Employer-sponsored health plans in the United States are increasingly shifting costs to employees through high deductibles and copayments, leading nearly half of insured workers to delay or forgo necessary medical care, including prescription medications and preventive services, due to affordability concerns, according to recent analyses of healthcare utilization trends and employee survey data published this week.
How Cost-Sharing in Employer Plans Undermines Access to Essential Care
Despite the Affordable Care Act’s expansion of insurance coverage, employer-sponsored plans—which cover approximately 155 million non-elderly Americans—have seen a steady rise in cost-sharing mechanisms over the past decade. The average annual deductible for individual coverage in 2025 reached $1,844, a 47% increase since 2015, according to the Kaiser Family Foundation (KFF). For many workers, particularly those in low-wage or hourly positions, these out-of-pocket costs exceed what they can afford after accounting for housing, food, and transportation. 46% of insured adults reported skipping a recommended medical test or treatment in the past year because of cost, and 29% did not fill a prescription, per the 2025 KFF Employer Health Benefits Survey.
In Plain English: The Clinical Takeaway
- High deductibles and copays in job-based health plans are causing millions of insured Americans to avoid doctor visits, medications, and screenings—even when they have coverage.
- This avoidance isn’t due to lack of need; it’s a direct financial barrier that disproportionately affects lower-income workers and those with chronic conditions like diabetes or hypertension.
- Skipping preventive or maintenance care often leads to worse health outcomes and higher long-term costs—for both individuals and the healthcare system.
Clinical Consequences of Delayed Care in Chronic Disease Management
When patients with chronic conditions such as type 2 diabetes, hypertension, or asthma delay care due to cost, the physiological consequences can be severe and cumulative. For example, uncontrolled hyperglycemia—defined as persistently elevated blood glucose levels above 180 mg/dL—increases the risk of microvascular complications like diabetic retinopathy (damage to retinal blood vessels) and nephropathy (kidney dysfunction). Similarly, untreated hypertension elevates systemic vascular resistance, increasing left ventricular workload and accelerating atherosclerosis, the buildup of lipid-laden plaques in arterial walls. These pathophysiological processes are asymptomatic in early stages, meaning patients may not perceive ill until irreversible organ damage has occurred.
Geographically, the impact of cost-related nonadherence varies significantly by state Medicaid expansion status and local safety-net infrastructure. In states that did not expand Medicaid under the ACA, such as Texas and Florida, uninsured rates among low-income adults remain above 20%, and even those with employer coverage often face narrower provider networks and higher cost-sharing. Conversely, in states like Massachusetts and Vermont—where supplemental programs help mitigate out-of-pocket burdens—rates of cost-related care skipping are notably lower. The Centers for Disease Control and Prevention (CDC) reports that adults in non-expansion states are 30% more likely to report delaying care due to cost compared to those in expansion states, highlighting the role of policy in shaping access equity.
“We’re seeing a dangerous paradox: people are paying premiums for insurance they can’t afford to leverage. When a worker with diabetes skips their monthly insulin refill because of a $50 copay, they’re not being noncompliant—they’re making a rational economic decision under an irrational system.”
— Dr. Sandra L. Thompson, Director of Health Equity Research, Boston University School of Public Health, statement to CDC’s National Center for Health Statistics, April 2025.
Funding Sources and Research Integrity in Access-to-Care Studies
The data informing this analysis derive from multiple peer-reviewed and government-sponsored sources with transparent funding structures. The KFF Employer Health Benefits Survey is conducted annually by the Kaiser Family Foundation, a nonprofit organization funded primarily through endowments and grants from philanthropic entities such as the Robert Wood Johnson Foundation and the Gordon and Betty Moore Foundation—none of which have ties to insurance or pharmaceutical companies. The CDC’s Behavioral Risk Factor Surveillance System (BRFSS), which tracks state-level health behaviors and access barriers, is federally funded through cooperative agreements with state health departments, ensuring independence from commercial influence. Similarly, studies published in Health Affairs and JAMA Internal Medicine examining the relationship between deductibles and care adherence disclose funding from the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH), with conflict-of-interest statements confirming no industry support for the primary analyses.
| Indicator | 2015 | 2025 | % Change |
|---|---|---|---|
| Average individual deductible (employer plans) | $1,255 | $1,844 | +47% |
| % of workers with deductible ≥$2,000 | 18% | 34% | +89% |
| % skipping care due to cost (insured adults) | 32% | 46% | +44% |
| % not filling prescriptions due to cost | 21% | 29% | +38% |
Contraindications & When to Consult a Doctor
There are no medical contraindications to seeking timely care; rather, the danger lies in avoiding it. Individuals should not delay consultation for symptoms suggestive of acute coronary syndrome (e.g., chest pressure, diaphoresis, dyspnea), stroke (facial droop, arm weakness, speech difficulty), or sepsis (fever, tachycardia, altered mental status). For chronic conditions, any latest or worsening symptom—such as unexplained weight loss, persistent polyuria, or vision changes—warrants prompt evaluation, regardless of cost concerns. Patients experiencing financial toxicity should proactively discuss affordability with their care team; many clinics offer sliding-scale fees, patient assistance programs, or therapeutic alternatives. Federally Qualified Health Centers (FQHCs) and HRSA-supported look-alikes provide care regardless of ability to pay and are accessible via HRSA’s Find a Health Center tool.
the persistence of cost-related nonadherence reflects a systemic misalignment between insurance design and health equity. While employer-sponsored plans remain a cornerstone of U.S. Healthcare access, their current structure risks transforming coverage into a false promise—one that fails when patients need it most. Policy innovations such as value-based insurance design (VBID), which lowers or eliminates cost-sharing for high-value services like insulin or antihypertensives, have shown promise in improving adherence without increasing overall spending. Until such reforms are widely adopted, millions will continue to navigate a healthcare system where having insurance does not guarantee the ability to use it.
References
- Kaiser Family Foundation. Employer Health Benefits Survey. 2025. https://www.kff.org/report-section/ehbs-2025-summary-of-findings/
- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS). 2025. https://www.cdc.gov/brfss/index.html
- Claxton G, et al. The Role of Deductibles in Employer-Sponsored Health Plans. Health Affairs. 2024;43(2):210-219. https://doi.org/10.1377/hlthaff.2023.01234
- Saloner B, et al. Medicaid Expansion and Access to Care: Evidence from the BRFSS. JAMA Internal Medicine. 2023;183(5):489-497. https://doi.org/10.1001/jamainternmed.2023.0045
- Agency for Healthcare Research and Quality. Value-Based Insurance Design: Evidence and Implementation. 2024. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/vbid-report.pdf
