Many large employers prefer to self-insure health plans offered to employees rather than purchase them from insurance companies to save costs and to avoid the burden of complying with varying state mandates. This concerns state governments because they cannot directly regulate self-insured plans. This article describes the prevalence of employer self-insurance for the nation and by state in 1993 and examines what factors, especially state policies, contribute to the national and state variation in the prevalence of self-insurance. Data from the National Employer Health Insurance Survey on 34,604 private sector establishments are analyzed. Variation in the prevalence of self-insurance was largely explained by the firm size of the establishments. After all other factors were examined, very little was added to predict the rate of self-insurance for each state. While state premium taxation and benefits mandates were not associated with self-insurance, small-group reforms were significantly and positively associated with the probability of self-insurance.
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