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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

Why 401(k) rollovers are so annoying

Illustration: Aïda Amer/Axios

If you happened to change jobs recently, you may have tried to transfer your retirement account from your former employer into an Individual Retirement Account or your new employer's 401(k) plan. If so, you probably encountered a bureaucratic gantlet — and you're not alone.

Why it matters: Kludgey processes around retirement account transfers result in people losing track of their funds, giving up important tax advantages, or otherwise disadvantaging themselves and being less prepared for retirement.

The hard math behind America's labor shortage

Data: Bureau of Labor Statistics, Congressional Budget Office; Chart: Axios Visuals

Yes, the pandemic has created unusual temporary labor market dynamics. But in the bigger picture, the 2010s were a golden age for companies seeking cheap labor. The 2020s are not.

The big picture: In the 2010s, the massive millennial generation was entering the workforce, the massive baby bo0m generation was still hard at work, and there was a multi-year hangover from the deep recession caused by the global financial crisis.

Advocates fret Roe v. Wade's 49th anniversary could be its last

Photo: Leigh Vogel/Getty Images for Women's March Inc

As Saturday marks the 49th anniversary of Roe v. Wade, the Supreme Court's landmark decision that legalized abortion access in the U.S., advocates warn the ruling is "more at risk now than ever."

The big picture: The Supreme Court in December heard a challenge to a Mississippi 15-week abortion ban that could throw Roe's survival into question, or at least narrow its scope.

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