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A lot of attention has rightly been paid to the Trump-era degradation of the ACA marketplace, where reduced subsidies (starting in Plan Year 2026) have harmed the subsidy-eligible, and a roughly 40% two-year increase in base premiums has slammed the subsidy-ineligible (e.g., those subjected to the restored income cap on subsidies).
It’s also no secret that employer-sponsored insurance is imposing increasingly untenable costs, especially on employees of small businesses and on low-income employees.
In my work with lawfully present immigrants, earning hourly wages in the $18-25 range, I’ve had a chance to witness what healthcare access in the U.S. looks like to unaccustomed eyes. Examples:
A married couple, both working as dental assistants for different practices: each is offered individual insurance starting at $400/month, and insurance for two at simply double that. Deductibles begin, if I remember right, at $2,500. They are healthy, and can’t imagine paying well over 10% of income for coverage that doesn’t kick in until they spend thousands more. They are uninsured.
A single man working as a driver for a private company that provides government-funded transportation to the disabled. The employer offers three health plans, all from one major insurer, with deductibles of $1,750, $3,500, or $7,500, and out-of-pocket maximums of $3,500, $4,000, and $8,000. The most expensive plan is relatively decent coverage by U.S. standards, as many services are not subject to the $1,750 deductible — but the premium is about $340/month for an individual. The middle plan has the advantage of a fairly low OOP max, but all services are subject to the deductible, and the premium is only modestly lower: $300/month. The cheapest plan, at $125/month, is the only one my friend considered in the realm of possibility — but it covers nothing before the $7,500 deductible is reached (except mandatory free preventive care). He went for that one — patching it, for another $15-odd dollars per month, with accident and critical illness indemnity plans. Welcome to America.
A single man working two jobs, one of them at Fedex, which offers relatively decent insurance (by low-wage U.S. standards) for people working at least 17 hours per month. At the location in question, Fedex reduced workers’ hours over several months — and then terminated this person’s insurance because his hours slipped below the threshold. He learned about this when he tried to fill a prescription. Perhaps notice was sent — by snail mail, email, whatever — but, as so often happens, he didn’t see it. Or perhaps there was no notice.
A father of three, working at a county-owned hospital, offered a welter of insurance plans online, only half of which were actually available, as the employer had cut one of two insurers. HR personnel at this jobsite apparently shepherd employees into just two of the 20-plus plans on the menu — rightly, I think, as all but two have $16,000 family OOP maxes. After some angst, this person chose the cheaper of the two plans, at a bit under $400/month for family coverage. That’s actually pretty good by American standards — though a steep increase over last year, in a state that’s undergoing a crisis in its employee benefit system. But for the individual in question, it’s an almost unfathomable bite out of a paycheck that’s also reduced by a 7% pension contribution.
A friend , who works as a nurse in a public school (not a recent immigrant and not a low-wage worker), is happy with her coverage. The premium, as is normal, is deducted from her paycheck. While we were discussing the coverage (as friends do, right?), I asked her what the premium was. She looked at her biweekly paycheck: just under $200 was deducted. That’s a premium above $400/month, for single person coverage. For a public school employee!
Drew Altman, president and CEO of KFF, published a column last week purporting to debunk the notion that employer-sponsored health plan costs are out of control:
On average, employer premiums rose 1% in 2022, 7% in 2023 and 2024, 6% in 2025, and 5% in 2026. These are substantial increases but far from the double-digit increases we saw back in the early 2000s, and short of the increases that benefits officers always tell consulting firms to expect.
Point taken: recent increases have not been as bad as in some eras. But they do exceed both overall inflation and wage increases from 2023-2026. And, Altman continues, “In a year with a moderate overall premium increase, it was surprising to see the worker share of premiums rise 9% this year, almost twice the rate of increase in employer premiums and three times the rate of inflation.” And further, “Smaller employers are basically helpless and take what they can get.”
Altman, who has been tracking healthcare costs for decades at the helm of the country’s top nongovernmental provider of healthcare data, has seen worse. But for low-wage workers in particular— and people new to this country and its healthcare vagaries — the cost of securing access to healthcare often seems prohibitive — and, if accessed, can cause real hardship.
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