Blog & News
Pandemic-Era Trends in Employer-Sponsored Health Insurance (ESI), 2019-2020July 7, 2022:
The COVID-19 pandemic continues to disrupt many patterns of life and work in the United States and internationally, while exacerbating many long-standing concerns regarding health care affordability, access, and utilization as well as rates of health insurance coverage for Americans. In this regard, one area of potential pandemic-related impact to consider is coverage rates for employer-sponsored health insurance (ESI), which remains the largest source of coverage for Americans, with 60.1 million private-sector employees enrolled in ESI in 2020.1
In anticipation of the release of the 2021 Medical Expenditure Panel Survey Insurance Component (MEPS-IC) data, SHADAC researchers analyzed private-sector ESI estimates from the 2020 MEPS-IC to better contextualize the forthcoming 2021 estimates. Understanding 2020 coverage data will supply a pandemic-era baseline, while providing a critical vantage point from which to observe and interpret trends in ESI composition, affordability, and access in this critical market.
This narrative provides an overview of the 2020 MEPS-IC private-sector ESI estimates, covering firm size, ESI cost, and access. It’s important to note that the overlay of COVID-19 on this data makes it difficult to interpret the cause of certain changes when compared to pre-pandemic estimates. One area where this is evident is within the composition of private-sector employees by employer firm size.
Small firms declined significantly in 2020
Many employers offer ESI to their employees, regardless of the number of individuals they employ. However, while ESI remains the most common source of coverage for Americans, the composition of private sector employees enrolled in ESI shifted significantly from 2019 to 2020. Specifically, the number of employees in small firms (defined here as <50 employees) experienced a 19 percent decline over this timeframe, leaving a greater proportion of medium and large firms (defined here as >50 employees) to drive trends in ESI access to coverage and cost.
With larger firms comprising an increasingly significant portion of the private sector, trends among this subset of firms are driving overall changes between 2020 and 2019. For this reason, it is difficult to analyze changes in ESI estimates from 2020 to 2019, as these changes could be attributed to actual trends in access, cost, and affordability, or they could be directly tied to this shift in composition of employers and employees.
Number of private-sector employees in the United States, by firm size: 2019—2020
|50 or more
|2019-2020 Percent Change||-7%||-19%||-2%|
Source: SHADAC analysis of the Medical Expenditure Panel Survey—Insurance Component, 2019, 2020.
ESI costs and premiums remain mostly stable
Monitoring costs associated with ESI is essential for understanding health care-related financial burdens for employees. Nationally, 2020 premiums and cost sharing remained relatively stable for employees enrolled in ESI. While premiums for single coverage increased slightly by 2.5 percent ($177), family premiums, employee contributions, and deductibles (for both single and family coverage) remained steady when compared to 2019.
When examined on a state-level, 2020 ESI costs are more varied. Nationally, the average premium for single coverage was $7,149. Certain states exceeded that average in 2020, with Alaska and New York monthly premiums surpassing $8,000 ($8,635 and $8,177 respectively). Meanwhile, Alabama had the lowest premium for single coverage at $6,393. There was also a great deal of variation across states in the size of deductibles. Nationally, the average deducible for single coverage was just under $2,000 in 2020. However, deductibles ranged from an average of $2,500 in Montana to less than $1,500 in Hawaii.
High-deductible health plans (HDHP) represent one common form of ESI. Nationwide, the percent of employees enrolled in a HDHP increased in 2020, rising from 50.5 to 52.9 percent. Moreover, the majority of private-sector employees were enrolled in a HDHP across 36 states in 2020. North Carolina had the highest percentage of HDHP-enrolled employees at 69.5 percent, and Hawaii was at the other end of the spectrum with only 17.6 percent of employees enrolled in HDHPs.
Access to coverage varies by state
Employee access to ESI has three components:
Employee Offer: An employee must work in an establishment that offers coverage.
Employee Eligibility: An employee must meet the criteria established by the employer to be eligible for coverage that is offered.
Employee Take-Up: The employee must decide to enroll in (“take up”) the offer of ESI coverage.
The decision to offer ESI to employees is determined by the employer, with 51.1 percent of private sector firms choosing to offer coverage in 2020 (compared to 47.4 percent in 2019). However, although over half of employers provided optional ESI, not all of their employees were eligible to enroll in that coverage. Meaning, while 86.9 percent of employees worked for an employer offering ESI coverage in 2020, only 80.5 percent were eligible for that coverage; eligibility could be based on a minimum number of hours worked per pay period or a minimum length of service with an employer, for example. Among employees eligible for ESI, overall enrollment declined in 2020, dropping from 71.9 percent to 70.8 percent—a difference of 1.745 million employees.
ESI access also varied across states in 2020. In Hawaii, Tennessee, Massachusetts, Illinois, Pennsylvania, New Jersey, and the District of Columbia (D.C.), more than 90 percent of employees worked at a firm that offered ESI. Meanwhile, less than 75 percent of Montana and Wyoming employees worked for an employer that offered ESI (73.8 percent and 70.6 percent, respectively).
It’s important to note that trends in access are particularly difficult to interpret due to the sharp decline in employees who work in firms with <50 employees, as small firms are much less likely to offer coverage.
To revisit 2019 ESI findings from SHADAC, see the following products:
- Printable version of 2019 ESI Report Narrative
- Companion Blog and Infographic highlighting key findings at the national level regarding ESI coverage affordability and access
- Two-Page Profiles on ESI trends for each state
- 50-State Interactive Map showing levels of, and changes in, average annual premiums for single and family coverage in 2019, with links to state profile pages
- 50-State Comparison Tables including 2015-2019 ESI data
Notes and Sources
Hawaii has a broad employer mandate that preceded the ACA. The Hawaii Prepaid Health Care Act, enacted in 1974, requires private employers to provide health insurance for employees who work at least 20 hours (some exceptions apply).
High-deductible health plans (HDHP) are defined as plans that meet the minimum deductible amount required for Health Savings Account (HSA) eligibility (e.g., $1,400 for an individual and $2,800 for a family in 2020).
The labor market changed significantly between 2019 and 2020 with a dramatic reduction in small firm employment. It is difficult to determine whether 2020 changes in ESI were driven by this change in the labor force or reflect actual changes in ESI access and cost.
Data are from the 2019–2020 Medical Expenditure Panel Survey–Insurance Component (MEPS-IC), produced by the Agency for Healthcare Research and Quality (AHRQ), and are available on SHADAC’s State Health Compare web tool at statehealthcompare.shadac.org.
1 State Health Access Data Assistance Center. (n.d.). Health Insurance Coverage Type (2020)* http://statehealthcompare.shadac.org/bar/279/health-insurance-coverage-type-2020-by-total#0/1/5,4,1,10,86,9,8,6/32/325
Blog & News
Updates to Minnesota's Community and Uninsured Profile Resource to Reflect 2016-2020 ACS EstimatesJune 2, 2022:
Following the release of the 2020 U.S. Census Bureau’s American Community Survey 5-year data file (2016-2020), SHADAC has made important updates to the Minnesota Community and Uninsured Profile resource to incorporate an analysis of the 2020 data.
The Community and Uninsured Profile can be used in two ways: (1) to support other equity-focused work, advocacy work, strategic planning, community needs assessments, and grant-writing, and (2) to target health insurance coverage outreach and enrollment efforts.
The Community and Uninsured Profile provides rates and counts of Minnesotans at a range of geographic levels. Users can explore characteristics of the total population and the uninsured population in a specific ZIP code while also overlaying in-depth community characteristics. In addition, users can look at rates and characteristics of the community and uninsured within the state as a whole, by region, county, and state legislative district. Users can also filter by MNsure rating areas -- the geographic regions health insurers use to set premiums on MNsure.
This resource was originally developed as part of “Minnesota’s Uninsured and the Communities in Which They Live,” a project funded by the Blue Cross Blue Shield Foundation of Minnesota that supports targeted outreach and enrollment activities of health insurance navigators and provides information about the uninsured to Minnesota policymakers as they develop strategies to reach the remaining uninsured in Minnesota.
To download the Profile, access additional information, or request the development of a similar tool for another state, visit the Minnesota Community and Uninsured Profile Resource page.
Blog & News
State and Federal Relief Prevented Deep Backslide in Health Care Affordability in California in 2020 (CHCF Cross Post)May 18, 2022:
The following content is cross-posted from California Health Care Foundation. It was first published on May 18, 2022.
Author: Colin Planalp, Research Fellow, SHADAC
In 2020, the start of the COVID-19 pandemic meant the imposition of incredible burdens on every corner of US society, particularly the health care system and the people it serves. There were well-founded fears that the pandemic, and the concurrent economic crisis, could make health insurance and health care unaffordable for even more people — already a long-standing problem in California.
In response to the pandemic, the US government enacted historic relief programs, including multiple instances of direct cash payments to a majority of US families. Those federal policies coincided with California health insurance reforms that, while developed before the pandemic, were implemented in 2020.
This analysis of the California Health Insurance Survey (CHIS) shows that Californians were largely protected from experiencing a major erosion in their ability to pay for health insurance and care. Despite this overall positive finding, the 2020 CHIS data on health care affordability continued to demonstrate clear inequities by income and race/ethnicity.
California’s uninsured rate declines, yet cost remains top reason for lacking health insurance. The rate of Californians under 65 without health insurance reached a historic low of 7.0% in 2020. However, 51.9% of uninsured people said they lacked coverage because it was too expensive.
Rate of going without needed care due to cost dropped in 2020. Among the 8.6% of Californians who reported forgoing needed medical care in 2020, 32.0% said it was concerns about the cost that caused them to go without care. That rate was significantly lower than the rate of 43.6% in 2019.
Fewer Californians reported difficulty paying medical bills. From 2019 to 2020, the rate of Californians reporting that they’ve had trouble paying medical bills in the past year declined significantly, from 13.3% to 11.1%. However, when breaking out the data by income, only those with higher incomes saw statistically significant improvement. Californians with lower incomes — 200% to 299% of federal poverty guidelines (FPG), 100% to 199% FPG, and below 100% FPG — reported no significant changes.
Less trouble affording necessities due to medical bills in 2020. In 2020, the rate of Californians who reported having trouble paying for basic necessities (such as food or clothing) because of medical bills declined significantly to 31.0% from 39.8% in 2019. Rates of trouble paying for necessities due to medical bills also declined across most income levels.
Practice of using credit card debt to finance medical bills declined. In 2020, the rate of Californians who reported taking on credit card debt to finance medical bills declined significantly, from 56.5% in 2019 to 44.3%. That finding held consistent for Californians across income levels — except for those with the lowest incomes.
Racial and ethnic disparities persisted in 2020. Although California experienced significant improvements in some measures of health care and insurance affordability in 2020, certain long-standing inequities persisted. For example, Black people reported the highest rate of trouble paying medical bills in 2020, at 14.0%, followed closely by Latinos/x, at 12.7%. Asians, Black people, and Latinos/x also reported similarly high rates of trouble paying for necessities due to medical bills (39.4%, 36.2%, and 33.1%, respectively).
Together, these findings provide some encouraging news. In a year of massive economic upheaval that would typically have caused serious financial problems for many Californians, they instead reported improvements in health care and insurance affordability. However, improvements were likely due, at least in part, to federal programs that were mostly designed to be temporary. Some have already expired. Additionally, the historically high inflation of 2021 and 2022 have since strained people’s finances.
But the fact that California experienced such measurable improvements in health insurance and health care affordability during a broad and deep recession shows that those problems don’t have to be intractable. In the future, it will be key to monitor these measures as policymakers in California and at the federal level consider initiatives to protect people against unaffordable health care and insurance costs, which remain a long-term challenge.
Blog & News
2021 NHIS Full-Year Health Insurance Estimates Early Release: Coverage Rates Remain Stable Overall, Changes Visible across Demographic Groups (Infographic)May 10, 2022:
The National Center for Health Statistics (NCHS) released health insurance coverage estimates for 2021 from the National Health Interview Survey (NHIS) as part of the NHIS Early Release Program. The estimates captured in this report are some of the first available coverage estimates for 2021 from a federal survey.
National-level estimates are available by breakdowns including age, sex, poverty status, race and ethnicity, and by state Medicaid expansion status. The NHIS full-year estimates for 2021 do not include either full or partial state-level data, as has been the case since the survey was redesigned in 2019. However, NCHS periodically releases state-level estimates of coverage, which SHADAC has previously covered on our blog and will continue to monitor and report on any future releases.
Changes between the 2020 and 2021 coverage estimates were minimal when examining rates of private coverage and those without health insurance coverage. However, the 2021 report indicates a slight uptick in public coverage which is consistent with trends in survey and administrative data since the start of the coronavirus (COVID-19) pandemic in the United States. The rates across all coverage types experienced several more notable shifts when examined by sex as well as race and ethnicity.
Changes in the NHIS
The COVID-19 pandemic significantly impacted 2020 NHIS field procedures (including interview format), response rates, and resulting data analytic files, though NCHS found minimal nonresponse bias in the 2020 NHIS. A recent SHADAC issue brief reported on these and other changes to federal surveys that were similarly impacted by the pandemic.
It is also worth noting that 2021 NHIS coverage estimates are based on information collected from 29,696 sample adults and 8,293 sample children. In 2019, the NHIS underwent a substantial redesign of its content and structure and one of the largest changes, the elimination of the family questionnaire, has resulted in a substantial reduction of the available sample size for the survey (though the NCHS also estimates a positive effect on higher response rates). It is likely that a survey with a larger sample size would find more significant year-over-year changes in coverage rates.
Notes on Race and Ethnicity Estimates from NHIS
The NHIS Early Release report from which the figures for the race/ethnicity category are drawn does not further disaggregate statistics by more detailed race and ethnicity categories. Individuals not identifying as Hispanic; non-Hispanic White, Black, or Asian; or identifying with multiple, non-Hispanic race categories are classified as “multiple races or any other race.”
Additionally, there are many factors that historically widen disparities in coverage across race and ethnicity; race-based discrimination in employment and systemic racism are two possible contributors.
Cohen, R.A., Cha, A.E., Terlizzi, E.P., & Martinez, M.E. (2022, May 5). Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2021. National Center for Health Statistics (NCHS). https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202205.pdf
Blog & News
Minnesota’s uninsured rate hit historic low in 2021 but racial disparities increased (Minnesota Department of Health Cross Post)July 14, 2022:
Today, the Health Economics Program (HEP) of the Minnesota Department of Health (MDH) and the University of Minnesota School of Public Health, State Health Access Data Assistance Center (SHADAC) released results from the 2021 Minnesota Health Access Survey (MNHA) - a biennial state-based population survey that collects information on how many people in Minnesota have health insurance and how easy it is for them to get health care. The survey is conducted as a partnership between MDH and SHADAC.
Key findings from the survey showed mixed results, with the statewide uninsured rate dropping to its lowest-ever rate (4.0%) and periodic uninsurance dropping significantly (2.9% from 4.8%). However, the survey also found that disparities in coverage increased when examined by race and ethnicity, with uninsured rates among American Indians and people of color rising to 10.2%.
The following content from the full press release is cross-posted from the Minnesota Department of Health published on April 21, 2022.
Authors: Alisha Simon, MDH; Stefan Gildemeister, MDH; Kathleen Call, SHADAC
The Minnesota Department of Health (MDH) released new data showing mixed news regarding health insurance coverage in Minnesota during 2021. While actions taken by state officials helped drop the state’s uninsured rate to the lowest level ever measured, racial disparities in coverage worsened.
Federal and state policies and funding during 2021 shielded Minnesota’s health insurance coverage against the pandemic’s economic shock. With the help of these efforts, the state’s uninsured rate fell to 4.0%, the lowest-ever measured level, essentially tying the 2015 rate.
Economic downturns often result in higher rates of uninsurance in the U.S. due to the link between employment and health insurance coverage. With the help of state and federal funding, Minnesota took steps to prevent insurance loss in 2020 and 2021, including government efforts to maintain coverage for low-income Minnesotans and premium subsidies in the individual market. Data from the Minnesota Health Access Survey found that 34,000 fewer Minnesotans went without health insurance in 2021 compared to 2019. Fewer Minnesotans also said they went without some type of needed health care due to cost in 2021 (20%) compared to 2019 (25%).
However, not all Minnesotans were equally able to access or retain coverage. Racial disparities worsened as the uninsured rate among Minnesotans of color and American Indians rose from 7.6% in 2019 to 10.2% in 2021. In contrast, the uninsured rate dropped among non-Hispanic Whites from 3.7% in 2019 to 2.4% in 2021.
“The investments we made before and during the pandemic to ensure Minnesotans had access to affordable health coverage helped more people stay insured, even in the midst of job losses and economic instability,” said Minnesota Commissioner of Health Jan Malcolm. “Sadly, we saw that people of color and American Indians did not benefit as much from these efforts. We must learn about what worked and what didn’t so we can adapt our approach to reach the goal of ongoing and equitable access to affordable health care for all Minnesotans.”
The number of Minnesotans with public insurance increased by 238,000 so that 41.2% of those insured had coverage through public sources in 2021, including Medicare, Medical Assistance and MinnesotaCare. This growth in public coverage made up for a decrease in private coverage – down from 57.8% in 2019 to 54.8% in 2021.
While most Minnesotans weathered the first two years of the pandemic with health insurance, there are concerns about maintaining coverage moving forward. Many government programs that added financial supports to families, increased subsidies for private health insurance plans sold through MNsure to make insurance more affordable or allowed people to stay on Medicaid longer ended or are set to expire this year.
“Historically, Minnesota has enjoyed a strong labor market and a strong employer-sponsored insurance market,” said Kathleen Call, a professor with the University of Minnesota School of Public Health and an investigator at the State Health Access Data Assistance Center. “However, alongside the crisis of the pandemic, the long-term erosion of private coverage over the past two decades, combined with the fact that not all employees are offered insurance and not all Minnesotans can afford it, reminds us that continued commitments are needed to support and promote Medical Assistance, MinnesotaCare and premium subsidies in the individual market available through MNsure.”
The survey suggests that COVID-19 had an impact in delaying care in 2021 but didn't keep most people from getting that care eventually. In the second year of the pandemic, COVID-19 concerns affected only 8% of people not receiving health care. The primary reasons for not using health care were cost or not needing it.
Both physical and mental health declined during the pandemic, according to the survey. The number of unhealthy days reported for a 30-day period climbed to an average 3.3 days for physical health and 4.3 days for mental health, compared to 2.8 for physical health and 3.7 for mental health in 2019.
“The reports of Minnesotans having fewer healthy days in 2021 are concerning, particularly in light of the continued strain on the state’s health care workforce and our structural weaknesses in mental health care,” said Stefan Gildemeister, MDH state health economist. “We will continue to monitor how effective our investments in community connections and resources during the pandemic are in reversing lingering harms to physical and mental health as the state moves into the next stage of the pandemic and as the economy recovers.”
The Minnesota Health Access Survey is a biennial state-based population survey that collects information on how many people in Minnesota have health insurance and how easy it is for them to get health care. The survey is conducted as a partnership between MDH and the University of Minnesota School of Public Health, State Health Access Data Assistance Center. The survey had responses from more the 18,000 Minnesotans across the state and was conducted between October 2021 and January 2022. More findings from the survey are available on the MDH Health Economics Program website.
MDH Uninsurance Chartbook MNHA 2021 Survey Infographic MNHA Survey Tool