Research Report Employer-Sponsored Insurance Access, Affordability, and Enrollment in 2018
State and National Estimates and Implications for Low-Income Working Families
Emily M. Johnston, Genevieve M. Kenney, Dulce Gonzalez, Erik Wengle
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This brief examines access to, affordability of, and reliance on ESI using data from the 2008–18 Medical Expenditure Panel Survey-Insurance Component (MEPS-IC). We provide estimates for full- and part-time employees, those working in small and large firms, and those in establishments with majority and fewer low-wage employees in 2018—both nationally and by state. Understanding ESI for workers in small firms, those in majority low-wage establishments, and those working part time is particularly important, as workers in families with low incomes are more likely to be in these three work situations and to be uninsured than other workers. We further assess how ESI access, affordability, and enrollment have changed nationally since 2008.

We find that certain groups of workers were not eligible for ESI from their own employer in 2018, and among those eligible ESI may not have been an affordable coverage option. Part-time employees and those working in small firms or majority low-wage establishments were much less likely to be eligible for ESI compared with full-time employees and those in larger firms and establishments with fewer low-wage employees. When considered as a share of income for families with low incomes, average required employee premium contributions, deductible amounts, and out-of-pocket maximums often constituted a large share of household resources and were well above the levels associated with 2018 federally subsidized marketplace coverage. These patterns hold up in almost every state and highlight systematic and widespread gaps in access to affordable ESI that may be especially pronounced for workers in families with low incomes. Low ESI enrollment rates, particularly for part-time employees and those in small firms or establishments with majority low-wage employees, reflect these gaps.

Without access to affordable ESI, workers and their families are at risk of uninsurance, financial hardship, unmet health care needs, and poor health outcomes. As policymakers look to address the pressing needs of Americans losing their jobs because of the public health and economic crisis related to COVID-19, it will also be important to keep in mind that many groups of workers did not have access to affordable ESI coverage before the COVID-19 pandemic and economic crisis. Therefore, policymakers will also want to make sure that workers in families with low incomes who are able to maintain their employment have access to affordable health insurance coverage and health care. Many workers in families with low incomes will likely require Medicaid or subsidized marketplace coverage, rather than ESI, to have affordable health insurance coverage. Meeting the health needs these workers, in addition to the newly unemployed, will be critical to discussions about how to structure Medicaid and marketplace coverage in the post-COVID-19 era.

Executive Summary

State-by-State Appendices

Research Areas Health and health care
Tags Private insurance From Safety Net to Solid Ground
Policy Centers Health Policy Center