Bill Thompson’s wife had never seen him smile with confidence. For the first 20 years of their relationship, an infection in his mouth robbed him of teeth, one by one.

“I didn’t have any teeth to smile with,” the 53-year-old of Independence, Missouri, said.

Thompson said he dealt with throbbing toothaches and painful swelling in his face from abscesses for years working as a cook at Burger King. He desperately needed to see a dentist but said he couldn’t afford to take time off without pay. Missouri is one of many states that do not require employers to provide paid sick leave.

So, Thompson would swallow Tylenol and push through the pain as he worked over the hot grill.

“Either we go to work, have a paycheck,” Thompson said. “Or we take care of ourselves. We can’t take care of ourselves because, well, this vicious circle that we’re stuck in.”

In a nation that was sharply divided about government health mandates during the COVID-19 pandemic, the public has been warming to the idea of government rules providing for paid sick leave.

Before the pandemic, 10 states and the District of Columbia had laws requiring employers to provide paid sick leave. Since then, Colorado, New York, New Mexico, Illinois, and Minnesota have passed laws offering some kind of paid time off for illness. Oregon and California expanded previous paid leave laws. In Missouri, Alaska, and Nebraska, advocates are pushing to put the issue on the ballot this fall.

The U.S. is one of nine countries that do not guarantee paid sick leave, according to data compiled by the World Policy Analysis Center.

In response to the pandemic, Congress passed the Emergency Paid Sick Leave and Emergency Family and Medical Leave Expansion acts. These temporary measures allowed employees to take up to two weeks of paid sick leave for covid-related illness and caregiving. But the provisions expired in 2021.

“When the pandemic hit, we finally saw some real political will to solve the problem of not having federal paid sick leave,” said economist Hilary Wething.

Wething co-authored a recent Economic Policy Institute report on the state of sick leave in the United States. It found that more than half, 61%, of the lowest-paid workers can’t get time off for an illness.

“I was really surprised by how quickly losing pay — because you’re sick — can translate into immediate and devastating cuts to a family’s household budget,” she said.

Wething noted that the lost wages of even a day or two can be equivalent to a month’s worth of gasoline a worker would need to get to their job, or the choice between paying an electric bill or buying food. Wething said showing up to work sick poses a risk to co-workers and customers alike. Low-paying jobs that often lack paid sick leave — like cashiers, nail technicians, home health aides, and fast-food workers — involve lots of face-to-face interactions.

“So paid sick leave is about both protecting the public health of a community and providing the workers the economic security that they desperately need when they need to take time away from work,” she said.

The National Federation of Independent Business has opposed mandatory sick leave rules at the state level, arguing that workplaces should have the flexibility to work something out with their employees when they get sick. The group said the cost of paying workers for time off, extra paperwork, and lost productivity burdens small employers.

According to a report by the National Bureau of Economic Research, once these mandates go into effect, employees take, on average, two more sick days a year than before a law took effect.

Illinois’ paid time off rules went into effect this year. Lauren Pattan is co-owner of the Old Bakery Beer Co. there. Before this year, the craft brewery did not offer paid time off for its hourly employees. Pattan said she supports Illinois’ new law but she has to figure out how to pay for it.

“We really try to be respectful of our employees and be a good place to work, and at the same time we get worried about not being able to afford things,” she said.

That could mean customers have to pay more to cover the cost, Pattan said.

As for Bill Thompson, he wrote an op-ed for the Kansas City Star newspaper about his dental struggles.

“Despite working nearly 40 hours a week, many of my co-workers are homeless,” he wrote. “Without health care, none of us can afford a doctor or a dentist.”

That op-ed generated attention locally and, in 2018, a dentist in his community donated his time and labor to remove Thompson’s remaining teeth and replace them with dentures. This allowed his mouth to recover from the infections he’d been dealing with for years. Today, Thompson has a new smile and a job — with paid sick leave — working in food service at a hotel.

In his free time, he’s been collecting signatures to put an initiative on the November ballot that would guarantee at least five days of earned paid sick leave a year for Missouri workers. Organizers behind the petition said they have enough signatures to take it before the voters.

By Zach Dyer: zdyer@kff.org

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Amid rising inflation, annual family premiums for employer-sponsored health insurance climbed 7% on average this year to reach $23,968, a sharp departure from virtually no growth in premiums last year, the 2023 benchmark KFF Employer Health Benefits Survey finds.

On average, workers this year contribute $6,575 annually toward the cost of family premium, up nearly $500 from 2022, with employers paying the rest. Future increases may be on the horizon, as nearly a quarter (23%) of employers say they will increase workers’ contributions in the next two years.

Workers at firms with fewer than 200 workers on average contribute nearly $2,500 more toward family premiums than those at larger firms ($8,334 vs. $5,889). In fact, a quarter of covered workers at small firms pay at least $12,000 annually in premiums for family coverage.

This year’s 7% increase in average premiums is similar to the year-over-year rise in workers’ wages (5.2%) and inflation (5.8%). Over the past five years, premiums rose 22%, in line with wages (27%) and inflation (21%).

Among workers who face an annual deductible for single coverage, the average this year stands at $1,735, similar to last year. The average deductible amount has increased 10% over the last five years and 53% over the last ten years.  Workers at small firms (under 200 workers) on average face much larger deductibles than workers at larger firms ($2,434 vs. $1,478).

The modest rise in deductibles may reflect employers’ perceptions about the burden of cost-sharing on workers.  More than half (58%) of employers say that their workers have at least a moderate level of concern about the affordability of their plan’s cost-sharing requirements.  

“Rising employer health care premiums have resumed their nasty ways, a reminder that while the nation has made great progress expanding coverage, people continue to struggle with medical bills, and overall the nation has no strategy on health costs,” KFF President and CEO Drew Altman said.

Almost 153 million Americans rely on employer-sponsored coverage, and the 25th annual survey of more than 2,100 small and large employers provides a detailed picture of the trends affecting it. In addition to the full report and summary of findings released today, the journal Health Affairs is publishing an article with select findings online. The article will also appear in its November issue.

Some Large Firms Do Not Cover Legal Abortions; Others Do But with Restrictions

In the wake of the Supreme Court’s June 2022 decision that ended the federal constitutional right to abortion, states have adopted a range of new laws to prohibit or severely restrict access to abortion, creating challenges for large employers with workers in multiple states.

Among all large firms (with at least 200 workers), one in ten (10%) say that their largest plan does not cover legal abortions under any circumstances. An additional 18% say they only cover legal abortions under limited circumstances, such as in cases involving rape, incest, or health or life endangerment.

In contrast, nearly a third (32%) of large firms say they cover legal abortions in most or all circumstances. Another four in ten (40%) say they were unsure of their plan’s abortion coverage, potentially because their policies were in flux or they were unaware of the details.

With abortion banned or severely limited in some states, 7% of large employers say that they provide, or plan to provide, financial assistance for travel expenses for enrollees who have to go out of state to obtain a legal abortion. Very large employers (with at least 5,000 workers) are most likely to provide, or plan to provide, such travel reimbursements (19%).

Concerns Persist About Adequacy of Mental Health and Substance Use Networks

Among large employers (with at least 200 workers) that offer health benefits to at least some workers, the vast majority (88%) say their plan has enough primary care doctors to provide timely access for enrollees. Substantially fewer say the same about their mental health (59%) and substance use condition (58%) networks.

Nearly one in five (18%) of large offering firms say that they took steps in the past year to increase the number of mental health providers in their largest plan’s network. This includes 44% of the largest employers (with at least 5,000 workers).

On the other hand, one in five (21%) of large offering employers say their plan has limits on the number of covered mental health services, potentially restricting access for enrollees with long-term needs.

“For several years now, the survey has shown that many large employers do not believe that their networks have enough mental health providers to provide timely access to care. In 2023, many large employers, including nearly half of the largest employers, say that they are taking steps to better meet enrollees’ needs,” said Gary Claxton, a KFF senior vice president and director of the Health Care Marketplace Project, the lead author of the study and also of the Health Affairs article.

Other findings include: 

• Offer rate. Nearly all employers with at least 200 workers offer health benefits to at least some workers, though smaller firms are increasingly less likely to offer health benefits as they get smaller. For example, 83% of firms with 10 to 199 employees offer health benefits to at least some of their workers, while just 42% of firms with three to nine workers do so.
• Dental, vision and long-term care insurance. Among firms offering health benefits, most also offer separate dental coverage (91%) – double the share that did so in 2010 (46%). Most also offer vision (82%) insurance, also up sharply since 2010 (17%). Fewer offer long-term care insurance (26%).
• Coverage for gender-affirming surgery. Among employers with at least 200 workers, 23% cover gender-affirming survey in their largest health plan. More than a third (37%) say they do not cover such surgeries, while a large share (40%) are not sure about such coverage. Among the largest firms (at least 5,000 workers), nearly two thirds (62%) cover gender-affirming surgery, many of which expanded the benefit in the past two years.
• Centers of Excellence. About one in five (19%) offering employers with at least 200 workers say their plan includes a “center of excellence” program for specific services, either limiting enrollees to a narrower group or providers or offering lower cost-sharing for doing so. Among these firms, 22% have introduced a new center of excellence program within the last two years. Among firms with a center of excellence program, 45% had a program for joint replacement, 42% for back or spine surgery, 31% for bariatric surgery, 30% for mental health, and 28% for substance use disorders.

Methodology

KFF conducted the annual employer survey between January and July of 2023. It included 2,133 randomly selected, non-federal public and private firms with three or more employees that responded to the full survey. An additional 2,759 firms responded to a single question about offering coverage. For more information on the survey methodology, see the Survey Design and Methods Section.

ABOUT KFF:

KFF is the independent source for health policy research, polling and news.

ABOUT HEALTH AFFAIRS:

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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The new survey is one component of a new KFF program area aimed at identifying and monitoring health misinformation and trust in the United States, placing particular emphasis on communities that are most adversely affected by misinformation, such as people of color, immigrants and rural communities.  Alongside today’s survey findings, KFF will soon release companion survey reports highlighting the extent of health misinformation among Black and Hispanic adults, as well as rural residents. KFF will also soon release a regular “Health Misinformation Monitor,” which will document emerging health misinformation, identify its primary sources, and examine the role that social media and news outlets play in its spread. Sign up for alerts from KFF on this topic. KFF Health News is also expanding its reporting on this topic in conjunction with the new program.    “While many Americans struggle to separate health information fact from fiction, our survey shows that credible sources of information, and messengers, represent an opportunity to break through and help increase trust,” said Irving Washington, senior fellow for misinformation and trust at KFF. “We’ll continue to focus on this opportunity and what type of efforts can make a difference.” The misinformation examined in the survey includes:  Vaccines A third (34%) of adults say the false claim that COVID-19 vaccines have caused thousands of sudden deaths in otherwise healthy people is definitely (10%) or probably (23%) true. Black adults are more likely to believe this false statement than White adults, while Republicans and independents are more likely than Democrats to do so. People with college degrees are less likely than those with a high-school education or less to say this is true. Reproductive health About a third of adults say the false claim that using birth control such as the pill or an IUD makes it harder for most women to get pregnant once they stop using them is “definitely” (5%) or “probably” true (29%). Adults under the age of 65, Republicans, independents, and Black and Hispanic adults are more likely to say this claim is true than their counterparts. Gun violence. When asked about the inaccurate statement that people who have firearms at home are less likely to be killed with a gun, about four in ten (42%) say it is “definitely” (13%) or “probably” (29%) true. Gun owners are more likely than non-gun owners to say that this false claim is definitely or probably true (55% vs. 37%). The survey also reveals how varied people’s beliefs and perceptions are about what constitutes misinformation. For example, when asked to describe specific misinformation related to COVID-19 that they’ve heard, people volunteered statements that were in direct contradiction with one another, including about the safety and effectiveness of COVID-19 vaccines and of wearing masks to prevent the virus’ spread. Who People Trust for Health Information The survey also gauges people’s trust in various sources of health information: Doctors. Not surprisingly, people overwhelmingly say that they trust their own doctor’s recommendations – with 93% saying they trust their doctors at least a fair amount. Federal agencies. About two thirds of the public say they have at least a fair amount of trust in the Centers for Disease Control (67%) and the Food and Drug Administration (65%) to make the right recommendations when it comes to health issues. Democrats are more likely than either independents or Republicans to trust the two federal agencies. About half of Republicans say they trust both the CDC (49%) and FDA (54%). Traditional news sources. The largest shares of the public say they would have at least a little trust in health information reported by their local TV news stations (80%), national network news (72%), and their local newspaper (72%). CNN is the most trusted cable news network (58%), with smaller shares trusting MSNBC (52%), Fox News (49%), Newsmax (25%) or One American News Network (22%). Fewer than three in ten adults say they have “a lot” of trust in health information from any of these media sources. Social media sources. About a quarter (24%) of adults say that they use social media at least weekly to find health information or advice, including larger shares of Hispanic and Black adults, and people in low-income households. Of eight specific social media sources, half (52%) would trust information about health issues they saw on YouTube at least a little. Fewer say they would trust health information if they saw it on Facebook (40%), Twitter (29%), Instagram (27%), and other platforms. Fewer than one in ten say they have a lot of trust in health information from any of these social media sources. The survey report examines the sources to which people go to get their news and their susceptibility to misinformation. Less than half (45%) of adults say they have heard one of the five false COVID-19 and vaccine claims and believe it is definitely or probably true. That share rises to 76% of regular Newsmax viewers, and 67% of regular OANN viewers, and 61% of regular Fox News viewers. Similarly, 54% of those who use social media for health information and advice at least weekly say they have heard at least one of the false COVID-19 and vaccine claims and think it is definitely or probably true, compared to 40% of those who don’t use social media for health advice. Designed and analyzed by public opinion researchers at KFF, the KFF Health Misinformation Tracking Poll Pilot was conducted May 23-June 12, 2023, online and by telephone among a representative sample of 2,007 U.S. adults. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher. Support for this work was provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. Read the Survey

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Such problems vary across types of insurance but include such things as denied claims for care they thought was covered, difficulty finding an in-network doctor or other provider, and delays and denials of care that involved an insurer’s prior authorization. 

At least half within each of four major types of health coverage – employer, Medicaid, the Affordable Care Act’s marketplace, and Medicare – say they had a problem using their coverage in the past year. 

Such problems are more common among people with greater health care needs. For example:

• Two-thirds (67%) of consumers who rate their own health as “fair” or “poor” encountered a problem in the past year.
• About three-quarters (74%) of those who received mental health treatment in the past year reported a problem.
• More than three-quarters (78%) of those who received a lot of health care (more than 10 provider visits in the past year) reported a problem.

“The survey shows that the sheer complexity of insurance is as big a problem as affordability, particularly for those with the greatest needs,” KFF President and CEO Drew Altman said. “People report an obstacle course of claims denials, limited in-network providers, and a labyrinth of red tape, with many saying it prevented them from getting needed care.”

Today’s report captures key results from the nationally representative survey of 3,605 people with health coverage through an employer, Medicare, Medicaid or the Affordable Care Act’s marketplaces. Future reports will delve more deeply into the experiences of people with those types of coverage, as well as people with specific chronic conditions and needs across types of insurance.

The frequency that people encounter specific insurance problems varies by type of coverage. For example, people with employer and marketplace coverage report denied claims more often than people with Medicare or Medicaid, and people with Medicaid and marketplace coverage more often report problems finding in-network providers.

Insurance problems can contribute to unexpected costs, with more than a quarter (28%) of those who reported problems saying they had to pay more for their care as a result. This includes about a third of those with marketplace or employer coverage who reported problems in the past year.

Among those who reported recent insurance problems, half say they were able to resolve the issue to their satisfaction, while nearly as many say either that the issue had been resolved in a way they didn’t like (28%) or that it remained unresolved (19%). Most insured adults (60%) do not know they have appeal rights by law, and three quarters (76%) do not know what government agency to call for help dealing with their insurance.

Consumers’ insurance problems can affect their ability to get timely, needed care. Among those with recent problems, about one in six say that they were not able to get recommended care (17%), they faced a significant delay in receiving such care (17%), or their health declined (15%) as a direct result.

About half (51%) of insured adults report some difficulty understanding at least one aspect of their health insurance, such as what their insurance will cover (36%), what they will owe out-of-pocket for care (30%), or what their explanation of benefits statement means (30%). About a quarter say that they find it difficult to understand terms such as “deductible” or “copay” (25%) and to figure out which doctors, hospitals and other providers are in network (23%).

People with Mental Health Challenges Have More Problems

The report also probes the challenges facing insured people who rate their mental health as fair or poor, regardless of whether they sought or obtained mental health treatment. This includes about one in five of all people with insurance, and one in three of those with Medicaid coverage.

Substantial shares of enrollees in this group rate the availability (45%) and quality (37%) of mental health therapists and providers covered by their insurance as “fair” or “poor.” 

Among those who say their own mental health is fair or poor, 43% say that there was a time in the past year when they did not get needed mental health care. Among young adults under age 30 who describe their mental health as fair or poor, more than half (55%) say they did not get needed mental health care in the past year.

People cite various reasons for not getting needed mental health care, but insurance was a factor for many.  Among all insured adults who didn’t get needed mental health care, more than four in 10 (44%) say they couldn’t afford the cost, and more than a third say it was because their insurance wouldn’t cover it. 

• One in six (16%) of all insured people say they have had problems paying or an inability to pay for medical bills in the past year, including similar shares of those with marketplace (19%), employer (17%), and Medicaid (16%) coverage, as well as 12 percent of people with Medicare.
• Premiums also can be an issue for consumers, particularly for those with employer and marketplace plans.  About half of those with marketplace or employer coverage give their insurance plan low marks for the amount that they pay in premiums and the amount they pay out-of-pocket to see a doctor. Far fewer of those with Medicare or Medicaid rate those aspects of their coverage negatively.
• In spite of the problems people report using their insurance, a large majority (81%) give “excellent” or “good” ratings when asked to rate their insurance overall. 
• Large majorities of consumers with insurance say they would support requirements on insurers that could make it easier to avoid or resolve insurance problems. These include requirements to maintain accurate and up-to-date information about who is in their network (91%) and to provide simpler, easier-to read statements explaining coverage decisions and how to appeal if you disagree (94%), all of which have been enacted by Congress though not all have been implemented.   

Designed and analyzed by public opinion researchers at KFF, the KFF Survey of Consumers Experiences with Health Insurance was conducted February 21-March 14, 2023, online and by telephone among a representative sample of 3,605 adults in the U.S. with health insurance coverage, including 978 adults with employer-sponsored insurance, 815 adults with Medicaid coverage, 885 adults with Medicare, and 880 adults with marketplace insurance. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 2 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher. 

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