The increased use of managed care may potentially reduce substitution effects. Managed care penetration, which impacts the affordability of insurance, varies by region and also may impact substitution. Oregon, which has actually witnessed an increase in employer-sponsored insurance, has a relatively high-managed care penetration rate of approximately 60% or higher within the state's insured population. Managed care options such as health maintenance organizations (HMOs), preferred provider organizations (PPO), and point-of-service plans (POS)
are appealing insurance options for employers. A strong state economy and a competitive labor market that requires employers to provide insurance coverage as a means of attracting workers affect Oregon's high rates of employer-sponsored insurance. Costs to small employers for health insurance are also relatively low in Oregon: the average premium for a 2-50 person business is approximately $425-450 per month for family coverage, which is 15-25% less than the national average.