More Americans gain health coverage, but their cost-sharing keeps rising

The U.S. uninsured rate fell to another historic low in 2015, and premiums for employer-based plans barely budged in 2016. But those positive insurance numbers mask the fact that more Americans are becoming “underinsured” and face higher out-of-pocket obligations.

“I think it's the biggest change in healthcare in America that we are not really debating,” Kaiser Family Foundation CEO Drew Altman said.

In addition, premium rates are still rising at a faster annual clip than wages and inflation. Many Republican-led states also have refused to expand Medicaid eligibility under the Affordable Care Act, leaving millions of people uninsured who otherwise could have health coverage.

Two highly regarded studies of health insurance came out last week. Each offered a broader look at the state of coverage in the country that spans well beyond the politically contentious exchanges that have suffered from insurer pullouts and will likely see much-higher premium prices for next year.

New data from the U.S. Census Bureau confirmed just 9.1% of Americans had no health insurance in 2015, the lowest rate ever recorded and a figure that has been pinned to the ACA coverage expansion. Uninsured rates went down across nearly all races, age groups and income levels from 2014 to 2015. Young, working-age adults and Hispanics continue to have the highest uninsured rates. States that haven't expanded Medicaid, such as Texas and Florida, also had higher uninsured rates than those that did expand.

The 18th annual employer health benefits survey from the Kaiser Family Foundation and Health Research & Educational Trust—a snapshot of healthcare provided by about 1,900 companies—showed premiums for single and family coverage each increased by about 3% on average in 2016. More than 150 million Americans get their health coverage through their employers.

The census data indicate the law's reforms and new marketplaces have created a new insurance safety net.

“It's the lowest fraction of people without health insurance as long as we've been gathering data,” said Helen Levy, a health insurance researcher at the University of Michigan. “This is great news and essentially says the Affordable Care Act provisions are continuing to drive down the number of people without insurance.”

But the census and Kaiser Family Foundation reports also highlighted the continued rise of out-of-pocket costs that largely are associated with high-deductible health plans, which require single people and families to shell out more of their own money before insurance coverage kicks in. Moving to those types of plans has been a driver behind the moderate employer premium increases during the past several years.

“We've seen the trend over the last decade of increasing the out-of-pocket burden on insured people,” said Erin Trish, an assistant research professor of health policy at the University of Southern California. “This was going on in the employer-sponsored market even before the ACA came around.”

The average deductible among workers carrying one has doubled since 2008, from $735 to $1,478 this year, according to the Kaiser Family Foundation/HRET report. People who work at companies with 200 or fewer employees had an average deductible of more than $2,000.

Roughly 29% of employees were enrolled in a high-deductible health plan with some kind of tax-advantaged health savings account in 2016, compared with just 4% in 2006, according to the survey. Trish said high-income people often benefit more from HSAs since they have more disposable income to contribute to it. Approximately 40% of all insured Americans are in some kind of high-deductible plan, with or without an HSA.

Middle-class individuals and families have felt the weight of skimpier benefits and higher healthcare costs over time. Workers' earnings increased by 60% from 1999 to 2016, according to the Kaiser Family Foundation/HRET data, but the amount they paid for their premiums soared 242% over the same time period.

The average premium for employer-based family plans was $18,142 in 2016, with employers covering about 71% of that cost. Employer contributions for family coverage went up only 2.2% from 2015 to 2016, while workers had to pay 6.1% more on average.