP. Proponents will claim that competition exists, yet all 
insurance plans offered in the exchanges must contain the ten 
government-mandated essential benefits. Insurance premium 
prices must be approved by the government. Consequently, 
individuals and employers only have government-approved plans 
and not meaningful choices or real competition.

    The incentive of tax credits has not been significant 
enough to encourage employers to use SHOP. Obtaining the credit 
is so complicated that small businesses are unwilling or unable 
to spend the time and effort to complete the necessary forms.

    The SHOP Marketplace duplicates the private insurance 
marketplace with an added burden to taxpayers. Private 
association health plans, for example, have flourished for 
years without government financial support.

    Since employer interest and utilization of the tax credit 
is so small, the benefits of the SHOP Marketplace are unclear.

    Recommendations

    Designing an insurance exchange, whether it's private or 
government-run, offers each state, like Washington, the 
opportunity to reform health care delivery by starting with a 
``clean slate'' and moving toward a patient-oriented, consumer-
driven system. The exchange can be a transparent, information-
based market where individuals and small businesses can select 
the plan most appropriate to their needs. States can use the 
exchange as a mechanism to combine all existing state 
government insurance plans, such as Medicaid and Basic Health, 
into one administrative program.

    Done right, the exchange should be easy to use and should 
promote decreased health care costs. Insurance rates and 
benefit levels should be set by the insurance market and not by 
government regulations. The administration of the exchange 
should be done through a nonpolitical, independent board, not 
by a politicized bureaucracy.

    Under the ACA, all plans must contain the ten essential 
benefits that meet federal requirements. Washington state has 
57 benefit and provider mandates that overlap the federal 
benefits. Ideally, the state exchanges should be able to offer 
an array of ``mandate-free'' or ``mandate-light'' insurance 
plans that satisfy market needs. Greater use of high deductable 
insurance plans coupled with health savings accounts can 
control costs and offer more choices for patients and employers 
without compromising quality.

    Any subsidies in the exchange should flow to and be 
controlled by the patient, not by insurance executives or 
government officials. Tax credits or premium supports to 
purchase health insurance could also be offered in an exchange.

    Each state can function as a laboratory to design the most 
efficient, cost-effective exchange for small businesses and 
individual. Although the ACA includes hundreds of new mandates 
and regulations, states should have an opportunity to overhaul 
their existing programs, start fresh and establish a meaningful 
patient-directed, market-oriented health care system. The 
alternative is to submit to more government regulation and 
central planning with the attendant bureaucratic inefficiencies 
which will not increase competition, improve access, or 
decrease costs to patients and employers.
  Testimony of Professor Adam Beck to the Subcommittee on Health and 
                               Technology


                      Committee on Small Business


                 United States House of Representatives


                            Washington, D.C.


                           September 18, 2014


    Good morning.

    Thank you Mr. Chairman, Ranking Member Hahn and members of 
the Subcommittee for the opportunity to appear before you 
today. My name is Adam Beck and I am an assistant professor of 
health insurance at The American College in Bryn Mawr, PA. 
Since the College was founded in 1927, it has grown to become 
the nation's leading non-profit provider of higher education 
for professionals in the financial services industry. Today, 
The American College has the highest level of accreditation 
available and offers twelve professional designation and exam 
preparation programs, two master's degrees and a PhD in 
Financial and Retirement Planning. At The American College, I 
lead the Chartered Healthcare Consultant designation and teach 
courses focused on Health Care Reform for Employers and 
Advisers, Healthcare Consulting, Financing Long-Term Care for 
Seniors, and Life Insurance Law. I am the author of a textbook 
on the Essentials of Health Care Reform and the co-author of 
texts on healthcare consulting and long-team care financing. 
Additionally, I am an attorney with active licenses in New 
Jersey and Pennsylvania and advise medical and psychotherapy 
practices on matters relating to health insurance, Medicare, 
HIPAA and compliance with the Affordable Care Act.

    Small businesses and the people who work for them comprise 
the backbone of the American economy. Health insurance is a 
tremendously valuable, often life-saving, financial product, 
which our federal tax code affords special status. Therefore, 
it is an important and essential goal to allow small business 
owners the opportunity to offer quality, affordable health 
insurance coverage to their employees. Prior to the 
implementation of the Affordable Care Act, half of the 
uninsured in this country were part of the small business 
community--owners, employees and dependents.\1\ That is not for 
a lack of desire on the part of small business owners to offer 
health insurance coverage. The Small Business Health Options 
Program, or SHOP Marketplace, was designed by the 111th 
Congress to lower health costs for small business, increase 
competition and therefore choice for business owners, and 
simplify the process of offering health coverage. These are 
laudable goals, however it is my opinion that the SHOP 
Marketplace as it is currently structured and presented falls 
short of these goals. I believe the SHOP Marketplace will 
remain inadequate and continue to enroll relatively few 
companies so long as three factors remain: the existing tax 
incentives, the lack of engagement of agents and brokers, and 
shortcomings in information technology infrastructure.
---------------------------------------------------------------------------
    \1\ Gardiner, Terry and Pereera, Isabel. ``SHOPping Around'' Report 
of the Center for American Progress and Small Business Majority. June 
2011. http://www.smallbusinessmajority.org/reports/
shop--exchange.pdf

    I. The Small Business Health Care Tax Credit is Overly 
---------------------------------------------------------------------------
Complicated and Too Small

    The Patient Protection and Affordable Care Act created the 
Small Business Health Care Tax Credit to be an accompanying 
incentive to participate in the Small Business Health Options 
Program. Prior to the launch of SHOP marketplace on January 1, 
2014, the tax credit was available in a smaller form for most 
private market small group health plans enrolled in by 
qualifying business organizations during the tax years 2010 
through 2013. For the initial four years of the tax credit's 
existence, the maximum credit available was 35 percent for for-
profit entities and 25 percent for tax-exempt organizations. 
Beginning in 2014, the tax credit increased and became 
conditioned upon participation of eligible employers in a SHOP 
plan. The maximum available tax credit is today 50 percent for 
for-profit entities and 35 percent for tax-exempt 
organizations.

    While a fifty-percent tax credit may sound like a 
substantial incentive--particuarly considering that employers 
may still use pre-tax funds to pay for employee health 
benefits--the reality is far more nuanced. First, there is the 
limited universe of eligible employers. The credit is only 
available to business organizations with 25 or fewer full-time 
equivalent employees and average annual wages below $50,000. 
While this undoubtedly includes a substantial number of small 
businesses, it requires employers to engage in tedious and 
somewhat complex calculations of how many full-time equivalent 
employees they maintain in a given year, continually monitor 
compensation and face a perverse incentive for limiting pay, 
should increasing pay lead to average annual wages exceeding 
$50,000. Second, there is the sliding scale nature of the tax 
credit. The maximum credit of 50 or 35 percent is available 
only to businesses with 10 or fewer full-time equivalent 
employees and average annual wages below $25,000. The credit is 
then available in diminishing percentage amounts as the 
businesses grow larger or pay more. This again requires a 
complex calculation just so employers can estimate the 
potential tax incentives they could achieve from purchasing 
plans through a SHOP exchange. Third, the credit is time-
limited. Those who qualify may only claim the tax credit for 
two consecutive years.

    The Government Accountability Office estimates that up to 4 
million small businesses could qualify for the credit \2\, but 
this requires that small businesses know about the credit and 
go through the difficult process of determining eligibility. 
Further, even by the GAO's own admission, advocacy groups 
identify the 4 million figure as the likely high point of 
potentially eligible businesses, with some estimating that as 
few as 1.4 million employers would qualify. Linda Blumberg and 
Shanna Rifkin of the Urban Institute analyzed this issue in a 
report issued last month that was commissioned by the Robert 
Wood Johnson Foundation.\3\ They found that qualifying for the 
credit was particularly difficult in high cost-of-living areas, 
as the $50,000 limit in average annual wages applies uniformly 
nationwide. By way of comparison, someone earning $50,000 in 
Mason City, Iowa in 2014 would need to earn $73,104 annually to 
maintain the same standard of living in Los Angeles, 
California.\4\ Data from the first year of the tax credit 
(2010) indicate that the overwhelming majority of employers who 
were eligible for any credit were not eligible for the full 
credit. Only 17 percent were eligible for the full credit.\5\ 
The greatest obstacle, according to GAO analysis, was the 
annual wage requirement. In the first year, 68 percent of 
businesses who received less than the full credit would have 
qualified for the maximum percentage based on the number of 
full-time equivalent employees but failed to qualify based on 
wages.\6\ According to the Urban Institute report, many 
employers reported that they felt they needed the assistance of 
an accountant just to determine eligibility for the credit, a 
cost that sometimes exceeded the actual value of the credit.\7\ 
The GAO report offers a succinct summary of the degree of 
complexity involved in calculating the credit \8\:
---------------------------------------------------------------------------
    \2\ ``Small Employer Health Tax Credit: Factors contributing to low 
use and complexity.'' Report of the U.S. Government Accountability 
Office. May 2012. http://gao.gov/assets/600/590832.pdf (page 10)
    \3\ Linda Blumberg and Shanna Rifkin. ``Early 2014 Stakeholder 
Experiences With Small-Business Marketplaces in Eight States.'' Report 
of the Urban Institute. August 2014. http://www.rwjf.org/content/dam/
farm/reports/issue--briefs/2014/rwjf414995
    \4\ http://money.cnn.com/calculator/pf/cost-of-living/
    \5\ GAO report, supra, at page 10.
    \6\ Id.
    \7\ Blumberg and Rifkin at page 3.
    \8\ GAO report, supra, at page 13.

          On its Web site, I.R.S. tried to reduce the burden on 
        taxpayers by offering ``3 Simple Steps'' as a screening 
        tool to help taxpayers determine whether they might be 
        eligible for the credit. However, to calculate the 
        actual dollars that can be claimed, the three steps 
        become 15 calculations, 11 of which are based on seven 
        worksheets, some of which request multiple columns of 
---------------------------------------------------------------------------
        information.

    Setting aside the studies and statistics, it is very 
difficult to find a small business that has actually claimed 
the credit. They indeed exist, as we know from tax filings, but 
apparently in such small numbers that even a media outlet with 
the reach of the New York Tines was unable to find one to 
profile.\9\ When I teach my students about the tax credit, I 
always ask if any of the students--who are active brokers and 
financial advisers--have assisted any clients with this 
particular tax credit. No student has yet to answer in the 
affirmative.
---------------------------------------------------------------------------
    \9\ Robb Mandelbaum. ``Why the Health Care Tax Credit Eludes Many 
Small Businesses.'' The New York Times. September 25, 2012. http://
boss.blogs.nytimes.com/2012/09/25/why-the-health-care-tax-credit-
eludes-many-small-businesses/

    While the cost of premiums for plans available on many 
state SHOP marketplaces have been comparable to--and in many 
cases slightly lower than--similar plans prior to the opening 
of the SHOP, they generally remain higher than what many small 
businesses have determined they can afford to pay. This is 
where the tax credit is supposed to mitigate costs and increase 
the likelihood that a small business can actually afford to 
offer coverage. As expanded, simplified tax credit that is 
available for longer than two years would offer a real 
financial incentive for companies to either begin or continue 
---------------------------------------------------------------------------
offering health benefits.

    II. The Inclusion and Empowerment of Brokers has been 
Minimal

    For many small businesses that offer health insurance 
coverage to their employees, a health insurance agent or broker 
performs the bulk of the work necessary to facilitate benefit 
offerings. Small business owners frequently wear many 
(proverbial) hats, including that of human resources director, 
marketing director, and controller, among others. Thus, health 
agents and brokers play a critical role for small businesses. 
Many of these agents or brokers are comprehensive financial 
planners and advisers who work with small business clients on 
matters relating to life insurance and retirement benefits, 
investments and health insurance. The SHOP Marketplace will not 
succeed without a substantial buy-in from the agent and broker 
community. This much was readily acknowledged by John 
Arensmeyer, CEO of the pro-reform Small Business Majority, who 
said ``at the end of the day, the success of the small-business 
exchanges is going to be very heavily dependent on brokers and 
agents.'' \10\
---------------------------------------------------------------------------
    \10\ Robb Mandelbaum. ``Small Businesses Showing Little Interest in 
State SHOP Exchanges.'' The New York Times. December 23, 2013. http://
boss.blogs.nytimes.com/2013/12/23/small-businesses-showing-litle-
interest-in-state-shop-exchanges/

    Health insurance, like any financial product, is 
complicated and its purchase often requires the advice and 
assistance of a licensed professional, such as an insurance 
agent or broker. Particularly for small group policies, where 
the health and financial well-being of multiple lives and 
families is at stake, there should be substantial involvement 
of agents and brokers to ensure that business owners make 
decisions that are in the best interest of both their company 
---------------------------------------------------------------------------
and their employees.

    In its first year, at least in the states with fully or 
mostly functioning SHOP marketplaces, the marketing of the 
program to brokers, as well as the overall inclusion of brokers 
in the program, including empowerment, compensation and 
training, has been severely lacking. In short, even for those 
brokers who are aware of the SHOP marketplace in their state 
and the potential benefits available to clients, they must 
undergo state-mandated training and spend twice as much time on 
SHOP applications, all for the exact same level of compensation 
they would receive to sell a non-SHOP plan.

    In the states that operate their own SHOP marketplace, 
brokers are required to be certified through a state-specific 
training process, which may either be in-person or delivered on 
the web. Brokers who went through the training program have 
indicated that the materials were ineffective or even factually 
inaccurate. This included inaccurate exam questions and 
instructors who were required to teach material that was 
outdated. Further, many of the training programs covered SHOP 
only as part of a larger health care reform training, therefore 
requiring small business brokers to become educated upon issues 
unique to Medicaid, as opposed to more in depth discussion of 
SHOP.

    Those issues only apply to the brokers who feel they were 
included in the SHOP process. The marketing campaigns for state 
SHOP exchanges have often failed to target or reach small 
business health brokers, instead focusing on the federally-
funded navigators who primarily support individual exchanges. 
Additionally, and perhaps most importantly, the outreach to the 
business community about the existence of SHOP and the role 
that brokers can play in facilitating enrollment has been 
minimal. Many businesses remain unaware that they can turn to a 
local broker to discuss potential options under the Small 
Business Health Options Program.

    The degree and structure of compensation for brokers has 
discouraged substantial involvement. A broker will earn the 
same commission or fee for selling a plan directly through an 
affiliated carrier as he or she would for selling a plan 
through the SHOP marketplace.

    However, the time involved in enrolling a client in a SHOP 
plan is often double that required to enroll in a plan directly 
through a carrier. Some, including Lev Ginsburg of the Business 
Council of New York, estimate that the SHOP process is even 
more laborious, possibly as much as three or four times what it 
necessary to enroll in a non-SHOP plan.\11\ The additional time 
is due to the complexity of the IT system and application 
interface necessary to complete the SHOP process, as well as 
the opportunity cost involved with the time that often must be 
spent explaining the new employee choice model to client 
companies.
---------------------------------------------------------------------------
    \11\ Id.

    The commissions are not the doing of CMS. In its May 2013 
guidance, the Department of Health and Human Services clarified 
that broker commissions do not come from SHOPs, but rather from 
a negotiated arrangement between carriers and the brokers, but 
required that the rates be the same for a plan sold within a 
SHOP as it is for a plan outside of SHOP.\12\
---------------------------------------------------------------------------
    \12\ Memorandum from the Centers for Medicare and Medicaid 
Services. May 1, 2013. https://www.cms.gov/CCIIO/Resources/Regulations-
and-Guidance/Downloads/agent-brokers-5-1-2013.pdf

    This is not to say that either CMS or the state-run SHOPs 
have excluded agents or brokers. Indeed, they all have provided 
resource pages on their websites promoting the value of health 
insurance brokers and making materials available for the 
brokers themselves. It can be safely assumed that some broker 
perceptions are attributable to the focus during 2013 and 2014 
on the individual health insurance exchanges, while SHOPs were 
delayed or given a lower priority. However, as the SHOP 
marketplaces fully launch later this year, CMS and the state 
marketplaces will prioritize the inclusion of brokers and the 
---------------------------------------------------------------------------
trade organizations that support them.

    III. The Website Delay and IT Issues Increased Uncertainty, 
Hindering SHOP

    Third, and hopefully most obviously, the delay by the 
Administration of the Federal Facilitated SHOP Marketplace and 
the accompanying website limited the ability of small 
businesses in the 32 states relying on the federal marketplace, 
but it also created confusion for business owners, brokers and 
navigators in the states that had functioning SHOPs. 
Additionally, states that were operating their own SHOP 
Exchanges in 2014 experienced their own IT problems that 
hindered enrollments.

    On November 27, 2013, the Obama administration announced 
that the online enrollment component of SHOP would be delayed 
until November 2014, as opposed to launching in October 2013 as 
originally planned.\13\ (An earlier delay, announced September 
26, 2013, pushed back the October start to November.) While 
consumers were ultimately well aware of the online health 
exchanges, accessible through healthcare.gov, as evidenced by 
the 9.21 million online enrollments \14\, small business owners 
who visited the site in one of the federal-facilitated states 
found themselves unable to browse and compare plans online, as 
promised. This delay had real effects on the efficacy of SHOP. 
Promoters of the law and brokers speaking with small business 
clients were unable to say ``go to the website and explore your 
options.'' Further, the delays caused confusion among the small 
business community, which leads to uncertainty about SHOP as an 
effective means of obtaining insurance in the future.
---------------------------------------------------------------------------
    \13\ Sarah Kliff. ``Obamacare's online SHOP enrollment delayed by 
one year.'' The Washington Post. November 27, 2013. http://
www.washingtonpost.com/blogs/wonkblog/wp/2013/11/27/obamacares-online-
exchange-for-small-businesses-is-delayed-by-one-year/
    \14\ Charles Gaba. http://acasignups.net/

    The delays at the federal level were coupled with IT issues 
and a low prioritization in states that were running their own 
marketplaces. A thorough analysis of the impact of the 
Affordable Care Act in Pennsylvania was unable to draw 
meaningful conclusions about the efficacy of SHOP, as 
Pennsylvania did not have a functioning SHOP website.\15\ A 
spokeswoman for CoveredCA admitted that the launch of the 
individual exchange was the priority, and the California head 
of the National Federation of Independent Businesses said that 
even in his state ``the SHOP program has kind of taken a 
backseat.'' \16\ In states with their own SHOP marketplaces, 
the low prioritization was often overshadowed by IT problems. 
Maryland and Oregon, for example, had online systems that were 
non-functional.
---------------------------------------------------------------------------
    \15\ ``Beyond the Website.'' Fels Institute of Government, 
University of Pennsylvania. February 2014. https://www.fels.upenn.edu/
sites/www.fels.upenn.edu/files/
aca--final--feb--6.pdf
    \16\ Anna Gorman. ``California's Small Business Health Insurance 
Exchange Off To Slow Start.'' Kaiser Health News. May 8, 2014. http://
www.kaiserhealthnews.org/Stories/2014/May/08/Californias-Small-
Business-Health-Insurance-Exchange-Off-To-Slow-Start.aspx

    For brokers, there were IT issues that left many 
uncompensated for their work. Brokers would assist business 
clients with enrollment in a SHOP plan and then the online 
system would not record the involvement of the broker and the 
insurance carrier would not know to pay the broker. These IT 
---------------------------------------------------------------------------
issues discouraged both brokers and carriers alike.

    The most recent SHOP-related delay by the Administration 
will likely further hinder the program in 2015. On May 27, 2014 
the Administration issued final rules on the Employee Choice 
model in SHOP, which including transition relief allowing 
states the option of delaying Employee Choice until 2016.\17\ 
Eighteen states will delay Employee Choice an additional year. 
The Employee Choice model is an essential component of SHOP. In 
the past, small employees have been largely unavailable to 
provide choice or variety in health plans to their employees. 
While large firms overwhelmingly offer more than two plans to 
their employees, very few small employers were able to do so. 
The Employee Choice model will allow small businesses to offer 
employees a variety of plans within the same metallic tier or 
below a certain price point, which creates a real incentive for 
small employers to at least consider the options available 
within SHOP. An effective Employee Choice model, however, also 
requires a user-friendly information technology interface, 
which many states may not be fully prepared to offer.
---------------------------------------------------------------------------
    \17\ http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-
Insurance-Marketplaces/2015-Transition-to-Employee-Choice-.html

    While SHOP was supposed to be fully functional nationwide 
in 2014, what happened instead was a patchwork test run. In 
short, a key reason SHOP did not succeed in its first year was 
because its first year was postponed. A year with fully 
functioning structures and engaged players will be essential to 
---------------------------------------------------------------------------
truly judge efficacy.

    IV. Other Factors Impacting the Fist Year of SHOP

    Several other factors negatively affected SHOP during its 
initial year and will likely continue in the future. These 
include the many early renewals of small group plans in 2013, 
competition from private exchanges and the success of the 
individual marketplace.

    Many insurers actively encouraged small business clients to 
renew (or ``early-renew'') their existing small group health 
insurance plans prior to December 31, 2013. Any plans renewed 
on or after January 1, 2014 were required to comply with a host 
of new requirements under the Affordable Care Act, namely to 
offer a package of ten essential health benefits and limit 
cost-sharing. Thus, businesses with these early-renewed plans 
had no need to purchase health insurance plans in 2014, at 
least not until later this year. As many as 70 percent of small 
businesses may have opted to early renew policies in 2013.\18\ 
This dramatically limited the number of small businesses who 
otherwise may have been prime candidates for exploring plan 
options through the SHOP marketplace.
---------------------------------------------------------------------------
    \18\ Paul Demko. ``Small Business Exchanges off to rocky start.'' 
Modern Healthcare. July 14, 2014.

    Private exchanges are likely to grow in popularity over the 
coming years. Because the ACA requires the pricing of plans to 
be the same within a SHOP exchange as it is outside, the free 
market can be expected to result in competition from private 
actors who feel they can provide a greater variety of plans or 
a better customer experience. Private exchanges have been 
increasingly popular among larger companies, but the private 
---------------------------------------------------------------------------
exchanges are actively seeking to sell to small groups.

    Finally, despite the well-publicized disaster that was the 
launch of healthcare.gov, the Health Insurance Marketplace 
ended up enrolling far more people than nearly anyone had 
anticipated and millions of Americans found health insurance at 
a lower rate than they had previously paid. If employees of 
small businesses have the option of obtaining affordable health 
insurance on their own, usually with the assistance of a 
federal tax credit, many small businesses who have not offered 
coverage in the past will likely simply direct their employees 
to the public marketplace, thus rendering an employer-based 
plan unnecessary and alleviating a prospective burden from the 
employer.

    In conclusion, many small businesses want to offer health 
coverage. It simply needs to be more affordable, simpler and be 
facilitated by an experienced insurance broker. The Small 
Business Health Options Program has the potential to offer just 
that, but marketing, tax credits, information technology and 
broker involvement need to be dramatically increased in order 
for the program to achieve its laudable goals.
                              Statement of


                               Jon Gabel


                             Senior Fellow


                   NORC at the University of Chicago


               The Small Business Health Options Program:


                       Its Promise and Challenges


                               Before the


                        U.S. House Committee on


         Small Business, Subcommittee on Health and Technology

                         Statement of Jon Gabel


``The Small Business Health Options Program: Its Promise and Challenges


                           September 18, 2014


    Chairman Collins, Ranking Member Hahn, Members of the 
Committee.

    Thank you for the opportunity to discuss the promise and 
challenges of the Small Business Health Options Program (SHOP). 
I am Jon Gabel, a Senior Fellow at NORC at the University of 
Chicago. I am a nationally recognized expert on private health 
insurance with more than 35 years of experience. NORC is an 
independent non-profit, non-partisan research organization 
whose mission is to conduct objective research in the public 
interest. The views I present are mine, and not those of NORC.

    Today I will discuss factors promoting and inhibiting the 
success of SHOPs. Some of the analysis will be based on recent 
research for CCIIO/CMS.

    The authors of the ACA designed SHOPs to bring the 
efficiencies of the large group market to small employers. 
Historically, the small group market (firms with 50 or fewer 
workers) was characterized by higher premiums and 
administrative expenses, and greater volatility in premium 
increases from year to year. For coverage with identical 
financial protection the smallest employers (1-9 workers) paid 
premiums 18 percent more than large employers.\1\ Whereas 
administrative expenses constituted less than 10 percent of the 
premium dollar for the nation's largest firms, administrative 
expenses accounted for more than 20 percent of the premium 
dollar for small employers. One reason that administrative 
costs were higher in the small employer market was that 
insurers competed through medical underwriting--a technical 
term meaning making sure that an insurer does not sell to small 
firms with very sick pe9ple, or alternatively, charging higher 
premiums to reflect expected expenses plus risk. Medical 
underwriting entailed examining the medical records and past 
insurance claims of the prospective new customers. Insurers did 
so not because they were ``bad companies,'' but because the 
economic of health insurance dictated they do so. Medical 
expenses are concentrated among a few sick people. In employer-
based insurance, the sickest 1 percent will account for 27 
percent of claims expenses, the sickest five percent over 50 
percent of expenses, and the healthiest 50 percent account for 
5 percent of expenses. If an individual insurer unilaterally 
declined to medically underwrite, that insurer would attract 
the worst risks and be forced to price their products at non-
competitive rates. The Affordable Care Act prohibits setting 
premiums based on the health status of the insured population. 
It does allow insurers to set premiums based on the age of the 
population within limits, by geography, and smoking status. 
Thus, the ACA transforms the small group market so insurers no 
longer compete on their ability to identify and exclude high-
risk individuals and small groups, but now must compete on 
price and quality.
---------------------------------------------------------------------------
    \1\ J. Gabel, R. McDevitt, L. Gandolfo, J. Pickreign, S. Hawkins, 
and C. Fahlman, ``Generosity and Adjusted Premiums in Job-Based 
Insurance: Hawaii Is up, Montana Is Down,'' Health Affairs, May/June 
2006, 25(3): 832-843.

---------------------------------------------------------------------------
    Recent Trends in the Small Employer Market

    SHOPs are aiming to establish itself at a time of relative 
price stability in employer-based insurance including the small 
employer market. Data from the annual Kaiser Family Foundation/
Health Research and Educational Trust (KFF/HRET) Employer 
Health benefits Survey show that in 2013-2014 premiums fell 1.2 
percent (Exhibit 1) for employers with 3-50 workers. In 2013 
premium increases were 2.3 percent.\2\ For all firms premium 
increases in 2013-2014 for family coverage were only three 
percent. Small employers, similar to consumers in general, 
would be more likely to shop for new plans when premiums are 
rising rapidly.
---------------------------------------------------------------------------
    \2\ Neither of these figures were statistically significant from 
the previous year.
[GRAPHIC] [TIFF OMITTED] T9780.002

---------------------------------------------------------------------------
    Brief History of SHOPs and Purchasing Pools

    Exchanges for small employers are not a new idea. Over the 
past 25 years many states attempted to build what was termed 
``health insurance purchasing co-operatives'' (HIPCs), but none 
enjoyed widespread success. Among the states attempting to 
build HIPCs were California, Connecticut, Washington, Florida, 
Kansas, Colorado and Kentucky. Connecticut was perhaps the most 
successful and attained an eight percent market share in the 
late 1990s.\3\ Massachusetts invested more than a million 
dollars in research and marketing in 2012-13 to attract small 
employers to their ``Connector.'' Enrollment today is less than 
10,000 persons.
---------------------------------------------------------------------------
    \3\ Richard Teske, ``How the Kansas Business Health Partnership Can 
Learn from Other Health Purchasing Cooperatives (HPC's)'' Kansas Public 
Policy Institute, 2001.

    One clear lesson from earlier attempts to build HIPCs is 
that underwriting rules must be the same inside and outside the 
HIPCs.\4\ Many states prohibited medical underwriting within 
the pools but allowed it outside the HIPCs. The inevitable 
result was that brokers sent their high risk groups to the 
HIPCs, medical claims expenses and premiums rose each year, 
risk selection worsened, and the HIPCs went into a death 
spiral. Another challenge to HIPCs was that large insurers 
often did not want to participate.
---------------------------------------------------------------------------
    \4\ M. Hall, E. Wicks, and J. Lawler, ``Health arts, HIPCs, MEWAs, 
and AHPs: A Guide for the Perplexed,'' Health Affairs, 20:1 (2001): 
142-153.

    The authors of the ACA addressed many shortcomings of 
earlier HIPCs. Underwriting was prohibited on and off the 
Marketplace and plans offered on the Marketplace must also be 
offered off the Marketplace and are considered one plan. CCIIO 
requires carriers with market share of 20 percent or more in 
the state small employer market to participate on the SHOP. If 
a ``tied'' carrier refused to participate, the carrier was not 
---------------------------------------------------------------------------
allowed to sell plans on the individual exchange in that state.

    Employee Choice and Employer Models

    Other witnesses have described the structure and market 
rules of SHOPs, as well as operational issues encountered over 
recent years. I will not delve into those subjects, but will 
review the two SHOP models--the ``employee choice'' and 
``employer model.''

    With the ``employee choice model,'' the employer 
contributes a fixed amount for plan offerings on the SHOP, 
regardless of which plan the employee selects. Although there 
is variation from state-to-state, in general employees can 
select plans from different metal tiers and carriers. If an 
employee picks a plan whose premium exceeds the employer's 
contribution, the employee pays out-of-pocket the difference 
between the contribution and the premium for the selected plan. 
Thus the employee model provides a strong incentive for 
employees to select lower cost plans, while offering a wide 
choice of plans. All state-based SHOPs but Massachusetts use 
the employee choice model, whereas states relying on the 
Federally-Facilitated Marketplace (FFM) used the employer model 
in 2014.\5\ With the employer model, the employer chooses a 
single plan, and all employees that opt for coverage enroll in 
that plan.
---------------------------------------------------------------------------
    \5\ States may use different variations of the employee model--
allowing different breadths of plan options to employees, such as 
requiring them to choose from plans within a metal tier or offered by a 
single carrier--but most supported only limited choice for plan year 
2014. These variations could be incorporated into future multivariate 
analyses.

---------------------------------------------------------------------------
    Value-Added Features of SHOPs

    If SHOPs are to succeed in enrolling significant numbers of 
small employers, they must provide value-added features not 
available in the current off-SHOP Marketplace. SHOPs have the 
potential to do so. First, plans offered on the SHOP could have 
premium expenses lower than those plans only offered off the 
SHOP.\6\ Second, employers seeking tax credits must purchase 
plans on the SHOP. These tax credits are linked to the size of 
the firm and the percentage of the workforce who are low-income 
workers. Third, SHOPs can enhance employee choice. When using 
the employee choice-model, employers can make a defined 
contribution, and employees can then select plans among 
multiple carriers, and in some states, multiple metal tiers--
rather than having to choose one plan from one carrier. Fourth, 
the employee choice model is a defined contribution model, so 
employers reduce their financial risk against future increases 
in premiums. Note that two of these four features require the 
employee choice model.
---------------------------------------------------------------------------
    \6\ If an insurer offers a plan on the SHOP, it must offer the same 
plan off the SHOP at an identical premium. On the other hand, insurers 
can offer a plan off the SHOP only.

    A survey of small employers that my colleagues and I 
conducted with funding from the Commonwealth Fund and published 
in Health Affairs, found may potential ``value-added'' features 
are highly attractive to small employers--both firms offering 
and not offering health benefits.\7\,\8\ Exhibit 2 shows that 
among non-offering firms when considering whether to offer 
coverage, 82 percent say it is ``very important'' that 
insurance costs less than today; 73 percent indicate that it is 
very important that premiums don't go up when there is a sick 
employee; 61 percent say ``more plan choice'' is very 
important; 64 percent indicate that tax credits are very 
important and 59 percent consider the ability to send one 
monthly check very important. Similarly, Exhibit 3 displays 
that among small firms offering coverage that 41 percent 
thought it was ``very important'' to have more plan choice; 68 
percent to have the ability to compare plans; 37 percent to 
have a third party to handle claims questions and another 37 
percent to have a third party to answer questions.
---------------------------------------------------------------------------
    \7\ J. Gabel, H. Whitmore, J. Pickreign, J. Satorius, and S. 
Stromberg, ``Small Employers' Survey: Premiums, SHOP Exchanges, And 
Self-Insurance Are Main Concerns With The Affordable Care Act,'' Health 
Affairs, Web Special, October 16, 2013 and November, 2013, 32:11, 2032-
2039.
    \8\ About 45 percent of firms with fewer than 50 workers do not 
offer coverage, according to the Kaiser Family Foundations/Health 
Research and Educational Trust.
[GRAPHIC] [TIFF OMITTED] T9780.003

---------------------------------------------------------------------------
    Availability of SHOP Plans

    As noted previously, earlier HIPCs often encountered 
resistance from large plans. Aware of this history, CCIIO 
required carriers with 20 percent or more market share in the 
small group market to participate in the SHOP. In a study of 26 
states, we found on average there were 4.3 carriers selling on 
the SHOPs in the 26 states, and 56 plans in total offered per 
state.\9\ In these same states there is an average of three 
carriers selling to small employers off the Marketplaces only. 
But carriers selling on the SHOP also sell off-the-SHOP-only 
plans. In all there are about three plans sold off the SHOP 
only for every plan sold on the SHOP. Moreover, in many states 
only one or two carriers offer plans on the SHOP. Washington 
State has but one carrier. Hawaii, Vermont, Alabama, Florida, 
Kansas, Maine, and Tennessee have only two.
---------------------------------------------------------------------------
    \9\ J. Gabel et al., ``Is There a SHOP Risk Premium in Employee 
Choice States?'' NORC at the University of Chicago, June 2014, Contract 
with the Consumer Information and Insurance Oversight (CCIIO).

    Tied carriers represent about 1/3 of the carriers 
participating on the Marketplace. In about 2/3 of those states, 
non-tied carriers offer more plans per state than tied 
carriers. We conducted interviews with nine employers who 
purchased coverage on the SHOP. A more common complaint was 
---------------------------------------------------------------------------
that there was too much choice rather than insufficient choice.

    Cost of Plans on the SHOPs

    One potential added value feature of SHOPs is to offer 
lower premiums than in the traditional small employer market. 
In the 26 states we collected data from state insurance 
websites and SHOP Exchanges. We used descriptive and 
multivariate analysis to compare the cost of coverage for a 40 
year old non-smoker (a one employee firm) for plans sold on the 
Marketplaces with plans sold only off the Marketplaces i the 
same metal tier. In both descriptive and multivariate analysis 
we found that premiums were lower for plans on the Marketplaces 
(Exhibit 4) for the bronze, silver and gold tiers.
[GRAPHIC] [TIFF OMITTED] T9780.004

    In our multivariate analysis, we found, other factors held 
statistically constant, plans offered on the Marketplace on 
average have seven percent lower premiums that plans sold off 
the Marketplace only. Carriers not participating on the 
Marketplace have premiums two percentage points higher. One 
explanation for the lower premiums is that Marketplace plans 
are more likely to have narrower networks and thus obtain 
greater discounts from providers. Another possibility is the 
transparent and competitive market structure of Marketplaces 
leads to carriers offering lower premiums. A third explanation 
is the actuarial values used to assign plans to metal tiers are 
calculated for the essential benefit package. Non-Shop Plans 
may offer more non-essential benefits.

    Challenges to SHOP Success -- How Carriers View SHOPs

    We conducted nine interviews with carriers--both tied and 
non-tied ones.\10\ We found all carriers thought initial 
enrollment would be small, and it turned out to be smaller than 
they expected. The low set of expectations was largely based on 
the experience in Massachusetts and Utah. Most tied carriers 
would not have participated had it not been for the tying 
requirement, and would have preferred to watch and wait before 
entering. We interviewed one tied carrier that did not 
participate in the SHOP, and this carrier indicated that it was 
not planning to participate on the individual Marketplace, so 
the tying penalty was not the main issue.
---------------------------------------------------------------------------
    \10\ J. Gabel, A. Lischko, Analysis of SHOP Participation 
Requirement, NORC at the University of Chicago, Report to CCIIO for 
Contract, June 2013.

    Tied carriers and non-tied ones generally held divergent 
views about SHOPs. Non-tied carriers saw the SHOP as a means of 
entry or market share enhancement. The employee choice model 
offered an opportunity to enroll employees, whereas the 
tradition sale of one employer to one insurer would likely 
result in the dominance of traditional carriers. We spoke to 
Kaiser Plans and found that they were enthusiastic supporters 
of SHOPs. They viewed SHOPs as a useful way to reorganize the 
delivery of care and believed with employee choice they would 
be able to offer more value than the traditional fee-for-
service insurers. We concluded that if SHOPs are to succeed, it 
will be due to the competitive fringe, not the current dominant 
---------------------------------------------------------------------------
insurers.

    Challenges to SHOP Success-The Role of Brokers

    Eighty percent of small employers use brokers or agents. 
Brokers often perform tasks that benefit managers do in larger 
firms. For example, among small firms using brokers, 84 percent 
responded that brokers select a health plan, 79 percent enroll 
employees, 59 percent provide customer service such as denied 
claims, and 31 percent decide employee contributions towards 
premiums.\11\ Earlier HIPCs learned that broker buy-in was 
necessary for HIPC enrollment. Insurers reported in our 
interviews that brokers do not feel ``plugged in'' to the SHOP 
Marketplace and view SHOPs as competitors. Carriers stated that 
brokers believe they provide a valued service to small 
employers and that their role and income will be diminished if 
small employers purchase through SHOP. The dilemma for SHOPs is 
they need broker co-operation, but that SHOPs aim to reduce 
administrative expenses, and a major component of 
administrative expenses as brokers' fees that may constitute 
five percent of premiums or more.
---------------------------------------------------------------------------
    \11\ J. Gabel, H. Whitmore, J. Pickreign, J. Satorius, and S. 
Stromberg, ``Small Employers' Survey: Premiums, SHOP Exchanges, And 
Self-Insurance Are Main Concerns With The Affordable Care Act,'' Health 
Affairs, Web Special, October 16, 2013 and November, 2013, 32:11, 2032-
2039.

---------------------------------------------------------------------------
    Challenges to SHOP Success - Self-Insurance

    As unintended consequence of the ACA is it makes self-
insurance more economically attractive for small firms. Before 
the passage of the ACA self-insurance already had many 
regulatory advantages over full-insurance, ERISA pre-empts 
self-insured plans from state premium taxes, consumer 
protections, state mandated benefits, reserve requirements, and 
other state regulatory requirements. If an employer with a 
young and healthy workforce should self-insure, it would likely 
face lower premiums than if it were part of a larger pool of 
small employers as is the case with SHOPs. The foremost 
countervailing force to self-insuring has been the financial 
risk entailed with a catastrophic case, and the subsequent 
substantial increase in the cost of stop-loss coverage that 
would ensue. But the ACA eliminates medical underwriting so 
small firms can move into the fully-insured market if any 
insured workers or dependents were to experience catastrophic 
costs. Thus, self-insurance endangers both SHOPs and the 
traditional fully-insured market, and could repeat the 
experience of HIPCs. When there are two systems of insurance in 
the state, and one is risk-rated and the other is not, the 
risk-rated system will attract the better risks, and the non-
rated system will attract the sick, and over time go into a 
death cycle. Data from the 2014 KFF/HRET Employer Benefits 
Survey does not show this happening yet.

                            Summary

    If SHOPs are to succeed where HIPCs failed, they must 
demonstrate added value over the traditional small employer 
market. SHOPs can offer lower prices, tax credits not available 
off the SHOP, wider employee choice, and a defined contribution 
model that reduces the risk of future price increases. The 
authors of the ACA wrote into the legislation provisions that 
would address major problems of earlier HIPCs. Specifically, 
they required SHOPs and the off-the-SHOP market to play by the 
same underwriting rules. All plans sold on the SHOP must now be 
sold off the SHOP and priced as the same product. 
Administratively, CCIIO has tied large carriers to participate 
in the SHOPs.

    The promise of SHOPs is that they operate under ``fair'' 
market rules. Prices on the SHOPs are lower than off-the-SHOP 
for the same metal tier. Lower prices may be attributable to 
narrow networks, a competitive market structure, or fewer non-
essential benefits. But for employers seeking lower premiums, 
SHOPs are the place to shop. Multiple carriers are 
participating on the SHOPs in all but one state. With the 
employee choice model, employees can choose from multiple 
carriers and in some states multiple tiers. The defined 
contribution model limits the risk of future premiums 
increases. Carriers on the competitive fringe of the small 
employer market as well as non-profit vertically integrated 
organizations such as Kaiser Permanente see SHOPs as a way to 
build their market share.

    Of course, the immediate and perhaps major challenge for 
SHOPs is information technology difficulties that others have 
discussed. But beyond IT problems, many challenges remain if 
SHOPs are to succeed where HIPCs failed. Dominant insurers have 
an economic self-interest to see that SHOPs remain marginal. 
Along with established brokers and agents, they have a stake in 
maintaining the current delivery system where these groups have 
been so successful. The broker community poses a real dilemma. 
Health insurance is often too complicated and time consuming 
for small employers to master so small firms turn to brokers 
who are held in high regard. But SHOPs will perform many of the 
functions that brokers currently do. So to achieve broker buy-
in, SHOPs may have to forfeit many potential savings.

    If SHOPs and the fully-insured market are to survive, they 
must stand off threats by other insurance systems such as self-
insurance. To paraphrase Lincoln, ``A house divided cannot 
stand.'' Two insurance systems, one risk-rated and the other 
not, will lead to one system with a disproportionate share of 
bad risks, and one with favorable risks. Such a division could 
lead to the demise of the non-risk rated system.

    I want to close with an observation from my nearly 40 years 
studying the economics of our health care system. Change does 
not come instantaneously. I can recall articles I read or wrote 
about HMOs, PPOs, HRAs and HSAs where it was observed, ``What's 
the big deal over (fill-in the blank). They only have X percent 
enrollment. Why are we giving this so much attention?'' All in 
due time became prominent insurance products, but it required 
many years of growth. So to paraphrase John Lennon, ``Give 
SHOPs a chance.''

    I would be delighted to answer your questions.
    
    [GRAPHIC] [TIFF OMITTED]