Workers’ health insurance costs for premiums and deductibles have outpaced wages over the past decade, according to a report by a health care policy think tank. The trend in North Dakota, however, appears to have been somewhat mitigated by the oil boom.

The report, by the Commonwealth Fund, examined premiums and deductibles state by state for people under age 65 for 2008 through 2018. It used Census data for incomes and the federal Agency for Healthcare Research and Quality’s annual employer survey for insurance costs.

Employer-based insurance covers 165 million people, or nearly half the population of the United States.

For all but two states — North Dakota included — the total increase in costs for premiums and deductibles is now 10 percent or more of median income.

Premium costs in North Dakota, however, were in the lowest bracket, 4.1 to 6.0 percent, and the state also had the lowest average premium for family coverage, at $17,337. This suggests that higher wages and a tight labor market have helped take at least some edge off the trend.

Neighboring Montana, meanwhile, hit the middle bracket, 6.0 to 7.9 percent, for premium costs as a percentage of median income.

The rise in deductible amounts, however, is a particular concern when it comes to actually obtaining health care. Research has shown that people with high deductibles often do not get needed services because they cannot afford their deductible. That leaves them effectively underinsured.

North Dakota’s deductible as a percent of state median income shook out to the middle range, 4.0 to 4.9 percent, along with 23 other states, including Montana — but the figures do not include copay costs, meaning the trend is understated.

Policy experts consider those with deductibles of 5 percent or more of their income to be effectively underinsured.

To the extent that high deductibles cause people to forego care, this can also lead to increases in cost for services. That is because there are fixed costs for expensive equipment, highly trained personnel, and facility costs, all of which are being covered by fewer and fewer people.

Nationally, the rise in premium and deductible costs was harshest in the south, where wages are generally lower, and labor markets are generally not as tight. Areas with high wages and tight labor markets, such as North Dakota, were among states where the trend was less sharp.

David Blumenthal, M.D., president of the Commonwealth Fund, noted that the topic of high health care cost is already front-and-center in debates heading into the 2020 presidential campaign. Democrats have already made health care a talking point in preliminary debates, but Republicans are also talking about it.

“The majority of people under age 65 in the U.S. get their health insurance through an employer, and that insurance is less and less affordable for many of them,” he said. “Ensuring that everyone can afford health insurance and health care will require policy fixes and systemwide efforts to get to the heart of the health care cost problem — the exorbitant prices we often pay for health care in the United States.”

Sara Collins, lead author of the study, said the trend shows health care is steadily rising out of reach for millions of working families.

“Several simple policy steps, such as fixing the Affordable Care Act’s family coverage glitch, have the potential to make health care more affordable for U.S. families,” she suggested.

The family coverage glitch refers to protections in the Affordable Care Act that apply only to individuals with expensive health care plans, and not to families.

An individual whose premium for employer-based health insurance exceeds 9.86 percent of their income is eligible for marketplace subsidies. That situation also triggers a federal tax penalty for the employer, as do plans that cover less than 60 percent of health care costs on average.

These provisions, however, only apply to single-person policies. Families with an overly expensive employer plan do not qualify for marketplace subsidies.

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