State Health Plan for Employees and Retirees Reform

This is the third installment of a four-part series outlining a blueprint for meaningful state budget reform for North Carolina. This article focuses on the growing and unsustainable health insurance benefits provided to state government employees and retirees

  1. A Blueprint for Budget Reform
  2. Reforms Needed for North Carolina’s Ailing Pension System
  3. State Health Plan for Employees and Retirees Reform
  4. Medicaid Reform

Imagine you get a new job with good pay and excellent benefits. In fact, the health insurance coverage is the most generous you’ve seen. You pay nothing for coverage while you are working, and after a set number of years, you can get free coverage in your retirement years as well. Once the excitement about the new job and great benefits wears off, you may begin to wonder just how your employer is paying for all that health insurance not just for active employees, but for virtually every retired former employee who put in more than just a few years’ service.

Moreover, given that this is a large company, you know that the number of retirees receiving health coverage is large and growing fast, and that people are living longer than ever before – thus creating an ever growing fiscal burden on the company.

And you would likely be right to be concerned, because such obligations would prove to be unsustainable and the company could very well go bankrupt because of it.

Such a scenario is playing out with the North Carolina State Health Plan. Except unlike the scenario with the company that would go bankrupt, we are dealing with the state government who just continues to reach deeper into the pockets of taxpayers to fund their unsustainable obligations.

  • North Carolina state government has amassed a $33 billion unfunded liability for health benefits for state retirees.
  • Total expenses for the State Health Plan have risen 30 percent in just five years.
  • 27,000 additional retirees began receiving benefits in a recent five year span, a number equivalent to all the full-time state government workers in Nebraska.
  • The share of insurance premiums North Carolina state employees and retirees are asked to pay is only about one-fourth as much as workers at large private sector companies, and less than half of state and local governments in the southeast.
  • Taxpayer share of financing the State Health Plan has soared to $1.8 billion per year – and is growing fast.

Only a few state politicians have recognized the serious nature of the State Health Plan’s financial burden. A few very modest reforms have been enacted recently, but nothing remotely sufficient to make a noticeable difference. With some reasonable reforms to the program to make the State Health Plan benefits more closely aligned with those offered in the private sector and other state governments, however, the state can put the State Health Plan back onto a sustainable path.



The North Carolina State Health Plan (SHP) is the health insurance plan offered to state government employees and retirees. It is much more generous than what many workers now have – and it’s headed for fiscal calamity.

SHP now covers 664,000 state government employees (including teachers), retirees and dependents.[1]  The plan offers two PPO coverage options, both offered by the Blue Options network – administered by Blue Cross Blue Shield North Carolina.

The two plans are the “70/30 basic plan” and the “80/20 standard plan.” The 70/30 plan offers higher out-of-pocket expenses in return for lower premiums. The state budget is responsible for paying the majority of the premium costs for enrollees.[2] Eligible employees and retirees pay no premium on the 70/30 plan, and as of July 1, 2011 are asked to contribute a mere $22.76 per month for the 80/20 plan. Eligible employees and retirees can also enroll dependents onto the SHP, but are responsible for paying the full premiums.

To be eligible to enroll and receive state premium subsidies in the SHP, an employee must be a permanent staffer working 30 or more hours per week for nine or more months per calendar year. Part-time workers can also enroll in the plan, but are responsible for paying their own premiums.

Moreover, retirees hired before Oct. 1, 2006 must have only five years’ service, while those hired after that date must have 20 or more years of service, in order to receive the state-subsidized insurance in their retirement years. Also, as noted in a Dec. 2011 Fiscal Research presentation, “When the retiree becomes eligible for Medicare, the SHP coverage becomes secondary and the retiree is expected to enroll in Medicare Parts A and B, but not D.”[3] Thus, state retirees who are also enrolled in Medicare are somewhat less expensive for the state to cover.

How Much Does the SHP Cost? How is it Funded?

With the state offering such generous coverage to hundreds of thousands of people, the costs mount quickly. Total payment requirements for the State Health Plan are estimated to be roughly $3 billion in FY 2012-13.[4]

These expenses include medical and pharmacy claim payments and administrative costs. Ninety-eight percent of the revenue to cover the SHP expenses comes from premium contributions, with taxpayers picking up much of the tab. Funding to pay for the SHP premiums come from:

  • state agencies (i.e. your tax dollars) for active employees
  •  the Retiree Health Benefit Fund for retiree premiums, with funding from General Fund appropriations (i.e., your tax dollars)
  • premiums from employees and retirees making the small monthly contribution to the 80/20 plan as well as those paying for dependent coverage.[5]


The annual taxpayer share for the SHP for active employees and retirees comes to about $1.8 billion. This is nearly 10 percent of the state’s $20 billion General Fund budget.[6] Yet things are going to get much worse, and soon.

Of the nearly 665,000 participants in the SHP, nearly 314,000 are active employees, 159,000 are dependents of active employees, 167,000 are retirees and another 19,000 are dependents of retirees.[7] Of those participants, two-thirds are enrolled in the 80/20 standard plan – which began requiring the minimal monthly premium contribution from employees and retirees only last year.

Growing Health Care Costs Making SHP Unsustainable

As one might expect, the costs of the SHP have been rising rapidly over the last several years. In FY 2007-08, total expenses came to $2.3 billion.[8] Thus, the estimated $3 billion in expenses for FY 2012-13 would mark a dramatic 30 percent increase – or $700 million – in just five years for SHP expenses.

The explosive and unsustainable increases in SHP expenses have been recognized – although insufficiently – over the past few years, leading to some very modest reforms in an effort to curb the growing program. As mentioned above, legislation passed in 2011 asked employees and retirees enrolled in the 80/20 plan to contribute $22.76 per month toward the premiums for their health coverage. Also, a number of co-pays and other out-of-pocket expenses were slightly increased for both plans.[9]  Increasing the out-of-pocket expenses in the plan’s coverage was estimated to save the state about $75 million in FY 2012-13, while the new employee/retiree premium contributions for the 80/20 plan are estimated to save nearly $95 million.[10]

These reforms offer a step in the right direction, but are fairly minor when considering the total costs and the rate of cost increases confronting the SHP. For however dire the outlook is today, it’s going to get worse and worse in coming years.

Unfunded Liability for Retirees at $33 Billion – and Growing Fast

The most significant fiscal challenge facing the State Health Plan is the large and rapidly growing unfunded liability for state retirees. The most recent actuarial valuation conducted as of Dec. 31, 2010 estimated North Carolina’s unfunded liability for retirees at $33 billion. North Carolina’s per capita liability ranks 9th highest nationally, and is growing fast.[11] The $33 billion liability is up $9 billion from just five years prior – a stunning increase of 38 percent.[12] Furthermore, at its current trajectory, that liability is projected to exceed $50 billion in another seven years.[13]

The unfunded liability represents the present value of the amount of estimated premium subsidies for retirees’ health insurance the state will be responsible for over the next 30 years. What this means, in short, is that as more and more state employees retire and live longer, it will cost state taxpayers a rapidly escalating amount to cover SHP premiums.

To get an idea how quickly the annual payment required to cover retiree health benefits can climb, consider this: In FY 2012-13, more than half a billion in taxpayer dollars ($516 million) will be required to finance SHP premiums for state retirees from General Fund supported positions.[14] In FY 2000-01, that required amount was only $87 million, meaning the annual taxpayer contribution to cover state retiree health benefits had exploded virtually six-fold in just a dozen years.[15]

This problem will continue to worsen in dramatic fashion as the number of state retirees enrolled in the SHP continues to rise. For instance, the number of retired state employees enrolled in the SHP swelled from 133,486 in 2005 to more than 160,000 in 2010.[16] The additional 27,000 retired SHP enrollees marked an increase of 20 percent in just five years. To put that number into perspective: the state of Nebraska’s entire state government employs 27,000 full-time workers.[17]

The 2011 legislation asking retirees enrolled in the 80/20 plan to contribute a small share of SHP premiums will help to offset the rising liability crisis, but very slightly. Moreover, legislation passed in 2006 also attempted to curb the growing rate of retiree health benefit liabilities.[18]  Senate Bill 837 changed the eligibility requirements for state retirees to receive SHP premium coverage. For employees hired on and after October 1, 2006, retirees must have 20 or more years of service to receive the full state-funded premium support. This new threshold is up from the 5-year standard that had previously been in place. Furthermore, the legislation determines that retirees with 10 to 20 years’ experience can receive a state subsidy of 50 percent of the SHP premium, and retirees with five to ten years service can enroll in the SHP but pay the full amount of the premium.

This change too, however, was projected to have a non-significant impact on the cost of financing state retiree health premiums. Projections for the 10th year after this legislation’s passage suggest a taxpayer savings of between $11 and $13 million[19]– a barely noticeable amount given the size of the state’s health insurance obligations to retirees.

Generous Benefits Contributing to Rising SHP Costs and Liabilities

The primary drivers of the rapidly expanding costs of the State Health Plan are the growing costs of health care in general, and the highly generous benefits extended to state employees and retirees.

For the SHP offers perks that many employees in private industry and even in government in other states might well envy. Consider the following:

  • The active employees’ portion of the SHP premium they are now asked to share for the 80/20 plan is roughly 5 percent of the total cost of the premium (the state picks up the rest of the costs). For the basic 70/30 plan, employees can still enroll at zero cost to insure themselves.[20]For comparison:
    • Employees of large private sector firms pay an average of 19 percent of premium costs for their individual health coverage.[21]
    • State and local government employees in the South Atlantic region pay an average of 13 percent of premium costs.[22]
    • Few employers in the private sector offer medical benefits to both active workers and retirees, as North Carolina state government does. In 2010, only 28 percent of large private sector firms offered medical benefits to both employees and retirees.[23]
      • Of those large private employers that do offer medical benefits to both active workers and retirees, 40 percent require the retiree to pay the full premium for coverage while another 30 percent have capped the employer’s subsidy at a fixed dollar amount.[24]
      • Roughly 70 percent of states require retirees to contribute more than a nominal premium, which is all NC now asks.[25]
      • Only seven other states offer to pay 90 percent or more of retiree’s health insurance premiums – even after a maximum qualifying number of years of service.[26]
      • North Carolina is one of only ten states that offer retirees a significant health insurance premium subsidy after only 20 years of service.[27]

Reform Recommendations

North Carolina’s State Health Plan is clearly on an unsustainable path. Recent tweaks to the plan are but small steps in the right direction. Much more significant reforms are necessary. Health benefits for active employees are too generous to sustain, and benefits for retirees are even more unsustainable as evinced by the state’s massive unfunded liability. The state is struggling to meet its budget goals now; coming up with the billions needed to fund health benefits as they now exist would impose a crushing burden on the economy and taxpayers.

Reforms would also benefit workers, for the current plan sets up expectations that will be impossible to meet. There are options that would still offer state employees good benefits, and even improvements in the plans, while ensuring that the plan is sustainable. North Carolina lawmakers would be wise to implement the following reforms to the State Health Plan for active employees and retirees:

  • Require state employees to contribute 10 percent of the cost of their SHP enrollment in the 80/20 plan, and 5 percent for the 70/30 plan. The new contribution rate for the 80/20 plan would be roughly twice the current contribution rate, while this would mark the first time state employees would be asked to contribute to the 70/30 plan. This new contribution arrangement would cost state employees roughly $43 and $22 per month under the current premium costs of the plans, respectively.
    • As noted previously, these contribution rates would still be far below averages for large private sector employers, and less than average contribution rates for state and local government workers in the south Atlantic region.
    • Based on purely static analysis from enrollment figures of active employees from Sept. 2011, the new contribution rates would save taxpayers about $81.5 million annually.[28]


  • Require eligible state retirees to contribute 15 percent and 30 percent of the premiums in the 70/30 and 80/20 plans, respectively. This would be up from zero and 5 percent. In dollar terms, that would mean non-Medicare retirees would contribute $64.90 and $129.80 (up from $22.76) per month for enrollment in the 70/30 and 80/20 plans respectively. For retirees also on Medicare, that would translate into monthly contributions of $50.44 and $100.88 (up from $10.52) for the 70/30 and 80/20 plans. These are fair and reasonable goals, considering how the current benefits stack up against what most other state government and private sector retirees receive from their health plans.
    • Recall that very few large private sector employers offer health benefits to both active workers and retirees at all, and of those most require full or a significant share of premiums to be paid by the retiree.
    • Roughly 70 percent of other states require retirees contribute a significant share towards their health insurance premiums, and fourteen states contribute nothing for retiree enrollment into their state health plan.[29]
    •  Based on a static analysis using the same data as above, immediate savings from the new contribution rates would total $302 million annually.[30]

HSA Option

Another significant factor contributing to the unsustainable growth of the SHP is the rising cost of the insurance premiums. Recent estimates suggest the SHP’s premiums will increase more than 12 percent in the 2011-12 two-year biennium alone.[31]

However, high deductible health plans in tandem with health savings accounts (HSA) have proven to significantly curb the growth rate of health insurance premiums where they have been implemented.[32]

Offering a high-deductible insurance plan coupled with a health savings account (HSA) can help save the state millions. Moreover, it offers state employees the opportunity to build up thousands of dollars of savings to use for medical expenses – savings that they own whether or not they continue to work for the state.

Such plans also may offer features that are popular with workers. The most notable state government to offer high-deductible plans with an HSA is Indiana. The state began to offer such an alternative to state government workers in 2006. The initiative quickly gained in popularity, and by 2010 70 percent of state workers had enrolled in the option.[33] Enrollees in Indiana’s HSA plan are highly satisfied, only 3 percent had opted to return to the state’s PPO option as of 2010.[34] That shows how an HSA can be a plus for workers, too.

In short, under Indiana’s HSA plan, enrollees participate in a high deductible insurance plan which features a much lower premium. In exchange for the exposure to the high deductible, the state deposits $2,750 per year into a health savings account controlled by the employee, out of which they can pay their health bills for routine preventive check-ups, prescriptions, co-pays, etc.[35]  The state, in turn, covers the entire cost of the premium.

On net, the cost to the state likely ends up lower because the low premium combined with the HSA contribution is still lower than the high PPO plan premium.

The result of Indiana’s experience has been a substantial win-win for state employees and taxpayers. As of 2010, state employees participating in the HSA plan had accumulated a total of $30 million in their HSA accounts – an average of $2,000 per employee.[36] Only 6 percent had used their entire account balance. The accumulated HSA savings are owned by the employee, and can be taken with them even if they decide to stop working for the state.

Moreover, the savings to taxpayers has been significant. Consulting firm Mercer calculated that the state’s total health coverage costs were reduced by 11 percent due to the introduction of the HSA option, for a savings of at least $20 million in 2010.[37] And it should be noted, these savings were accumulated by an Indiana state workforce of only 30,000 – meaning the savings potential for North Carolina’s much larger SHP would be far more significant in dollar terms.

Yet more potential for savings for North Carolina state employees courtesy of an HSA plan involves coverage for dependents. Currently, workers pay the full premium for the cost to add dependents onto the SHP.  This leads to a substantial share of state employees opting not to add dependents onto the plan, leaving out many children from the plan. With an HSA option, however, children become much more affordable to insure. And by adding more children – typically very inexpensive to cover – into the SHP risk pool, premiums will tend to drop even further.

In closing, North Carolina should also offer a high-deductible health plan combined with a health savings account option for state employees and dependents. The savings could be significant, as the example of Indiana shows. For instance, if we assume North Carolina experiences similar enrollment rates and thus reaps 11 percent health care cost savings for state employees alone, the state would enjoy savings of roughly $138 million per year.[38]


For too long, state government has promised more health care benefits to employees and retirees than it can deliver. By acting now to create a health plan for the real-world, however, North Carolina can avert a fiscal disaster while treating workers fairly.

Asking state workers and retirees to merely chip in a minimal amount towards their premiums can secure the long-term viability of their health care benefits, while still leaving intact a benefit package more generous than other state governments and large private sector employers. The addition of a high-deductible plan accompanied by a health savings account as an option can likewise save the state millions while offering state workers additional options that may be right for their situation.

Elected officials in North Carolina owe it to its citizens and to state workers and retirees to implement sensible reforms to ensure fair coverage that doesn’t punish hardworking taxpayers. To kick the can further down the road would be irresponsible.

[1] North Carolina State Health Plan website:

[3] “Long-term Liabilities for Retired Employee Health Benefits,” prepared by the Fiscal Research Division of the North Carolina General Assembly for the House Select Committee on Legacy Costs from the State Health Plan, Pensions and ESC. December 13, 2011. Available online at:

[4] Legislative Actuarial Note for HB 1085. Available online at:

[5] Ibid.

[6] Estimate of employer contributions for active employee SHP premiums for General Fund-supported positions obtained from email correspondence with Fiscal Research. General Fund appropriation to the Retiree Health Benefit Fund to cover retiree SHP premiums calculated using contribution rate contained in FY 2012-13 budget bill times the covered payroll total for General Fund employees obtained in email correspondence with state Treasurer’s office.

[7] Actuarial Note for HB 1085, Supra.

[8] “Updated Financial Projection, 2009-2011 Biennium January 2010” Presentation to Board of Trustees. February 17, 2010. Page 6. Available online at:

[9] S.L. 2011-96 and S.L. 2011-85, Ibid.

[10] Fiscal Research Legislative Actuarial Note for HB 578. Available online at:

[11] “Long-term liabilities,” Ibid.

[12] “Recognition of Long-term Liabilities Under New Government Accounting Standards for Other Post-Employment Benefits,” Fiscal Brief, Fiscal Research Division. March 23, 2007. Available online at:

[13] “Long-term liabilities,” Ibid.

[14] Calculated using contribution rate contained in FY 2012-13 budget bill times the covered payroll for General Fund employees obtained in email correspondence with Fiscal Research Division.

[15] Calculated using General fund covered payroll estimates for previous years from state Treasurer’s office obtained via email times the contribution rate included in the FY 2000-01 state budget bill.

[16] 2010 numbers taken from legislative actuarial note for SB 323, and 2005 figure from legislative actuarial note for SB 837. Available respectively online at:

[17] U.S. Census Bureau, 2010 Annual Survey of Public Employment and Payroll. Available online at:

[19] Legislative actuarial note for SB 837. Available online at:

[20] “Long-term liabilities,” Ibid.

[21] Bureau of Labor Statistics, National Compensation Survey. March 2012. Table 3. Available online at:

[22] Ibid.

[23] “Long-term liabilities,” Ibid.

[24] Ibid.

[25] Ibid.

[26] “Retiree Health Plans: A National Assessment,” Center for State & Local Government Excellence. Sept. 2008. Available online at:

[27] Ibid.

[28] Enrollment figures taken from fiscal actuarial note for HB 1085

[29] “Retiree Health Plans,” Ibid.

[30] Fiscal actuarial note for HB 1085

[31] Legislative actuarial note for SB 323, available online at:

[32] “Companies going to high deductible insurance plans”, USA Today. Nov. 22, 2011. Available online at:

[33] “Hoosiers and Health Savings Accounts”, Gov. Mitch Daniels, Wall Street Journal. March 1, 2010.

[34] Ibid.

[35] Ibid.

[36] Ibid.

[37] Ibid.

[38] Based on total state contributions for General-Fund supported employee SHP premiums of $1.25 billion estimated for FY 2012-13 in email correspondence with Fiscal Research.



This article was posted in Budget & Taxes, Healthcare by Brian Balfour on September 4, 2012 at 1:41 PM.

© 2011 The Civitas Institute. Visit us on the web at
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Comments on this article

  • 1

    George Sep 05, 2012 at 9:23

    Please add to your comments that the salary for state SPA employment will be lower than that in much of the East and that even during good economic times a State worker will not receive CoL increases or performance raises. There will be very few in-range adjustments to bring experienced, productive and loyal employee’s salaries up to the level of the new hires that they will have to train. Many of those adjustments, if permitted, will be made out of political consideration rather than fairness.

    Don’t try to infer similarities between NC State employee’s salaries and benefits with those provided by the state of Wisconsin. That’s laughable and cast aspersions on the integrity of Civitas, an organization that I have held in high esteem. If state benefits including salaries are so much higher than in the private sector, perhaps the similar jobs should be analyzed and compared. Is the state to high or is business to low? Finally, we as Republicans are in somewhat of a quandary. We want to reduce the cost of government health care programs (Medicare, Medicaid) while arguing to reduce the cost of State healthcare benefits by pointing out that business doesn’t pay such high(?) benefits. Perhaps Civitas should give this more thought and much better study.

  • 2

    Brian Balfour
    Brian Balfour Sep 05, 2012 at 9:45

    Thanks for commenting on the article, however your comments are a bit murky at best. For instance, during good economic times state workers in NC routinely receive pay raises. Moreover, nowhere do I reference a direct comparison between NC state employees’ salaries and benefits with those provided by the state of Wisconsin – why do you bring it up? And why would such a comparison be “laughable” anyway – because you said so? I’d need more evidence than that.

  • 3

    Dave Sep 05, 2012 at 11:38

    Mr. Balfour,

    It is indeed sad that you hold State retirees in such poor regard. After 20 – 30 years loyal service to the citizens of North Carolina you advocate changing the retirement rules. When the retiree joined the State as an employee, a promise was made as to retirement. Now you advocate change to the rules for the retired who do not have a option to go back and do things differently. It is well known among the average workers in North Carolina that State employment is not at the top of the list in regard to salary. The State therefore has established a retirement system that in part makes up for the low salary during the working years. To change the rules retroactively for these folks is just wrong. It would show a total disregard for the years of service given and promises made.

    Moving forward, to increase the amount that a currently employed State worker contributes to their health plan is a good fiscal idea. I think we all can agree that the current North Carolina State Employee healthcare system needs some additional funding.

  • 4

    Brian Balfour
    Brian Balfour Sep 05, 2012 at 11:49

    Thanks for your comments. This issue is not a matter of holding anyone in poor regard – it is simple math.

    Politicians made promises they couldn’t keep. The sooner we realize that, the better. Changes to retiree benefits are inevitable, better to make them now because the longer we wait, the more severe the changes will need to be. We’ve kicked the can down the road for too long.

  • 5

    Shirley Parker
    Shirley Parker Sep 06, 2012 at 6:49

    Have you considered using AARP for retired workers? I believe the cost would benefit both the state and retirees. My husband has this plan and we are well pleased with it.

  • 6

    William Sep 16, 2012 at 23:19

    In regards to the AARP recommendation… somewhere between 15 and 25 million dollars of your husbands money is spent in partisan political lobbying efforts. I appreciate out-of-the box ideas, but there are more appropriate alternative supplements such as: Generation America, ASA or AMAC. All provide supplemental with the same or cheaper montly than AARP, and do so without spending millions promoting bad partisan policies.

    I’m a current state employee and thank Civitas for the work done here. I’d be willing share in the burden to promote a sustainable solution, but would prefer to avoid changing the rules for those who have already retired as mentioned in Dave’s comment.

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