The opioid epidemic continues to devastate many parts of the country, with thousands dying each year from opioid overdoses. The number of deaths is increasing, driven by a spike in overdoses from fentanyl and other synthetic opioids.¹  Of the roughly two million nonelderly adults with opioid use disorder (OUD), about a fifth are uninsured. Uninsured adults with OUD are particularly vulnerable because of limited access to treatment and care. Based on data from the 2016 and 2017 National Survey on Drug Use and Health (NSDUH), this data note describes uninsured nonelderly adults with OUD, including their demographic characteristics and treatment utilization.

As the #opioidepidemic continues, nearly 1 in 5 of the 2 million nonelderly adults who have opioid use disorders are uninsured. Evidence indicates that individuals without health coverage are less likely to obtain needed treatments.

Who Are Uninsured Adults with Opioid Use Disorder?

Nearly one-fifth (18%) of nonelderly adults with OUD were uninsured during the period analyzed (Figure 1). Of the two million nonelderly adults with OUD, 373,000 were uninsured. Lacking insurance coverage poses unique challenges to accessing health care services, particularly services for treating substance use disorders. Evidence indicates that individuals without health coverage are less likely to obtain needed treatments that their health care providers recommend for them than those with coverage.² 

Uninsured nonelderly adults with OUD were predominantly male, young adult, and white. Nearly seven in ten (67%) of the 373,000 uninsured nonelderly adults with OUD were male and 58% were ages 18 to 34 (Figure 2). Additionally, three-quarters were non-Hispanic white.

The opioid epidemic continues to be driven by misuse of prescription opioids. Among uninsured adults with OUD, nearly two-thirds (65%) reported prescription opioid use disorder³  compared to one in five (21%) who reported heroin use disorder. Another 14% reported using both types of opioids (Figure 3). These percentages were similar to those who had insurance coverage.

Six in ten of the uninsured nonelderly adults with OUD had low incomes (Figure 4). A quarter of uninsured nonelderly adults with OUD were living in poverty and more than a third (35%) had incomes 100-200% of the Federal Poverty Level ($24,120 for an individual in 2017).

What is the Health Status and Access to Treatment among Uninsured Adults with Opioid Use Disorder?

Nearly a quarter of the uninsured nonelderly adults with OUD reported being in fair or poor health (Figure 5). More than three in ten reported having a disability and nearly four in ten (37%) reported having a chronic condition and/or cancer in the past year. Pain management for chronic conditions and cancer can lead to opioid use and ultimately misuse, which is of growing concern for prescribers treating individuals with chronic or severe pain.⁴  Compared to all uninsured adults, those with OUD are more likely to have a disability or chronic condition (data not shown).

Over two-thirds of uninsured adults with OUD reported any mental illness in the past year. Additionally, more than a third (35%) reported a serious mental illness⁵  (Figure 6). These rates were similar among nonelderly adults with OUD regardless of insurance coverage.

Fewer than three in ten (28%) uninsured nonelderly adults with OUD reported receiving any treatment in the past year (Figure 7). By comparison, over four in ten nonelderly adults with OUD who had Medicaid and just over one in five of those with private insurance received any treatment. Overall receipt of drug and/or alcohol treatment was low among all nonelderly adults with OUD, with less than a third (31%) reporting they received treatment.

Nearly three-quarters of uninsured adults with OUD reported needing drug treatment in the past year, but did not receive it (Figure 8). Those with Medicaid were least likely to have unmet need for drug treatment, while more than eight in ten (82%) of those with private insurance reported having unmet need in the past year. The reasons for not accessing treatment vary, but common explanations included limited insurance coverage, lack of affordability, concerns about stigma or a negative effect on job, and not being ready to stop using the substance(s).⁶ 

Looking Ahead

Uninsured adults with OUD are predominantly male, young adults, and white and many have low incomes. Given the high rates of disability and chronic conditions as well as mental illness in this population, the lack of health insurance may hinder access to needed health care services. Less than a third of uninsured adults with OUD received drug and/or alcohol treatment in the past year. As the number of opioid overdose deaths, particularly due to overdoses from fentanyl and other synthetic opioids, continues to increase, uninsured nonelderly adults with OUD are particularly vulnerable. Expanding Medicaid in states that have not yet adopted the expansion could improve access to treatment for many low-income uninsured with OUD.

 

1. Kaiser Family Foundation State Health Facts, “Opioid Overdose Deaths by Type of Opioid,” accessed July 2019, https://modern.kff.org/other/state-indicator/opioid-overdose-deaths-by-type-of-opioid/. ↩︎
2. Rachel Garfield, Kendal Orgera, and Anthony Damico, “The Uninsured and the ACA: A Primer, Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act,” (Washington, DC: Kaiser Family Foundation, January 2019), https://modern.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/. ↩︎
3. In this analysis, fentanyl, a common synthetic opioid, is included as a prescription opioid; therefore, the misuse of illicitly manufactured fentanyl may not be fully captured. ↩︎
4. Han et al., “Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health,” (Ann Intern Med. 2017; 167(5):293:301. doi: 10.7326/M17-0865). https://www.ncbi.nlm.nih.gov/pubmed/28761945. ↩︎
5. Defined as a diagnosable mental, behavioral, or emotional disorder of sufficient duration, excluding substance use disorders and developmental disorders, that interferes/limits major life activities (NSDUH Methodological Summary and Definitions, https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHMethodSummDefs2017/NSDUHMethodSummDefs2017.pdf). ↩︎
6. Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53), (Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, September 2018), https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf. ↩︎

Introduction

Recently, many of the Democratic presidential candidates indicated support for expanding health coverage to undocumented immigrants. To help inform the implications of such an expansion, this brief provides an overview of current health coverage and care for undocumented immigrants.

Undocumented immigrants are at high risk of being uninsured because they have limited access to coverage options. They face barriers to accessing care due to their high uninsured rates.

Overview of Undocumented Immigrants

Undocumented immigrants are foreign-born individuals residing in the U.S. without authorization. This group includes individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired. The primary reasons individuals immigrate to the U.S. are for better job opportunities, to reunite with family, and for increased safety.¹  Undocumented immigrants account for roughly four in ten noncitizens, while the remaining six in ten are lawfully present immigrants. Many immigrant families include people with mixed immigration status, and the majority of children with a noncitizen parent are U.S.-born citizens.

It is estimated that there were 10.5 million undocumented immigrants residing in the U.S. as of 2017, accounting for about 3% of the total U.S. population.²  Estimates from the Pew Hispanic Center show that the number of undocumented immigrants in the U.S. has been declining since 2007 (Figure 1).³  This decline largely reflects a large decrease in the number of new undocumented immigrants. As a result, an increasing share of undocumented immigrants are people who have been living in the U.S. for many years. As of 2017, about two-thirds (66%) of undocumented immigrant adults in the U.S. had been in the U.S. for more than 10 years, up from 41% in 2007.⁴ 

Health Coverage for Undocumented Immigrants

Undocumented immigrants are at high risk of being uninsured. Among the total nonelderly population, 45% of undocumented immigrants were uninsured compared to about one in four (23%) lawfully present immigrants and less than one in ten citizens (8%) as of 2017 (Figure 2). Although noncitizens are more likely to be uninsured than citizens, citizens still account for the majority of the nonelderly uninsured, since noncitizens account for a small share of the overall population.

The higher uninsured rate among undocumented immigrants reflects limited access to health coverage options.

• Undocumented immigrants are not eligible to enroll in Medicare, Medicaid, or CHIP or to purchase coverage through the ACA Marketplaces. Under rules issued by the Centers for Medicare and Medicaid Services, individuals with Deferred Action for Childhood Arrivals (DACA) status are not considered lawfully present and remain ineligible for these coverage options.⁵  Since 2002, states have had the option to provide prenatal care to women regardless of immigration status by extending CHIP coverage to the unborn child. As of January 2019, 16 states had adopted this option.⁶ 
• Although most nonelderly undocumented immigrants live in a family with a full-time worker (Figure 3), they have limited access to employer-sponsored coverage. They are often employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Further, undocumented immigrants are more likely than other groups to be low-income, making it challenging to afford employer-sponsored coverage when it is available.

Current coverage among undocumented immigrants reflects a limited array of private coverage and some state- or locally-funded programs. Some undocumented immigrants may get coverage through their employer or as a spouse or dependent of an employee. Undocumented immigrants can also purchase private coverage on the individual market outside of the ACA Marketplaces, although many may not be able to afford this coverage due to their limited incomes and lack of subsidies to offset the costs of this coverage. Some undocumented immigrants may also be covered through student health programs. Six states (CA, IL, MA, NY, OR, and WA) and DC use state-only funds to cover income-eligible children regardless of immigration status.⁷  In June 2019, California approved an expansion in coverage for income-eligible young undocumented immigrant adults through age 25.

Health Care for Undocumented Immigrants

Given their higher uninsured rates, many undocumented immigrants delay or go without needed care. Research shows that having insurance makes a difference in whether and when people access needed care.⁸  Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat.⁹ 

Undocumented immigrants can obtain low-cost care through community health centers. However, care available through clinics is often limited to preventive and primary care, leaving them to face challenges in accessing specialty services.

Under federal law, hospitals are required to screen and stabilize every patient who seeks emergency care. Medicaid helps offset costs borne by hospitals in providing emergency care to undocumented immigrants by providing payments to hospitals for emergency care provided to individuals who are otherwise eligible for Medicaid but for their immigration status.

Immigrants spend less on health care, compared to their U.S. born counterparts.¹⁰  They also make larger out-of-pocket health care payments compared to nonimmigrants.¹¹  Immigrants have lower spending, in part, because they use less care due to their low coverage rates and limited access to care. They also tend to be younger and healthier than nonimmigrants, although this difference decreases over time as immigrants spend longer in the United States.¹² 

Current Issues

Research shows that shifting immigration policies under the Trump administration are leading to substantially increased fears among the immigrant community, affecting undocumented immigrants as well as lawfully present immigrants and citizen children of immigrants.¹³  Growing reports suggest that these fears are causing families to turn away from utilizing programs and services for themselves as well as their children, who are primarily U.S. born citizens and may qualify for Medicaid and CHIP.¹⁴  The administration is pursuing additional changes to public charge policies that may lead to even larger decreases in participation in Medicaid among lawfully present immigrants and citizen children of lawfully present and undocumented immigrants.¹⁵  Declines in coverage for families would increase barriers to care and financial instability, negatively affecting the growth and healthy development of their children.

Although the Democratic presidential candidates have indicated support for expanding coverage to undocumented immigrants, to date, there are no detailed proposals. The impact and costs of such an expansion would depend on how individuals are covered (e.g., through private coverage, Medicare, or Medicaid), what benefits are provided, and premium and cost-sharing levels. Some of the cost would be offset by existing resources currently going toward care for undocumented immigrants. An expansion would also likely shift the balance of how costs of care for undocumented immigrants are borne across the federal government, state and local government, private entities, and individuals. California’s recently approved expansion would cover young adults through the state’s Medicaid program using state-only dollars. The state has budgeted $98 million dollars for the expansion in the first year, which is estimated to cover 90,000 people.¹⁶  Even if coverage is expanded, fears among immigrant families could limit participation.

1. Kaiser Family Foundation, Health Coverage and Care for Immigrants, (Washington, DC: Kaiser Family Foundation, December 2017), https://modern.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants. ↩︎
2. Jens Manuel Krogstad, Jeffrey S. Passel, and D’Vera Cohn, 5 Facts About Illegal Immigration in the U.S., (Washington, DC: Pew Research Center, June 2019), https://www.pewresearch.org/fact-tank/2019/06/12/5-facts-about-illegal-immigration-in-the-u-s/ ↩︎
3. Ibid. ↩︎
4. Ibid. ↩︎
5. Cindy Mann to State Official and Medicaid Director, August 28, 2012, Center for Medicaid and CHIP Services, “Re: Individuals with Deferred Action for Childhood Arrivals,” SHO# 12-002, https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-12-002.pdf. ↩︎
6. Tricia Brooks, Lauren Roygardner, and Samantha Artiga, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 2019), available at https://modern.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-ofjanuary-2019-findings-from-a-50-state-survey/. ↩︎
7. Ibid. ↩︎
8. Rachel Garfield, Kendal Orgera, and Anthony Damico, The Uninsured and the ACA: A Primer, (Washington, DC: Kaiser Family Foundation, January 2019), https://modern.kff.org/report-section/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act-how-does-lack-of-insurance-affect-access-to-care/ ↩︎
9. Ibid. ↩︎
10. Lila Flavin, Leah Zallman, Danny McCormick, and J. Wesley Boyd, Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review, (Boston, MA: Tufts University School of Medicine, 2018), http://www.pnhp.org/docs/ImmigrationStudy_IJHS2018.pdf ↩︎
11. Ibid. ↩︎
12. Ibid. ↩︎
13. Samantha Artiga and Barbara Lyons, Family Consequences of Detention/Deportation: Effects on Finances, Health, and Well-Being, (Washington, DC: Kaiser Family Foundation, September 2018), https://modern.kff.org/disparities-policy/issue-brief/family-consequences-of-detention-deportation-effects-on-finances-health-and-well-being/. ↩︎
14. Samantha Artiga and Petry Ubri, Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health, (Washington, DC: Kaiser Family Foundation, December 2017), https://modern.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/; Samantha Artiga and Barbara Lyons, Family Consequences of Detention/Deportation: Effects on Finances, Health, and Well-Being (Washington, DC: Kaiser Family Foundation, September 2018),https://modern.kff.org/disparities-policy/issue-brief/family-consequences-of-detention-deportation-effects-on-finances-health-and-well-being/; and Hamutal Bernstein, Dulce Gonzalez, Michael Karpman, and Stephen Zuckerman, With Public Charge Rule Looming, One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018, (Washington, DC: Urban Institute, May 2019), https://www.urban.org/urban-wire/public-charge-rule-looming-one-seven-adults-immigrant-families-reported-avoiding-public-benefit-programs-2018 ↩︎
15. Samantha Artiga, Rachel Garfield, and Anthony Damico, Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, (Washington, DC: Kaiser Family Foundation, October 2018), https://modern.kff.org/disparities-policy/issue-brief/estimated-impacts-of-the-proposed-public-charge-rule-on-immigrants-and-medicaid/. ↩︎
16. “2019-2020 May Revision to the Governor’s Budget,” State of California Health and Human Services Budget Summary Chapter, Revised May 9, 2019, http://www.ebudget.ca.gov/2019-20/pdf/Revised/BudgetSummary/HealthandHumanServices.pdf ↩︎

Unlike other compensation, employer based health benefits are not taxed, meaning employees may receive thousands of dollars of tax benefits if they get their health insurance at work. The Congressional Budget Office estimates that the exclusion cost the federal government $300 billion in forgone revenues. Economists have long argued that providing this tax break encourages employers to offer more generous benefit plans than they otherwise would because employees prefer to receive additional benefits (which are not taxed) in lieu of wages (which are taxed). Employees with generous plans use more health care because they face fewer out-of-pocket costs, which economists argue contributes to the overall growth in health care spending.

To address this issue, the ACA included the High-Cost Plan Tax (HCPT), sometimes referred to as the “Cadillac Plan Tax”. The HCPT is a tax on employers based on the value of plans they provide in excess of designated thresholds, originally set at $10,200 for single coverage and $27,500 for family coverage. These caps grow annually with inflation. The CBO estimates that the thresholds will be $11,200 for individual coverage and $30,100 for family coverage when the law takes effect in 2022. Some employers with workers in high-risk industries or older workers face higher caps. Originally scheduled to take effect in 2018, the effective date of the HCPT has been twice delayed, most recently to 2022. While many employers anticipate the provision will be either delayed again or repealed, the tax as currently structure is projected to raise 193 billion dollars between 2022 and 2029.

We previously analyzed the percentage of employers with plans that would exceed the HCPT thresholds. Our purpose here is not to estimate the number of employers or employees who actually would pay the tax, but to look at the share of current plans that might meet the definition of “high cost” over time, assuming modest premium growth and no changes in plan design (i.e., we assume that employers do not increases deductibles to avoid the taxes). These estimates can be understood as the share of employers who have plans where the cost for some employees will exceed specified thresholds, presenting employers with the choice of restructuring their benefits or increasing either the firm’s or their employee’s tax liabilities.

As with our previous analysis, we focus on the value of plans providing single coverage due to the complexity of how family coverage is defined. There are some aspects of these proposals that we do not include. For example, the premiums for tax-preferred dental and vision coverage as well as certain workplace health clinics are included in total benefit costs but we do not have information on the amounts.

The High-Cost Plan Tax

The HCPT is a 40% tax on the cost of employer plans in excess of specified thresholds, which are projected to be $11,200 for individual coverage and $30,100 for family coverage. The tax is calculated for each employee at a firm based on their total health benefits, including spending on:

• The average cost for the health insurance plan (whether insured or self-funded);
• Employer contributions to a health savings account (HSA), Archer medical spending account (MSA) or health reimbursement arrangement (HRA);
• Contributions (including employee-elected payroll deductions and non-elective employer contributions) to a Flexible Spending Account (FSA);
• The value of coverage in certain on-site medical clinics; and
• The cost for certain limited-benefit plans if they are provided on a tax-preferred basis.

Consistent with our previous analysis, we use information from the 2018 Kaiser Employer Health Benefits Survey to estimate the share of employers with plans that would exceed the threshold. The survey contains information about plan premiums, employer contributions to health savings accounts and health reimbursement arrangements, and the amounts that employers permit their employees to contribute to a flexible spending account. We compute the total cost for each plan offered by an employer by adding together the total plan premium (employer and employee share), the employer contribution to an HSA and a portion of the promised HRA contribution as well as the permitted amount employees can contribute to an FSA. Because employees have a choice of whether or not to contribute to an FSA, we provide estimates with and without FSA amounts included in the plan total costs. These plan costs are trended forward based on the projected annual per-capita increases in spending in employer-provided coverage from the National Health Expenditure Accounts (NHE).

This @KaiserFamFound analysis estimates that the #CadillacTax on high-cost health plans could affect 1 in 5 employers when it starts in 2022 – and even more over time or when accounting for workers’ voluntary FSA contributions.

When the HCPT takes effect in 2022, an estimated 21% of employers offering health benefits will have at least one plan whose premium and account contributions would exceed the HCPT threshold (Figure 1). When potential FSA contributions are included, the percentage climbs to 31%. The impact of adding the FSA contributions is substantial because the maximum FSA contribution employees can elect (up to an estimated $2,900 in 2022) is quite large relative to the threshold. Since not all employees offered an FSA option make the maximum contribution, and some do not contribute, the threshold will be reached with respect to some employees at the firm and not others.

The percentage of employers with a plan reaching the threshold is projected to grow fairly rapidly over time, to 28% in 2025 and 37% in 2030 without including potential FSA contributions, and to 38% in 2025 and 46% in 2030 when they are included. This growth occurs because our assumed premium growth, which averages about 4.9% annually over the period, is higher than inflation projections (about 2.4%). If premiums grow more slowly than projected, the percentage of employers with a plan reaching the threshold would be smaller.  Twenty-one percent of firms offered a health plan in 2018 which already exceeded the HCPT thresholds, including 11% of firms exceeding the threshold without including FSA contributions.

Without other plan changes a larger percentage of large firms (200 or more workers) would sponsor health programs which exceed the thresholds than smaller firms (Figure 2 and Figure 3). Excluding any FSA contributions, 49% of large firms and 36% of smaller firms would have a program subject to the tax in 2030.

Both because of varying regional costs, and differences in plan generosity there is considerable variation in the cost of employer plans. Fourteen percent of covered workers are enrolled in a plan where the premium and employer account contribution exceed $9,000 in 2018. Conversely, 8% of covered workers are in a plan where the premium and account contributions are less than $5,000 (Figure 4).

There remains considerable uncertainty whether the HCPT will be implemented in 2022, delayed or repealed. In 2018, less than one-third (30%) of firms offering health benefits anticipate that the high cost plan tax will take effect as scheduled in 2022. Despite this, many employers, in particular large employers are already making changes to their health benefits to either reduce or avoid tax-liability if the provision takes effect. Among firms offering health benefits, 7% of small firms and 26% of large firms say they considered the potential impact of the upcoming tax when they made their benefit decisions for 2018.

Discussion

In 2018, 11% of employers offering health benefits, sponsored a plan which exceeds the HCPT tax thresholds, an additional 21% surpass theses thresholds when an FSA is included in plan costs. Given that most estimates suggest that health costs will continue to increase faster than inflation over time, a growing number of employers will be subject to the tax unless they make changes to their health programs. We estimate if the tax takes effect in 2022, 31% will be subject to the tax, increasing to 46% by 2030 unless firms reduce costs. Excluding workers FSA contributions, 21% of firms will be subject to the tax in 2022, increasing to 37% in 2030.

In addition to raising revenue to fund the expansion of coverage under the ACA, the HCPT provides powerful incentives to control health plans costs over time, whether through efficiency gains or shifts in costs to workers in the form of higher deductibles and other patient cost-sharing. While many employers do not expect that the tax will take effect in 2022, others are already amending their health programs in anticipation. If the HCPT is not delayed again, we can expect employers will continue to modify their offerings to limit their liability.

We used information about the premiums for employer-sponsored health insurance from the 2018 Kaiser Employer Health Benefits Survey (EHBS) to estimate the percentage of employers that would have at least one health plan subject to the law. The EHBS is an annual survey that collects information on health benefits from more than 2,100 employers with three or more employees. This method is largely consistent with our earlier estimates.

The EHBS collects information from employers about their largest plan for up to four plan types — health maintenance organization (HMO), preferred provider organization (PPO), point of service plan (POS), and high deductible health plan offered with a savings option (HDHP/SO). An HDHP/SO is a plan with a single deductible of $1,000 or more offered with a health reimbursement arrangement (HRA), or a health plan that qualifies the employee to make contributions to a Health Saving Account (HSA). For HDHP/SOs, the amounts that employers contribute to employees’ HSAs or make available to employees through HRAs are also collected. The 2018 EHBS includes information on the percentage of employers who sponsor a flexible spending account (FSA) and the maximum amount that they allow employees to contribute. FSAs are tax-preferred accounts employers may establish for their employees, so they can use pre-tax dollars for some medical spending. While three-quarters of large employers (those with 200 or more workers) sponsor FSAs, the ACA placed limits on the maximum amount that an employee may contribute ($2,650 in 2018).

Since HRAs are notional accounts, employers are not required to actually transfer funds until an employee incurs expenses. Thus, employers may not expend the entire amount that they commit to make available to their employees through an HRA. We therefore counted half of an employers total HRA contribution towards the plans total cost.

For the estimates, we took the single premium for each health plan offered by responding employers and increased them by National Health Expenditure Accounts (Table 3) projections in the annual percent change in private health insurance. For HSA-qualified plans, we added the amount that employers contribute to employees’ HSAs to the premium. For high deductible health plans with a Health Reimbursement Arrangement (HRA), the survey collects information about the amounts employers make available to employees, but not the amounts that are actually contributed. To be conservative, we added one-half of the amounts that employers make available through the HRA to the plan premium. The HSA and HRA amounts were also increased by NHE projections. For employers that reported offering an FSA, we added the maximum contribution the firm allows adjusted for inflation to the estimated premium for each plan type except HSA-qualified plans. We did not add the FSA amount to the premium for HSA-qualified plans because generally a person cannot establish an HSA if they have an FSA that could reimburse expenses before the plan deductible is met. We used the maximum contribution amount because we were evaluating if the cost for the plan could exceed the threshold for an employee. We used the projections in the CBO’s “Options for Reducing the Deficit: 2019 to 2028” for the threshold in 2022 and then assumed it increased at the Congressional Budget Office’s 2019 projections of the Consumer Price Index, All Urban Consumers (CPI-U) (Table 2-3).