On March 25, the U.S. Supreme Court heard oral arguments in two highly anticipated cases involving the Affordable Care Act (ACA) and competing claims of religious freedom and the access to contraception.
The ACA (also known as Obamacare) requires employers that provide health insurance to employees to cover several types of contraception. Two for-profit employers, Hobby Lobby and Conestoga Wood Specialties, object to four of the 20 forms of required contraception, which company owners believe cause abortions.
The penalty for failure to provide coverage for these additional forms of contraception could cost Hobby Lobby upwards of $475 million a year for its 13,000 employees, or almost $37,000 a year in fines per employee.
The key issue is whether the Religious Freedom Restoration Act (RFRA), passed by Congress in 1993 to protect the exercise of religion in all but extreme cases, applies to for-profit secular businesses and whether the religious beliefs of the owners can “pass through” the corporate veil and define corporate religious values that may violate a provision of federal law.
The Supreme Court must determine whether Hobby Lobby’s religious practice is “substantially burdened” by the contraception requirement. If so, the government needs to show that there is a “compelling state interest” and that it is using the “least restrictive means” to achieve the goal.
The federal government argues that the ACA is generally applicable to all companies and does not specifically discriminate against companies owned by individuals who object to the ACA on moral grounds. The government also argues that corporations do not have the same rights as individuals to exercise religious beliefs.
Hobby Lobby and Conestoga Wood are arguing that, because the Supreme Court found in Citizens United v. Federal Election Commission (2010) that corporations have free speech rights and can spend money in federal elections, then corporations also have religious rights under the First Amendment.
During the oral argument, Justices Elena Kagan and Sonia Sotomayor suggested that the companies could avoid the controversy altogether if they stopped providing health insurance and simply paid the $2,000 per-employee annual tax for not buying health insurance. For Hobby Lobby, that would amount to $26 million a year, far less than the cost of insurance itself.
In response, Chief Justice John Roberts said, “I thought that part of the religious commitment of the owners was to provide healthcare for its employees.”
The Supreme Court is unlikely to come to a consensus on this case, and a split decision is anticipated in June. The court may rule narrowly that corporations can seek an exemption from certain forms of contraception and that further issues along these lines need to be handled on a case-by-case basis. While the Hobby Lobby case may have an impact on the future of corporate law and how broadly free exercise of religion is defined, the decision will not likely have a significant effect on the ACA, which the court previously found constitutional. There will also likely be little impact on how the insurance industry will interpret and apply the law.
Insurance regulation has traditionally been the near-exclusive province of the states, a right jealously guarded by the states and secured by Congress in 1945 after the Supreme Court ruled insurance could be regulated by the federal government under the Commerce Clause of the Constitution.
Any fear that the FIO report would call for an end to state regulation proved unfounded, but industry members might be well-advised to prepare for the eventualities that may result as the FIO uses both the soft power of the bully pulpit and the harder power of the federal government to achieve its aims. As the designated U.S. insurance representative in international forums that more and more mold financial services regulation, and as an arbiter of standards that could be imposed on the states, the FIO and this report should not be ignored.
Having met with the FIO’s leadership team, we believe there are concerns that uniformity at the state level cannot be achieved without federal involvement. We further believe the FIO plans to work to translate its potential into an actual impact in the near future, making a clear-eyed understanding of the report and what it may herald for insurers a prudent and necessary step in regulatory risk management.
The biggest surprise about the FIO report may well have been that there were no surprises. There were no strident calls for a wholesale revamp of the regulatory system, and praise for the state regulatory system was liberally mingled among the criticisms.
The lack of any real blockbusters in the details of the FIO report may seem to lend implicit support to those who foresee a continuation of the status quo in insurance regulation. But, taken as a whole, this report and the regulatory atmosphere in which it has been released should be considered a subtle warning of changes that may yet come.
The report may quietly help to usher in an acceleration of the current evolution of insurance regulation. The result could be a regulatory climate that offers more consistency and clarity for insurers and reduces the cost of regulation. The result could also be a regulatory climate that offers more stringent regulatory requirements and increases both the cost of compliance and capital requirements. Most likely, the result could be a hybrid of both.
Either way, preparing to influence and cope with any possible changes portended in the report would be preferable to ignoring the portents.
Part of the disconnect between the short-term reception and the long-term impact of this report may be because of the implicit FIO recognition in the report of the lack of political will needed to enforce any real changes in current U.S. insurance regulation, most especially any that would require increased expenditures or personnel at the federal level. In our current economic and political environment, plugging gaps in state regulation by using measures that would require federal dollars may quite reasonably be construed to be off the table.
But the difference between identified problems and feasible solutions may offer an opportunity. States, industry and other stakeholders could act together to bring needed reform to the insurance regulatory system in a way that adds uniform national standards to regulation, reduces the possibility of regulatory arbitrage and maintains the national system of state-based regulation, all while recognizing the industry’s strengths and needs and not burdening the industry with unnecessary, onerous regulation.
There is much to praise in the current state regulatory system. A generally complimentary federal report on the insurance industry and the fiscal crisis of the past decade noted, “The effects of the financial crisis on insurers and policyholders were generally limited, with a few exceptions…The crisis had a generally minor effect on policyholders…Actions by state and federal regulators and the National Association of Insurance Commissioners (NAIC), among other factors, helped limit the effects of the crisis.”
While the financial crisis demonstrated the effectiveness of the current insurance regulation in the U.S., it is also evident that, as in any enterprise, there are areas for improvement. There are niches within the industry – financial guaranty, title and mortgage insurance come to mind – where regulatory standards and practices have proven less than optimal.
There are also national concerns that affect the industry. The lack of consistent disciplinary and enforcement standards across the states for agents, brokers, insurers and reinsurers is one obvious concern. Similarly, the inconsistent use of permitted practices and other solvency-related regulatory options could lead to regulatory arbitrage. At a time when insurance regulators in the U.S. call for a level playing field with rivals internationally, these regulatory differences represent an example of possible unlevel playing fields at home that deserve regulatory attention and correction.
A Bloomberg News story in January 2014, for example, quoted one insurer as planning to switch its legal domicile from one state to another because the change would allow, according to a spokeswoman for the company, a level playing field with rivals related to reserves, accounting and reinsurance rules.
For insurers operating within the national system of state-based regulation, one would hope that that level playing field would cross domiciles, and no insurer would be disadvantaged because of its domicile in any of the 56 jurisdictions.
But perhaps one of the greatest challenges to the state-based system of regulation is the added cost of that regulation, partly engendered by duplicative requests for information and regulatory structures that have not been harmonized among states. How to respond to that may represent the biggest gap in the FIO report. It may also be the biggest opportunity for both insurers and regulators to rationalize the current regulatory system and ensure the future of state-based regulation.
The FIO report notes that the cost per dollar of premium of the state-based insurance regulatory system “is approximately 6.8 times greater for an insurer operating in the United States than for an insurer operating in the United Kingdom.” It quotes research estimating that our state-based system increases costs for property-casualty insurers by $7.2 billion annually and for life insurers by $5.7 billion annually.
According to the report, “regulation at the federal level would improve uniformity, efficiency and consistency, and it would address concerns with uniform supervision of insurance firms with national and global activities.”
Yet the report does not recommend the replacement of state-based regulation with federal regulation, but with a hybrid system of regulation that may remain primarily state-based, but does include some federal involvement.
At least one rationale for this is clearly admitted in the report. As it says, “establishing a new federal agency to regulate all or part of the $7.3 trillion insurance sector would be a significant undertaking … (that) would, of necessity, require an unequivocal commitment from the legislative and executive branches of the U.S. government.”
The result of that limitation is a significant difference between diagnosis and prescription in the FIO report. Having diagnosed the cost of the state-based regulatory system as an unnecessary $13 billion burden on policyholders, the FIO's policy recommendations may possibly be characterized as, for the most part, the policy equivalent of “take two aspirin and call me in the morning.”
Still, as the Dodd-Frank Act showed, even Congress can muster the will to impose regulatory solutions if a crisis becomes acute enough and broad enough. Unlikely as that may now seem, the threat of federal radical surgery should not be what is required for states to move toward addressing the recommendations of the FIO report.
Indeed, actions of the NAIC over the past few years have addressed much of what is in the FIO report. Now the NAIC, industry and other stakeholders can take the opportunity provided by the report to work to resolve some of the issues identified in it. The possible outcome of an even greater federal reluctance to become involved in insurance regulation would only be a side benefit. The real goal should be a regulatory system that is more streamlined, less duplicative, more responsive, more cost-efficient and more supportive of innovation.
Kevin Bingham has shared this article on behalf of the authors of the white paper on which it is based: Gary Shaw, George Hanley, Howard Mills, Richard Godfrey, Steve Foster, Tim Cercelle, Andrew N. Mais and David Sherwood. They can reached through him. The white paper can be downloaded here.
As the GOP settles in for a long-term fight about what it would like to put in Obamacare’s place, it should look hard at a just-released reform plan from the House Republican Study Committee written principally by Reps. Steve Scalise (R-La.) and Phil Roe (R-Tenn.).
The most revolutionary aspect of the House plan — officially titled the American Health Care Reform Act — is its decoupling of insurance from employment.
Americans have gotten health insurance through their jobs essentially since World War II, when wage and price controls forced employers to compete for workers by offering generous fringe benefits, like health insurance. This insurance, of course, is simply tax-free income provided by employers.
Individuals, by contrast, have had to purchase coverage with dollars that have already been taxed.
This system puts entrepreneurs and the self-employed at a significant disadvantage — and limits people’s employment choices. Workers may stay in jobs they don’t want, simply so that they don’t lose their health insurance, particularly if they or their family members have a pre-existing condition.
The RSC health reform plan would give a tax deduction of $7,500 to every American — and $20,000 to every family. If a person bought coverage that cost less than that, then he could keep the difference as untaxed income.
This system would help arrest the non-stop growth of health costs. After all, most Americans over-consume health care because their employer-subsidized coverage insulates them from the full cost of their care. Such over-consumption drives up costs.
The RSC plan would also grant consumers the ability to purchase health insurance issued in other states, where it may be cheaper.
That makes a lot of sense. There is no reason that health insurance should cost two and a half times as much in Rhode Island as in Alabama. Increasing the size of the insurance marketplace — and therefore increasing competition — will drive down prices.
The RSC proposal would inject consumerism into the healthcare marketplace in other ways, too. For instance, it could lead to more use of Health Savings Accounts (HSAs). These accounts allow patients to save pre-tax dollars for health services — and to keep whatever they don’t spend. Consequently, HSAs encourage Americans to take care of their health and shop smartly for care. About 15 million Americans today have HSAs.
The RAND Corporation estimates that the average American worker who switches from a traditional health plan to a consumer-directed one uses 14 percent fewer medical services – without any associated adverse effect on health outcomes.
Overall health costs come down, too, because providers have to compete for patients’ business. According to RAND, expanding the share of employers with HSA-style plans to 50 percent — from the current 13 percent — would reduce national health costs by $57 billion per year.
Critics of consumer-driven care claim that it prevents those with pre-existing conditions from finding affordable coverage. All the tax-free savings in the world won’t be of use if coverage is too expensive.
The Study Committee’s plan would ensure that folks with pre-existing conditions could get affordable coverage by devoting $25 billion in federal funding for state-level, high-risk pools. Premiums in these pools would be capped at 200 percent of the average premium in the state.
Finally, the RSC plan attempts to rein in the more than $100 billion spent every year on unnecessary treatments and testing ordered by doctors trying to protect themselves from the threat of lawsuits. GOP lawmakers would limit the amount of lawyers’ fees and non-economic damages in medical liability cases.
The RSC plan isn’t perfect. Tax deductions favor the relatively well-off; those with lower incomes often can’t take advantage of the full value of the deduction. So lawmakers should swap out the deduction for a refundable tax credit that applies equally to all Americans, regardless of income. In addition, while the intent is right on limiting lawyers’ fees and damages, tort reform of this sort is better left to the states, which traditionally have jurisdiction in medical-liability cases.
The House Republican Study Committee plan is also incomplete. Lawmakers must reform Medicare and Medicaid, too. Spending in the two programs already exceeds private health insurance spending — and will only grow in the future.
Congress must bring Medicare and Medicaid outlays under control — and vouchers for beneficiaries and states are the best way to do so. Empowering individuals and state leaders to spend their Medicare and Medicaid dollars as they see fit will inject much-needed competition into the healthcare marketplace — and thereby reduce costs.
Although the House Republican Study Committee’s plan is an exciting starting point for replacing Obamacare, it ought not be the finish.
Employees of shipping giant United Parcel Service recently got an unexpected delivery. The company announced that it would stop offering health coverage to the spouses of 15,000 workers.
UPS’s workers and their families can thank Obamacare for this special delivery. And UPS isn’t alone. American businesses are discovering each and every day that the president’s signature law will raise health costs for them and their employees in short order.
In a memo explaining the decision to employees, UPS stated that increasing medical costs “combined with the costs associated with the Affordable Care Act, have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost.”
One day before UPS’s big announcement, the University of Virginia announced that it would cut benefits for spouses who have access to health care through jobs of their own. The rationale was similar.
Delta Airlines recently revealed that Obamacare will directly increase its direct health costs by $38 million next year. After taking into account the indirect costs of the law, the company is looking at a 2014 health bill that’s $100 million higher.
Increasingly, large employers who aren’t dropping spousal health benefits are requiring their employees to pay monthly surcharges in the neighborhood of $100 per spouse.
Many small businesses are dropping family coverage altogether because they expect that Obamacare’s new tax on insurers will be passed on to them in the form of higher premiums. One Colorado-based business received notice from its insurer that the tax would increase premiums more than 20 percent.
The story is similar in Massachusetts. One new report concludes that over 45,000 small businesses in the Bay State will see premium increases in excess of 30 percent. In all, more than 60 percent of firms in the state will see their premiums go up.
Last month in California, the largest insurer for small businesses — Anthem — declared that it would not participate in the state’s small-business health insurance “marketplace,” Covered California. Only two years ago, Anthem covered one-third of small businesses in California.
Anthem’s exit represents one less choice for consumers — and a sign that competition may not be as robust in the exchanges as the Obama Administration promised.
Small businesses are responding to these higher premiums by trimming their labor costs in other ways. That’s not good news for workers.
Seventy-four percent of small employers plan to have fewer staff because of Obamacare, according to a recent U.S. Chamber of Commerce survey. Twenty-seven percent are looking to cut full-time employees’ hours, 24 percent to reduce hiring, and 23 percent to replace full time with part-time employees.
One in four small companies say that Obamacare was the single biggest reason not to hire new workers. For almost half, it’s the biggest business challenge they face.
These findings are consistent with a recent Gallup Poll showing that 41 percent of small businesses have already stopped hiring because of Obamacare. Another 19 percent intend to make job cuts because of the law.
All this tumult in the labor market is fueled by more than the increase in premiums engendered by Obamacare. The law effectively encourages companies to cut full-time jobs.
Obamacare requires employers with 50 or more workers to provide health insurance to all who are on the job for 30 or more hours per week. The law originally called for this “employer mandate” to take effect in 2014, but the Administration decided in July to delay enforcement of the mandate until 2015.
Employers are responding by doing just enough to avoid Obamacare’s dictates.
Administrators at Youngstown State University in Ohio recently told adjunct instructors, “[Y]ou cannot go beyond twenty-nine work hours a week. . . . If you exceed the maximum hours, YSU will not employ you the following year.” A week prior the Community College of Allegheny County in Pittsburgh made a similar announcement.
Hundreds of employees at Wendy’s franchises have seen their hours reduced for the same reason.
Meanwhile, companies with fewer than 50 employees are thinking twice about expanding — and thus being ensnared by Obamacare’s requirement that they provide health insurance.
The cost of each additional employee could be staggering. A firm with 51 employees that declined to provide health coverage would face $42,000 in new taxes every year — and an additional $2,000 tax for each new hire. Providing coverage, of course, would be even more expensive.
Meanwhile, as private firms large and small grapple with Obamacare-fueled cost increases, one large employer — the federal government — has been quietly exempting itself from portions of the law.
Top congressional staffers like their current benefits under the Federal Employee Health Benefits Plan (FEHBP), wherein the government pays up to 75 percent of the premiums.
But the law requires those who work in lawmakers’ personal offices to enter the exchanges. And in many cases, staffers make too much to qualify for health insurance subsidies through the exchanges. So they’d be facing a hefty cut in their compensation.
Fearing a mass exodus of congressional staffers from Capitol Hill, the Obama Administration fudged the law to permit lawmakers’ employees to receive special taxpayer-funded subsidies of $4,900 per person and $10,000 per family.
Yet only three months ago, Senate Majority Leader Harry Reid (D-Nev.) claimed that Congress wouldn’t make exceptions for itself.
President Obama no doubt knows that these congressional favors won’t go over well with ordinary Americans. So he’s called on his most popular deputy — former President Bill Clinton — to try to sell the law to the public once again.
But unless the former president can lower employer health costs with little more than the power of his words, his sales pitch will likely fall flat.
This article was first published at Forbes.com.
Congress enacted the Americans with Disabilities Act in 1990 which included the terms “job-related and consistent with business necessity” in Section 703(k) of Title VII as part of a Congressional compromise. The amendment to the act which went into effect in 2008 did not affect the business necessity provision.
Case law regarding business necessity is very limited; however, a recent case in point is Atkins v. Salazar, 2011 U.S. App. LEXIS 25238 (5th Cir., Dec. 12, 2011), in which the Fifth Circuit issued an instructive opinion analyzing the business necessity defense in the context of diabetes.
The Fifth Circuit described the business necessity standard as follows:
For a qualification to be “job-related,” “the employer must demonstrate that the qualification standard is necessary and related to 'the specific skills and physical requirements of the sought-after position.'” Similarly, for a qualification standard to be “consistent with business necessity,” the employer must show that it “substantially promote[s]” the business' needs.
The court further noted, based on an earlier ruling, that it must “take into account the magnitude of possible harm as well as the probability of occurrence … the probability of the occurrence is discounted by the magnitude of its consequences.”
Under the Americans with Disabilities Act, not only must a medical exam be job-related, it must also be consistent with business necessity. This means that the medical exam must relate to the essential functions of the job. The medical exam must test the ability to perform the primary functions of the job. For example, if you are a cashier at a grocery store, the essential functions of your job would be to ring people up and help them bag their items. Any medical exam your employer required would have to be related to how you perform those functions in order to be consistent with business necessity. It is important to note that as long as the medical exam evaluates some function of the job, it should satisfy the elements of business necessity.
Under the Americans with Disabilities Act, an employer may have the ability to make disability-related inquiries or require medical examination. After the applicant is given a conditional job offer, but before starting work, an employer may make disability-related inquiries and conduct medical examinations, regardless of whether they are related to the job, as long as it does so for all entering employees in the same job category (post-offer). After employment has commenced, an employer may make disability-related inquiries and require medical examinations only if they are job-related and consistent with business necessity.
The Americans with Disabilities Act requires that all medical information obtained during such inquiries or testing be treated as confidential medical information. While this provision covers all employees, only disability-related inquiries and medical examinations are subject to the Americans with Disabilities Act's restrictions. A disability-related inquiry is defined as asking questions or testing that is designed to elicit information about a person's disability. Therefore, questions or testing that is not designed to ask or evaluate information about an individual's disability are not prohibited under the ADA.
A medical test as defined under the Americans with Disabilities Act is a procedure or test that seeks information about an individual's physical or mental impairments or health. Factors that determine if it is a medical test include:
- whether the test is administered by a health care professional;
- whether the test is interpreted by a health care professional;
- whether the test is designed to reveal an impairment or physical or mental health;
- whether the test is invasive;
- whether the test measures an employee's performance of a task or measures his/her physiological responses to performing the task;
- whether the test normally is given in a medical setting; and,
- whether medical equipment is used.
The topic of medical testing, especially functional testing, is a controversial subject. In the fall of 2009 two major case precedents brought to light these very issues — Indergard vs. Georgia Pacific and the class action lawsuit brought against Sears. On September 29, 2009, the U.S. Equal Employment Opportunity Commission (EEOC) announced a record-setting consent decree resolving a class lawsuit against Sears, Roebuck and Co. under the Americans with Disabilities Act for $6.2 million.
These recent rulings bear out that the Functional Capacity Evaluation (FCE) may be a medical exam. Even when classified as medical evaluations, Functional Capacity Evaluations don't physically correlate with true physiological function. The issue becomes whether or not these tests are able to accurately or objectively test for functionality. These rulings illustrate that Functional Capacity Evaluations that contain validity measurements that are subjective observations, do not correlate with effort and are not consistent with affected body parts are not legally defensible.
As we have seen with the Indergad and Sears cases, courts are examining these issues closely and unless there is an objective assessment, the employer or carrier is left virtually unprotected. For ADA compliance, the testing needs to be repeatable, objective, and address functionality.
Under the Americans with Disabilities Act, an employer may not require a current employee to undergo a medical examination unless the examination “is shown to be job-related and consistent with business necessity.” 42 U.S.C. § 12112(d) (4) (A). This section applies to all employees, whether or not they are disabled under the Americans with Disabilities Act. The Indergard decision clearly demonstrates the need for an objective measure of performance that must conform with business necessity.
In addition, recent case law — EEOC vs. Celadon Trucking — illustrates that if an individual does not meet the essential functions of the job, an employer needs to enter into the interactive process for the position for which they were applying or for any other open position for which the candidate is qualified.
Given all the legal mandates for the ADA and EEOC, coupled with state workers' compensation laws and Federal Mandatory reporting issues for work-related injuries, why do post-offer pre-placement tests? A better solution is baseline testing or a book end solution.
The Americans with Disabilities Act regulates testing that has the potential to evaluate a disability. So if a baseline test is non-invasive, captures the essential functions of the job with not only a reliable validity measurement but with an objective assessment of the muskuloskeltal system and is not read at the time of testing, it is not only acceptable under ADA but technically outside the scope. Why? Data is not evaluated at the time of the baseline test so no disability is identified and no medical questions are asked. It can be done at post-offer or with existing employees.
The book end solution is completed when there is a work-related incident, another test is performed under the workers' compensation pending case, and the results are compared. In the work-related case, the medical evaluation post loss test is allowed and not a violation of the Americans with Disabilities Act. Appropriate releases are signed prior to conducting the baseline testing, and the data is kept confidential. If no work-related injury occurs, the baseline data is never interpreted.
In summary, according to the Fifth Circuit ruling in the Atkins case, for a qualification standard to be “consistent with business necessity,” the employer must show that it “substantially promote[s]” the business' needs. The business needs in the case of baseline tests are to provide better and faster treatment for the injured worker and to accept claims that arise out of the course and scope of employment.