Kaiser Family Foundation/LA Times Survey Of Adults With Employer-Sponsored Insurance
Since the passage of the Affordable Care Act (ACA) in 2010, much attention has been paid to the parts of the U.S. health insurance landscape that were most directly impacted by the law, including the individual insurance market and expanded Medicaid programs in some states. Yet, the number of people covered by employer-sponsored health insurance in the U.S. far exceeds the number covered in the individual market or by any government program. In 2017, about 156 million people had employer-based coverage, representing almost half the total U.S. population and 60 percent of non-elderly adults.1 Surveys of employers point to the growing cost burden of health insurance for this population. Between 2008 and 2018, premiums for employer-sponsored insurance plans increased 55 percent, twice as fast as workers’ earnings (26 percent). In addition, workers are finding themselves on the hook for bigger deductibles before their insurance will kick in. Over the same time period (2008-2018), the average health insurance deductible for covered workers increased by 212 percent.2
Against this backdrop, the Kaiser Family Foundation partnered with the Los Angeles Times to conduct a representative survey of adults with employer-sponsored health insurance.3 Some key themes from the survey are summarized here, and a full report of the findings follows.
Overall, the survey finds that most people with employer-sponsored insurance (ESI) are generally satisfied with their health plans, and large shares say they feel “grateful” and “content” about their insurance while fewer say they are “angry” or “frustrated.” However, insurance does not offer iron-clad protection against health care affordability challenges. Four in ten report that their family has had either problems paying medical bills or difficulty affording premiums or out-of-pocket medical costs, and about half say someone in their household skipped or postponed some type of medical care or prescription drugs in the past year because of the cost. Seventeen percent say they’ve had to make what they feel are difficult sacrifices in order to pay health care or insurance costs; for some, the sacrifices they report making are extreme.
The experiences and attitudes of people with employer coverage differ vastly depending on whether they are in a higher or lower deductible plan. The higher the deductible, the more likely an individual is to have negative views of their health plan, and the more likely they are to experience problems affording care or to put off care due to cost. One reason people with higher deductibles are having trouble affording care is that many of them do not have enough savings to cover the full amount of their deductible. Among those in the plans with the highest deductibles (at least $3,000 for an individual or $5,000 for a family), over half say the amount of savings they could easily access in the short term is less than the amount of their deductible.
Another group that is particularly vulnerable to health care affordability issues are those with chronic conditions. Just over half (54 percent) of those with employer-sponsored coverage say that someone covered by their plan has a chronic condition such as hypertension, asthma, a serious mental health condition, or diabetes. About half of this group reports that their family has had problems paying medical bills or difficulty affording premiums or out-of-pocket costs, compared to about three in ten of those in families without a chronic condition. The combination of a chronic condition and a high deductible leads to even higher rates of problems and worries. For example, three-quarters of those in the highest deductible plans who say someone on in their family has a chronic condition say that a family member in their household has skipped or delayed some type of medical care or prescription drugs for cost reasons in the past year.
The survey also finds that cost has taken on greater importance in health insurance decision-making over the last decade and a half. When asked to choose the most important feature in a health plan, about six in ten people with employer coverage choose cost-related factors (low premiums, deductibles, or co-pays), while about a quarter choose coverage-related factors (choice of providers or range of covered benefits). These shares are essentially the opposite of what they were in 2003, when one-third chose cost-related factors and six in ten chose range of benefits or choice of providers. Similarly, among those whose employer offered a choice of plans, the share who say they picked their plan based on the cost increased from 21 percent in 2003 to 36 percent in the current survey.
Seven in ten people with employer coverage report engaging in some type of cost-conscious health care shopping behavior in the past 12 months, the most common of which is asking for a generic instead of a brand-name drug (47 percent). Less common behaviors are those that might actually lead to lower prices on services, including shopping around at different providers to find the best price for a medical service (17 percent) and trying to negotiate with a provider for a lower price (9 percent). One selling point of high deductible health plans is that they may incentivize enrollees to engage in more cost-conscious behaviors, including price-based shopping. The survey finds mixed evidence that this is the case; while the lowest rate of reporting these behaviors occurs among those in plans with no deductible, with a few exceptions, those in high deductible plans are not significantly more likely than those in lower deductible plans to report engaging in price-based shopping. In addition, those in high deductible plans paired with a health savings account (HSA plans) are not significantly more likely than those in plans with similar deductible levels to report shopping for lower-priced health care services. Overall, those enrolled in HSA plans – who make up 18 percent of adults with employer coverage – are more likely to view them as a way to pay for current medical bills than as a way to save money for the future.
Confusion and lack of access to cost information can also be a barrier for individuals to engaging in cost-conscious health care behaviors. Two-thirds say it is difficult to find out how much medical treatments and procedures provided by different doctors and hospitals would cost them, and over four in ten say they have had difficulty understanding how much they will have to pay out of their own pocket when they use care.
Finally, while most people with employer insurance feel that the cost of health care for people like them is too high, more say the current U.S. health insurance system works well for people with employer coverage than say it works well for people on Medicare or Medicaid or those who purchase their own insurance. Asked who is to blame for high costs, majorities point the finger at pharmaceutical and insurance companies, while fewer see hospitals, doctors, or employers as deserving of blame.