“Choose the Plan That’s Right for You”: Choice Devolution as Class-Biased Institutional Change in U.S. Employer-Sponsored Health Insurance

This study examines the distributional consequences of U.S. employers’ efforts to devolve responsibility for managing their employees’ medical insurance risk. The logic of consumer choice has increasingly come to dominate insurance benefit design, requiring that employees learn to be their own actuaries. We ask, to what extent does the individuation of choice (between insurance plans with disparate levels of cost-sharing) alter the social stratification of out-of-pocket (OOP) medical expenditure burdens across socioeconomic status class strata? Our analysis draws on an insurance claims database from a large multi-employer commercial insurer, which includes information on plan offerings and realized OOP expenditure burdens for more than 37 million persons from 2002 to 2012. Consistent with expectations, the results of pooled difference-in-difference event study models reveal that transitions to devolved choice result in modestly greater increases in realized OOP burden among lower socioeconomic status enrollees, compared with the growth among higherstatus enrollees. However, the magnitude of the increase in the between-class expenditure burden disparity is small in substantive terms.