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Illustration: Sarah Grillo/Axios

There has been appropriate handwringing since 2010 about the affordability of Affordable Care Act plans in the marketplaces. But new data show that health insurance is decidedly less affordable for lower income people who get coverage at work than for their counterparts with similar incomes in the marketplaces.

Why it matters: It’s another example of how, when we focus so much on the ACA markets, we lose sight of problems in the employer-based health system where far more people get their coverage. For lower-wage workers, their coverage is decidedly worse than ACA coverage is.

The details: A low-income family with a marketplace plan pays 8.4% of their income on premiums and out-of-pocket costs, compared to 14% for a lower-wage family with employer coverage (those with incomes below twice the poverty level).

  • That's based on Current Population Survey data on what people at that income level paid for employer coverage, plus exchange premium data collected from Healthcare.gov and state-based ACA marketplaces.

How it breaks down:

  • For low-income families with marketplace plans, the out-of-pocket costs are 4.7% of their income, while the premiums are just 3.7% of their income.
  • For those with coverage through work, the out-of-pocket costs are 5% of their income, roughly the same as the families with marketplace plans.
  • The big difference is in the premiums — because the low-income families with workplace coverage pay about 9% of their income to cover those payments.

The largest share of group insurance premiums, paid by employers, also depresses wages for lower-wage and other workers.

Between the lines: It’s not really surprising that marketplace enrollees do better. The ACA provides financial protections for lower-income people enrolled in subsidized health plans in the marketplaces or in Medicaid, and there are no similar income-based subsidies that apply to employer plans.

  • In fact, as employers shift more costs to employees, low and moderate-income families face several thousand dollars in premium contributions and cost sharing.  
  • For firms that employ disproportionately low-wage workers, it can simply be too expensive for employers to provide good coverage. Premiums averaged $6,896 for a single policy and $19,616 for a family plan in 2018.  

We tend to think of everyone with employer coverage as one big group, but it’s really lower wage workers — and, while it’s a different subject, also people with major illnesses — who take it on the chin in the current private health insurance system. They are also the group with employer coverage who would benefit the most from a Medicare-for-All style plan.

The bottom line: Employer-based coverage is by far the largest source of health insurance, and it now provides the least financial protection for lower income workers who need it most. We debate affordability in the ACA marketplaces a lot, but we don’t talk about this far larger problem much, if at all.

Go deeper

Biden speaks with Macron for first time since diplomatic crisis

President Biden and French President Emmanuel Macron have a conversation ahead of the NATO summit in Brussels, on June 14, 2021. Photo: Dursun Aydemir/Anadolu Agency via Getty Images

President Biden on Wednesday spoke with French President Emmanuel Macron for the first time since a diplomatic row erupted over a scrapped submarine order, per the White House.

Driving the news: Macron said that the French ambassador will return to Washington next week and will resume working with senior U.S. officials.

54 mins ago - World

Scoop: U.S. and Israel held secret talks on Iran "plan B"

Bennett and Biden. Photo: Sarahbeth Maney/Pool/Getty Images

The U.S. and Israel held secret talks on Iran last week to discuss a possible “plan B” if nuclear talks are not resumed, two senior Israeli officials tell me.

Why it matters: This is the first time a top-secret U.S.-Israel strategic working group on Iran has convened since the new Israeli government took office in June.

1 hour ago - World

Scoop: Jake Sullivan plans to visit Saudi Arabia, Egypt and UAE next week

Sullivan. Photo: Yasin Ozturk/Anadolu Agency via Getty Images

White House National Security adviser Jake Sullivan is planning to travel to the Middle East next week, including a stop in Saudi Arabia. He would be the most senior Biden administration official to visit the kingdom.

Why it matters: Sullivan's first trip to the region since taking office is expected to include stops in Saudi Arabia, the United Arab Emirates and Egypt, sources briefed on the plans tell Axios. All three countries are longtime U.S. partners who have faced some early tensions with Biden.

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