The share of workers enrolled in HDHPs—29 percent—returned to a historic high in 2018 after dipping slightly in 2017.


Oct. 8—In 2018, the share of workers enrolled in high-deductible health plans (HDHPs) resumed increasing, and deductibles among all workers increased by an average of 11 percent from the year before, according to a national survey.

When authors of the benchmark Kaiser Family Foundation (KFF) Employer Health Benefits Survey examined deductibles in employer-sponsored insurance (ESI) plans and included those without a general annual deductible, the average deductible among all covered workers rose to $1,350 in 2018. That was a 53 percent increase from five years earlier.

Eighty-five percent of people with ESI coverage had a general annual deductible—an increase from 81 percent in 2017.

Among only those who had deductibles, the average deductible was $1,573 for single coverage and was much bigger at small firms ($2,132) than at large firms ($1,355).

Forty-two percent of covered workers in small firms and 20 percent in large firms were in a plan with a deductible for single coverage of at least $2,000—similar rates to 2017.

“Deductibles of $2,000 or more are increasingly common in employer plans, which means the bills can pile up quickly for workers who require significant medical care,” said Gary Claxton, a KFF vice president and director of the Health Care Marketplace Project.

The size of the average deductible for single coverage ranged widely­—from $870 in health maintenance organizations (HMOs) to $1,204 in preferred-provider organizations (PPOs), $1,598 in point-of-service (POS) plans, and $2,349 in high-deductible health plans (HDHPs) with savings options, such as health savings accounts (HSAs).

Fifty-eight percent of covered workers had a general annual deductible of $1,000 or more for single coverage, compared with 51 percent in 2017.

However, the majority of covered workers with a general annual deductible did not have to meet the deductible before coverage began for certain services, such as physician office visits or prescription drugs. For instance, primary care office visits were covered pre-deductible for 80 percent in HMOs, 75 percent in PPOs, 74 percent in POS plans, and 44 percent in HDHPs or health reimbursement arrangements (HRAs).

ESI covers about 152 million Americans, among which the annual survey of nearly 2,200 small and large employers aims to highlight ongoing trends.

Record Enrollment

The share of workers enrolled in HDHPs—29 percent—returned to a historic high in 2018 after dipping slightly in 2017, according to the survey. The survey defined HDHPs as plans with a deductible of at least $1,000 for single coverage and $2,000 for family coverage offered with an HRA or that meet the federal legal requirements to allow enrollees to use an HSA.

The increase echoed the direction that was described an August survey by the Centers for Disease Control and Prevention, which found enrollment in HDHPs reached 47 percent of the commercially insured, pre-Medicare population in 2018, representing an increase of 3.3 percentage points from 2017.

The KFF survey also found that 29 percent of firms that provided health benefits offered an HDHP with an HRA, an HSA-qualified HDHP, or both, which is the second-highest share since the survey started.

“Higher deductibles have helped to keep premium increases relatively low, but it is unclear how long that trend will continue,” the report authors concluded. “Given the importance of health benefits to workers and prospective workers, employers may find it increasingly difficult to impose higher cost sharing in what is essentially a full employment economy.”

The survey concluded that enrollment growth in HDHPs with a savings option stalled during the past three years, and viewed that trend as a sign that employers were reluctant “to rock the benefit boat for their workers.”

Similarly, the share of large employers planning to offer only HDHPs declined for the first time in seven years, according to the annual large-business survey that the National Business Group on Health released in August. The share of employers expecting to offer only HDHPs for 2019 was 30 percent among the 170 companies surveyed, compared with 39 percent for 2018.

For a smaller share of workers, the shift in enrollment to HDHPs with savings options did not greatly increase their out-of-pocket costs because their employers subsidized those costs, the KFF survey found. For instance, 8 percent of workers in an HDHP with an HRA and 2 percent in an HSA-qualified HDHP received employer contributions at least equal to their deductible. And 37 percent of workers in an HDHP with an HRA and 26 percent in an HSA-qualified HDHP received contributions that would reduce their deductible to less than $1,000.

Typical HDHPs with savings options rarely had cost-sharing requirements for hospital admissions. Copayments for hospital admissions applied to only 2 percent of enrollees in those plans, which was lower than the average across all types of insurance coverage.

Employers can contribute to their workers’ HSA plans, but 40 percent of those offering single-coverage HSA-qualified HDHPs and 39 percent of those offering family coverage for such plans do not make contributions toward HSAs. Among those that do, average annual employer contributions were $603 for single coverage and $1,073 for family coverage.

Other Out-of-Pocket Costs

Whether or not they face a general annual deductible, a large share of covered workers also pays a portion of the cost when they visit an in-network physician.

For primary care, 66 percent of covered workers had a copayment and 24 percent had coinsurance. For specialty care, 64 percent had a copayment and 27 percent had coinsurance. Average copayments were $25 for primary care and $40 for specialty care. Average coinsurance was 18 percent for both primary and specialty care. These amounts were similar in 2017.

Most workers also face additional cost sharing for a hospital admission or outpatient surgery. After meeting any general annual deductible, 68 percent of covered workers had coinsurance and 11 percent had a copayment for hospital admissions. The average coinsurance rate was 19 percent and the average copayment was $284 per hospital admission. The cost-sharing provisions for outpatient surgery followed a similar pattern.

Almost all (99 percent) covered workers’ ESI plans had an out-of-pocket maximum for single coverage, but with considerable variation in the dollar limits. Among covered workers in plans with an out-of-pocket maximum for single coverage, 14 percent had a limit of less than $2,000, while 20 percent had an out-of-pocket maximum of $6,000 or more.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, October 09, 2018