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The Cost and Coverage Impacts of a Public Plan: Alternative Design Options
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The Cost and Coverage Impacts of a Public Plan:
Alternative Design Options
Staff Working Paper #4
Prepared by:
John Sheils
Randy Haught
April 6, 2009
(Amended April 8, 2009)
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About The Lewin Group
The Lewin Group is a health care and human services policy research and management
consulting firm. We have over 25 years of experience in estimating the impact of major health
reform proposals. The Lewin Group is committed to providing independent, objective and non-
partisan analyses of policy options. In keeping with our tradition of objectivity, The Lewin
Group is not an advocate for or against any legislation. The Lewin Group is part of Ingenix, Inc.,
which is a wholly owned subsidiary of the UnitedHealth Group. To assure the independence of
its work, The Lewin Group has editorial control over all of its work products.
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Summary and Introduction
President Obama has proposed to create a “public plan” that would compete for enrollment
with the private insurance industry, but has provided few details on how it would work.
During the 2008 campaign, Senators Clinton and Edwards proposed a public plan administered
through Medicare using Medicare provider reimbursement levels. Employers and individuals
would have been able to purchase coverage from the public plan by paying a full cost premium,
with subsidies provided for low-income families.
The public plan is difficult to evaluate because no one has specified in legislation how it would
work. During the presidential campaign the President did not specify that the plan would be
modeled on Medicare, and said that the plan would be open to only individuals, the self-
employed and small firms. Senator Baucus has also proposed a public plan, but has not yet
specified payment levels or the groups that would be eligible to enroll.
Consequently, in this paper, we present impact estimates under several variations on the public
plan model. Under each variation, we assume that the public plan is implemented together with
President Obama’s coverage expansion proposals, which we estimate would cover about 28
million uninsured people.
If Medicare payment levels are used in the public plan, premiums would be up to 30 percent
less than premiums for comparable private coverage. On average, the monthly premium in the
public plan for a typical benefits package would be $761 per family compared with an average
of $970 per family in the private market for the same coverage.
If as the President proposed, eligibility is limited to only small employers, individuals and the
self-employed, public plan enrollment would reach 42.9 million people. The number of people
with private coverage would fall by 32.0 million people. If private payer reimbursement levels
are used by the public plan, enrollment would be lower, with only 10.4 million people
switching to the public plan from private insurance.
If the public plan is opened to all employers as proposed by Senators Clinton and Edwards, at
Medicare payment levels we estimate that about 131.2 million people would enroll in the public
plan. The number of people with private health insurance would decline by 119.1 million
people. This would be a two-thirds reduction in the number of people with private coverage
(currently 170 million people). Here again, if the higher private payer levels are used,
enrollment in private insurance would decline by only 12.5 million people.
Medicare premiums would be lower than private premiums because of the exceptional leverage
Medicare has with providers. Medicare pays hospitals about 30 percent less than private
insurers pay for the same service. Physician payments are about 20 percent less than under
private coverage. Also, because Medicare has no allowance for insurer profits or broker/agent
commissions, administrative costs for this population are about one-third of administrative
costs in private health plans.
Assuming Medicare reimbursement rates and eligibility for all individuals and employers,
provider net income would decline under this public plan proposal, even after accounting for
reduced uncompensated care and increased utilization for the newly insured. Net hospital
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revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33
billion (6.8 percent). If eligibility is restricted to individuals and small firms, net hospital
revenues would actually increase by $11.3 billion due to the increase in newly insured
individuals. But net physician incomes would decline by $3.0 billion.
Our estimates and methodology are presented in the following sections:
Features of the public plan;
Premiums in the public plan;
Coverage effects;
Provider impacts;
Simulating effects for individuals; and
Simulating effects for employers.
A. Structure of the Public Plan
For illustrative purpose, we begin the analysis by estimating the effect of creating a new public
plan modeled on Medicare that is available to individuals and the self-employed. Also, all
employers would be able to purchase coverage for their workers through the public plan. We
assume that providers would be reimbursed using Medicare payment levels.
We assume that the benefits provided under the public plan are the same as the BlueCross/Blue
Shield Standard Option offered to members of Congress and federal workers under the FEHBP
(as proposed by President Obama). These benefits include hospital care, physician services,
prescription drugs, substance abuse and mental health services and dental care. For in-network
utilization, there is a $15 copayment for office visits with no deductible. The plan includes a
$250 deductible and higher copayments for out-of-network utilization, up to a maximum out-
of-pocket limit amount of $4,000.
In addition, we assume that the public plan would be implemented as part of a health reform
program that includes coverage expansions similar to those proposed by President Obama in
the 2008 campaign. For illustrative purposes, we assume the following:1
There would be a mandate for children to have coverage;
Medicaid eligibility is expanded to include all adults living below 150 percent of the
Federal Poverty Level (FPL), including able-bodied adults without custodial
responsibilities for children;
Tax credits are provided to people purchasing private insurance who live between 150
percent and 400 percent of the FPL;
Medical underwriting and health status rating is eliminated in all insurance markets,
but rating by age is permitted;
Large employers are required to offer insurance or pay a payroll tax; and
1
“McCain and Obama Health Care Policies: Cost and Coverage Compared,” The Lewin Group, October 8, 2008.
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Tax credits are provided to small employers (fewer than 10 workers) with low-wage
workers for up to 50 percent of employer spending for worker coverage.
We used The Lewin Group Health Benefits Simulation Model (HBSM) to simulate the effect of
such a program on coverage.2
B. Premiums in the Public Plan
We estimate that premiums for the public plan under this scenario would be between 30
percent and 40 percent less than premiums for comparable private coverage. As shown in
Figure 1, provider payment levels for hospital services under Medicare are equal to only about
71 percent of what is paid by private health plans for the same services. In fact, Medicare
payments to hospitals are actually equal to only between 92 percent and 95 percent of the cost
of the services provided by hospitals.3 For physician services, Medicare pays only about 81
percent of what is paid by private health plans for the same services.4
Figure 1
Benefits and Administrative Costs Under a Medicare-based Public Plan and Private Insurance
Source: American Hospital Association, “Trends Affecting Hospitals and Health Systems,” TrendWatch
Chartbook April 2008; “Report to Congress: Medicare Payment Policy,” Medicare Payment Advisory
Commission (MedPAC), March 2008; and State Health Facts, The Kaiser Family Foundations (KFF), 2003
report.
Administrative costs are also expected to be lower for the public plan than under private
insurance, reflecting that the public plan would not include an allowance for insurer profit and
insurance agent and broker commissions and fees. Administrative costs, including profit and
commissions, for privately insured small groups are on average equal to about 31.7 percent of
covered benefits. If implemented through Medicare, administrative costs would be equal to
about 13.2 percent of covered services.
2
“The Health Benefits Simulation Model (HBSM): Methodology and Assumptions,” The Lewin Group, February
19, 2009.
3
American Hospital Association, “Trends Affecting Hospitals and Health Systems,” TrendWatch Chartbook, April
2008.
4
State Health Facts, The Kaiser Family Foundations (KFF), 2003 report.
71%
81%
Hospital Care
Physician Care
31.7%
13.2%
Private
Public
Medicare Provider Payments as a
Percent of Private Payer Rates
Administrative Costs as a Percent
of Claims Costs: Small Firms
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Our estimate of administrative costs is based upon a detailed analysis of administrative costs
under insurance pools which we present in our model documentation.5 These administrative
costs are about twice what administrative costs currently are in the Medicare program (about
6.5 percent of benefits). Costs will be higher in the public plan than in Medicare because the
program will need to process the movement of individuals across health plans when people
decide to change their source of coverage. The plan will also need to collect premiums from
individuals and employers who decide to enroll. These functions are not required for the
current Medicare populations once enrolled.
Figure 2 presents our estimates of the average cost of insurance for individuals in the public
plan and in the private insurance markets. Premiums for family coverage under the public plan
would average $761 per month compared with $970 per month in the current private insurance
market.
Figure 2
Impact of Using Medicare Provider Payment Rates on Premiums in the Public Plan
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).
C. Coverage Effects
We estimate that the Obama-like health reform program described above would reduce the
number of uninsured by about 28 million people. If we assume that the public plan is open to
all individuals, the self-employed and all firms, the public plan would enroll about 131.2 million
people (includes some uninsured who become covered). The number of people with private
health insurance would decline by about 119.1 million people (Figure 3). This is equal to about
5
“The Health Benefits Simulation Model (HBSM): Methodology and Assumptions,” The Lewin Group, February
19, 2009.
$405
$761
$970
$298
Single Adult
Family
Private Coverage
Public Plan at
Medicare Rates
Private Coverage
Public Plan at
Medicare Rates
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70 percent of all people currently covered under private health insurance (excludes
supplemental coverage for Medicare beneficiaries).
As discussed above, the President’s campaign proposal would have limited enrollment to
individuals, the self-employed and small employers. Large employers would not be permitted
to cover their workers through the public plan. Under this scenario, about 42.9 million people
would be enrolled in the public plan (Figure 3). The number of people with private coverage
would fall by about 32.0 million people.
The impact of the program on private coverage would depend largely on the levels of
reimbursement under the program. While Medicare payment levels have been proposed, it
would be possible to pay providers at other levels. To illustrate, we estimated the number of
people enrolling in the public plan under two alternative payment level assumptions.
Figure 3
Public Plan Enrollment and Reduction in Private Coverage Under a Public Plan Using Medicare
Payment Levels 2010 (millions)
a/ Changes in coverage under Medicaid and other programs not shown.
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).
For example, the program could be implemented using private payer rates (i.e., “negotiated”
rates). Under this scenario, premiums would be only about 9 percent less than in private plans,
reflecting that the program would still have lower levels of administrative costs than private
Public
Medicaid
Private
Uninsured
Plan
Coverage
Open to Small Firms and
Individuals Only
Open to All Firms
and Individuals
42.9
16.5
131.2
16.1
-119.1
-28.0
-32.0
Public
Medicaid
Private
Uninsured
Plan
Coverage
-27.4
Public
Medicaid
Private
Uninsured
Plan
Coverage
Open to Small Firms and
Individuals Only
Open to All Firms
and Individuals
42.9
16.5
131.2
16.1
-119.1
-28.0
-32.0
Public
Medicaid
Private
Uninsured
Plan
Coverage
-27.4
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insurance. Public plan enrollment, assuming all firms are eligible to enroll, would fall from
131.2 million people with Medicare reimbursement levels to about 20.6 million people at private
payer levels (Figure 4). We also show enrollment assuming payments are set at the midpoint
between Medicare and private payment levels.
Figure 4
Enrollment in Public Plan Under Alternative Provider Reimbursement Scenarios
Eligible Groups
Small Firms, Self-employed and
Individuals Only
All Firms, Self-employed and
Individuals
Private
Payer
Levels
Midpoint
Payment
Levels
Medicare
Payment
Levels
Private
Payer
Levels
Midpoint
Payment
Levels
Medicare
Payment
Levels
Public Plan Premiums as
Percent of Private
-10%
-25%
-40%
-9%
-18%
-32%
Coverage Effects (millions)
Reduction in Uninsured
23.8
26.1
27.4
25.1
26.7
28.2
Enrollment in National
Public Plan
17.0
31.5
42.9
20.6
77.5
131.2
Change in Private Coverage
-10.4
-21.5
-32.0
-12.5
-67.5
-119.1
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).
D. Provider Impacts
The program would have a significant impact on provider net incomes. Expanding coverage
would reduce uncompensated care for uninsured people and would result in increased health
services utilization for the newly insured, all of which would represent new revenues to
providers. These increases in revenues would be largely offset by reductions in payment levels
for people who shift from private insurance to the public plan and the provider’s cost of
providing additional care to the newly insured.
Assuming the public plan is open to all individuals and all employers, total hospital margin
would fall by $36.0 billion in 2010 (Figure 5). This is equal to about 4.6 percent of total hospital
net revenues (i.e., gross revenues less contractual allowances) in that year. Physician net income
would fall by about $33.1 billion, which is equal to about 6.8 percent of physician revenues.
Thus, under this scenario, health care providers are providing more care for more people with
less revenue.
The effect on provider income is substantially smaller under a scenario where large firms are
excluded from participation in the public plan. For example, hospital margin would actually
increase by $11.3 billion in 2010, assuming the plan is limited to only individuals, the self-
employed and small firms. Thus, the increased revenues for newly insured people (including
reduced uncompensated care) are greater then the loss of revenues for people who would
become covered under the public plan. Physician income net of practice expenses would fall by
$3.0 billion under this scenario.
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Figure 5
Impact of Public Plan on Provider Income if Medicare Provider Payment Rates Used
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).
In Figure 6, we present estimates of the impact of the program on provider incomes under
alternative payment level assumptions for the public plan
Figure 6
Impact on Hospital and Physician Net Income in 2010 (billions)
Hospital Income
Physician Income
Small
Firms Only
All Firms
Eligible
Small
Firms Only
All Firms
Eligible
Assuming Medicare Payment Levels
Payment Level Reduction
-$10.7
-$58.0
-$6.0
-$36.1
Payments for Previously Uncompensated Care
$22.0
$22.0
$3.0
$3.0
Net Change
$11.3
-$36.0
-$3.0
-$33.1
Change as a Percent of Total Revenue
1.0%
-4.6%
-1.6%
-6.8%
Assuming Midpoint Payment Levels (i.e., between Medicare and Private Payer Rates)
Payment Level Reduction
-$6.1
-$29.3
-$4.8
-$19.8
Payments for Previously Uncompensated Care
$22.0
$22.0
$3.0
$3.0
Net Change
$15.9
-$7.3
-$1.8
-$16.8
Change as a Percent of Total Revenue
2.0%
0.9%
-0.5%
-3.1%
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).
$11.3
-$33.1
-$36.0
-$3.0
Small Firms Only Eligible
All Firms Eligible
Hospital
Margin
Physician
Net Income
Hospital
Margin
Physician
Net Income
Hospital
Margin
Physician
Net Income
Hospital
Margin
Physician
Net Income
Hospital
Margin
Physician
Net Income
Hospital
Margin
Physician
Net Income
Change in Provider Income Net of Reduced Uncompensated Care
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E. Simulating Effects for Individuals and Self-employed
We simulate the individual’s decision to enroll in the public plan by estimating the premium
that these individuals would pay in the current private market for the benefits offered in the
public pool. The public plan could increase coverage if it provides coverage to uninsured
people at a lower cost than in the current market. This can also result in shifts in coverage from
existing sources to the public plan.
1. Simulating Changes in Number with Coverage
We begin by estimating the program’s effect on the number of people with coverage. We first
identify uninsured people who would now be able to purchase coverage at a lower price than
they would pay in the individual market under current law. We interpret this as a reduction in
premiums that will cause some people to take coverage. We simulate their decision to take that
coverage using research on how changes in premiums affect the likelihood of taking coverage.
We assume that newly insured people will enroll in whichever coverage option is least costly.
In the next step, we identify currently insured people who would now face a higher premium.
This would occur in cases where the availability of the public plan is coupled with changes in
insurer rating regulations affecting the premiums in both the private market and the public
plan. For example, the Obama proposal would prohibit medical underwriting, which will
generally increase premiums for relatively healthy individuals now covered in the individual
market. We also simulate losses of coverage for these people using the same research on how
price affects the individual’s decision to take coverage.
2. Allocation to Public and Private Coverage
In this step, we identify privately insured people who would be eligible to purchase coverage at
a lower cost through the public plan. We then simulate their decision to shift to the public plan
based upon studies of how people respond to changes in the relative price of insurance within
employer groups offering a choice of health plans.6 We simulate these shifts in a two step
process that allocates affected people into one of the following three groups:
People who remain with their current private health plan rather than shifting to the
public plan;
People who drop private coverage to enroll in the public plan due to the lower
premiums; and
People who leave the public plan to enroll in a lower cost HMO.
In the first step, we model the shift of privately insured individuals to the lower cost public
plan. We do this using “plan change price elasticity” estimates developed by Strombom et al.,
which averages about -2.47. This means that on average, a 1.0 percent decrease in the price of an
alternative source of coverage is associated with a 2.47 percent migration of enrollees to the
lower cost health plan. As shown in Figure 7, the likelihood of shifting to a lower cost plan is
6
Strombom, B., Buchmueller, T., Feldstein, P. “Switching Costs, Price Sensitivity and Health Plan Choice,” Journal
of Health Economics, 21 (2002), 89-116.
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lowest for older and sicker people, reflecting that these groups are typically less willing to
change providers. Individuals were randomly selected to shift to an HMO based upon these
price changes and these price elasticity estimates.7
Figure 7
Health Plan Change Price Elasticity Assumptions by Age and Health Risk
All Insured Groups
HMOs Only
Age of Participant
Low Risk
High Risk a/
Low Risk
High Risk a/
Under 31
-5.8
-5.3
-7.0
-8.0
31 – 45
-3.9
-3.6
-5.9
-6.4
Over 45
-2.4
-2.1
-4.3
-4.5
a/ The study defines high risk people as those who have selected illness or hospitalizations. In our
model, as a proxy for this definition, we assumed that people with expected spending in excess of the
80th percentile of spending are “high risk”.
Source: Strombom, B., Buchmueller, T.,Feldstein, P. “Switching Costs, Price Sensitivity and Health Plan
Choice,” Journal of Health Economics 21 (2002) 89-116.
These estimates are consistent with other studies showing that people leaving fee-for-service
(FFS) health plans for HMOs and other managed care plans tend to have lower costs than those
who remain with these FFS plans. Similarly, people who leave HMOs for a FFS plan tend to
have higher costs than those who remain with the HMO.8
In the second step we model risk selection against the public plan. Some managed care plans
would develop products that tend to attract younger and healthier people through benefits
design or marketing practice. This will tend to leave the public plan with higher cost
individuals. We simulate this by assuming that private HMOs are able to offer a product that is
four percent less costly than the premium for the public plan. This assumption is based upon
research showing that utilization of health services in HMOs is about four percent less than in
PPO and other FFS plans.
We simulate the shift of individuals from the public plan to these HMOs using the plan change
price elasticity estimates presented above in Figure 7. This approach tends to leave higher cost
individuals in the public plan, with lower cost individuals shifting to HMOs.
F. Simulating Effects for Employers
Under the public plan scenarios presented above, some or all employers would have the option
of covering their workers under the public plan by paying a premium. In some cases, non-
insuring employers would start to offer coverage in response to the lower premium available in
the public plan. Also, many currently insuring employers will shift to the public plan to take
advantage of the lower public plan premium. The approach we use to simulate the impact of
7
Newly insured people were randomly assigned to HMOs based upon the percentage of privately insured people
who are in HMOs after we have executed our simulation for currently insured people.
8
David M. Cutler and Richard J. Zeckhauser, “Adverse Selection in Health Insurance,” National Bureau of
Economic Research, working paper 6107, July 1997; and Paolo Belli, “How Adverse Selection Affects the Health
Insurance Market,” Harvard School of Public Health.
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the public plan on employer coverage is similar to that used to simulate coverage decisions in
the individual market.
1. Simulate Changes in the Number of Employers Offering Coverage
We first identify non-insuring employers who would now be able to purchase coverage at a
lower price than they would pay in the current insurance market. We simulate their decision to
take that coverage due to the price reduction using studies of how changes in premiums affect
the likelihood that a firm will offer coverage. We assume that newly insured people will enroll
in whichever coverage option is least costly.
In the next step, we identify firms that would now face a higher premium. Under the Obama-
like health reform proposal modeled here, the elimination of medical underwriting would
increase premiums for younger and healthier groups while reducing premiums for older and
sicker groups. We simulate losses of coverage for these people using the studies of the effect of
changes in premiums on the firm decision to offer insurance.
2. Re-allocation to Public Plan
In this stage, we identify privately insured firms that would be eligible to purchase coverage at
a lower cost through the public plan. We simulate these shifts in a two step process that
allocates affected people into one of the following three groups:
Employers that remain with their current private health plan rather than shifting to the
public plan. (These will tend to include employers with older and less healthy workers
who decide not to change their source of coverage, perhaps to retain their current
physician);
Employers that drop private coverage to enroll in the public plan due to the lower
premium; and
Employers that leave the public plan to enroll in a lower cost HMO.
In the first step, we simulate the employer decision to switch to the lower cost public plan based
upon the plan change price elasticity estimates used in our individual market simulations (see
Figure 7 above). We do this by estimating the plan change price elasticity for each worker in the
firm based upon the age and health status of each worker. We then use this average price
change elasticity for workers in each firm to simulate the employer decision to change their
source of coverage.
In the second step we model risk selection against the public plan. We assume that managed
care plans would develop products that tend to attract younger and healthier people through
benefits design or marketing practice. This will tend to leave the public plan with higher cost
individuals. We simulate this by assuming that private HMOs are able to offer a product that is
four percent less costly than the premium for the public plan. This assumption is based upon
research showing that utilization of health services in HMOs is about four percent less than in
PPO and other FFS plans. We simulate the shift of individuals from the public plan to these
HMOs using the plan change price elasticity estimates presented above in Figure 7.
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This approach tends to leave higher cost individuals in the public plan, with lower cost
individuals shifting to HMOs. This accumulation of a disproportionate share of higher cost
individuals in a given plan is called “adverse selection.”
Figure 8 presents our estimates of the changes in sources of coverage assuming that providers
are paid according to Medicare payment levels. The figure shows the number of workers and
dependents in employer plans under current law, the number who remain with their current
health plan, the number shifting to the public plan and the number who leave the public plan to
enroll in a lower cost HMO. The figure shows average health benefits costs for each group of
firms. These data demonstrate the degree of adverse selection for the public plan, separately for
fully insured and self-funded groups.
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Figure 8
Workers and Pure Premiums in Firms by Type of Coverage Offered Under the Illustrative Health Reform Proposal
Currently Insuring Firms
Currently Non-Insuring Firms
Small Firms
Large Firms
Small Firms
Large Firms
Self-
insured
Fully-
insured
Self-
insured
Fully-
insured
Total
Self-
insured
Fully-
insured
Self-
insured
Fully-
insured
Total
All Workers in Firm and PMPM Costs: Includes Insured and Uninsured Workers in Firms
Employees (1,000s)
1,059
23,498
55,491
35,119
115,169
0
34,705
0
12,053
46,758
Costs
$630
$570
$619
$562
$592
$0
$400
$0
$291
$372
Current Law Premium
$630
$537
$619
$519
$572
$0
$437
$0
$385
$423
Policy Premium
$630
$517
$619
$514
$566
$0
$436
$0
$383
$422
Public Plan Premium
$404
$405
$422
$409
$414
$0
$341
$0
$309
$333
Offer Private Coverage Under Health Reform Proposal
Employees (1,000s)
431
1,308
9,855
6,843
18,437
0
604
0
1,099
1,703
Costs
$289
$780
$406
$614
$507
$0
$670
$0
$354
$466
Current Law Premium
$289
$635
$406
$536
$468
$0
$505
$0
$420
$450
Policy Premium
$289
$615
$406
$536
$467
$0
$542
$0
$441
$477
Public Plan Premium
$415
$482
$406
$427
$419
$0
$424
$0
$355
$379
Do Not Offer Coverage Under Health Reform Proposal
Employees (1,000s)
47
1,347
3,291
3,097
7,782
0
20,356
0
2,922
23,278
Costs
$699
$618
$434
$465
$480
$0
$365
$0
$235
$349
Current Law Premium
$699
$518
$434
$470
$464
$0
$409
$0
$332
$400
Policy Premium
$699
$500
$434
$472
$462
$0
$417
$0
$365
$411
Public Plan Premium
$354
$392
$392
$375
$385
$0
$327
$0
$295
$323
Offer Coverage in the Public Plan
Employees (1,000s)
467
17,549
34,863
20,298
73,176
0
8,530
0
5,777
14,308
Costs
$924
$553
$690
$559
$622
$0
$486
$0
$312
$416
Current Law Premium
$924
$534
$690
$521
$607
$0
$498
$0
$408
$462
Policy Premium
$924
$514
$690
$514
$601
$0
$479
$0
$388
$442
Public Plan Premium
$412
$403
$430
$408
$417
$0
$375
$0
$312
$350
Offer Private HMO Coverage
Employees (1,000s)
115
3,295
7,483
4,882
15,775
0
5,215
0
2,254
7,469
Costs
$689
$554
$648
$561
$602
$0
$366
$0
$279
$340
Current Law Premium
$689
$520
$648
$516
$581
$0
$435
$0
$378
$418
Policy Premium
$689
$501
$648
$513
$576
$0
$427
$0
$365
$408
Public Plan Premium
$353
$393
$420
$408
$410
$0
$334
$0
$295
$322
a/ Pure premiums include benefits costs only and exclude administration, profit and broker and agent commissions.
Source: The Lewin Group estimates using the Health Benefits Simulation Model (HBSM).