In the Fund report Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families, Collins and her Fund colleagues documented the growing crisis in out-of-pocket costs for lower-income—and now even middle-income—families. Based on national survey data, nearly nine of 10 people who sought coverage through the individual market in the past three years never actually purchased a health plan.⁽¹³⁾ One-third of those who sought coverage said that it was very difficult or impossible to find a plan that met their needs, and 58 percent reported that it was very difficult or impossible to find one they could afford. One-fifth were turned down or would have been charged higher prices because of preexisting conditions.

Many employers, particularly small businesses, try to alleviate their health costs by sharing more expenses with workers in the form of higher deductibles, copayments, or increases in maximum employee costs. In an article published in Health Affairs, a Fund-supported team led by Jon Gabel found that workers in small firms are more likely than those in larger firms to have deductibles; their deductibles also tend to be higher. Employees in small firms pay an average of 18 percent more in premiums than those in large firms when taking into account actuarial value—the percentage of total medical expenses paid by health plans.⁽¹⁴⁾ Employees in rural states, like Wyoming, also tend to pay more for health insurance—after accounting for the actual medical benefits covered—than do those in states with large urban populations, like California.