"They don't give a rat's butt about people like me," she said.
Inside the high-deductible insurance revolution that is transforming
"We are super middle class," she said. "How are we stuck with everything?"
Health insurance - never a standard protection in the
But a steep run-up in deductibles, which have more than tripled in the last decade, has worsened inequality, fueling anger and resentment and adding to the country's unsettled politics, a
Many wealthy Americans - already reaping most of the benefits of the last decade's economic growth - have weathered the dramatic increase in deductibles in recent years in part by putting away money in tax-free Health Savings Accounts.
Very poor Americans, millions of whom gained coverage through the 2010 Affordable Care Act, can see a doctor or go to the hospital at virtually no cost, thanks to Medicaid, the half-century-old government safety-net program.
Squeezed in the middle are legions of working Americans who face stagnant wages, insurance premiums that take more and more of their paychecks and soaring deductibles that leave them with medical bills they can't afford.
"The system increasingly doesn't work for this group in the middle," said
"These people may have health insurance ... but they can't pay the bills."
This middle-class squeeze and the class divisions it is exposing are among the corrosive effects of the high-deductible revolution, which The
"Among the most angry focus groups I have done in my career was [one] with working-class women in
Although a majority of workers remain content with their health benefits, a quarter now report feeling frustrated, according to a nationwide poll of Americans with job-based coverage conducted for this project in partnership with KFF.
One in seven is angry about their insurance.
The discontent is even more pronounced among workers with the highest deductibles: four in 10 report frustration, and nearly a quarter say they're angry.
"I'm not hard-core political, but it kind of stings sometimes," said
"You work and do what you're supposed to, and you really pay the price," said Stevens, whose family was on a high-deductible plan through his Home Depot job outside
Stevens, whose family makes about
"They told me I made too much," he recalled. "I thought, 'I'm not poor enough? I feel pretty poor.' "
Most workers blame drug companies and health insurers for high healthcare costs, The
But deep partisan lines also divide Americans' views of the affordability crisis.
Six in 10
The law, for the first time, guaranteed Americans could get insurance if they're sick.
It also gave millions of very poor working Americans access to Medicaid, which does not have deductibles. The expansion produced a historic drop in the number of Americans without health insurance.
But many health plans being sold on the law's insurance marketplaces have very high deductibles, mirroring the run-up that has happened with job-based benefits.
And although the expansion of Medicaid is broadly popular, it has highlighted the strains on
Two groups of workers - those with high incomes and those with low deductibles - are more likely to believe they have better coverage than Medicaid enrollees, who typically have to make less than
But workers in households making less than
That includes people with deductibles of more than
As deductibles and premiums have surged, a growing number of low-income workers who have job-based health benefits are enrolling their children in Medicaid and the related
But many workers cannot get the same cost-free government coverage for themselves.
"There was no fear," he said. "You didn't have to be afraid to go to the doctor."
Overall, four in 10 American workers said they had trouble affording healthcare in the last year, despite having job-based health coverage, The
That number, however, masks a large disparity in Americans' experiences.
Two-thirds of workers in households making less than
By comparison, fewer than one-third of workers with incomes of at least
This income divide is baked into the way employers provide coverage to workers in America: Companies with better-paying jobs have long offered more generous benefits.
In 2018, for example, workers at firms with higher wages had to pick up about a quarter of the cost of a family health plan, according to an annual employer survey KFF has been conducting for years. The employer paid the remaining three-quarters.
Americans who work for low-wage employers, by comparison, had to pay nearly 40% of the cost of a family health plan.
That meant workers at firms that pay less also got hit with an average of some
That pay-based disparity didn't matter as much when deductibles were lower, giving low-wage workers some protections against large medical bills if they became ill.
As recently as 2006, the average deductible for individual coverage in job-based plan was just
But since the early 2000s, employers have rapidly shifted costs onto workers as they've scrambled to control their own healthcare spending.
The average deductible has more than tripled, to
Companies often didn't pay full attention to the extra burden on workers, said
"The average chief executive couldn't put themselves in the shoes of a worker trading off healthcare with paying a bill to stay in a home or an apartment," Critelli said.
Most top wage-earners, who already have more savings, are better positioned to adjust to higher deductibles.
But they got additional help from a change in tax law that accelerated the shift in health insurance, data show.
In 2003, President
Conservative politicians and health economists touted Health Savings Accounts, or HSAs, and high deductibles as a way to give patients "skin in the game" and an incentive to shop for lower-priced medical care.
Shortly after the 2003 law was enacted, former House Speaker
None of that happened.
Middle- and low-income workers, whose incomes and savings have barely budged in recent decades, hardly use HSAs, even as their deductibles have soared.
For wealthier Americans, by contrast, the accounts have become a generous savings and investment tool.
In 2013, for example, people with income greater than
By contrast, Americans with incomes below
"There's no doubt that these accounts have been far more valuable to higher-income people," said
New research conducted by the institute in partnership with The
Analyzing wage and insurance data from a large national corporation with an HSA plan, Fronstin and his colleagues found that employees with individual coverage who earned more than
That was nearly three times as much as workers earning less than
By the end of 2016, the high-income workers also had more than three times as much saved, averaging almost
The higher-income employees also were nearly twice as likely to invest their accounts, a recommended strategy for maximizing the tax benefits of HSAs.
Related research by Fronstin indicates that workers with higher HSA balances use more healthcare, even accounting for differences in workers' ages.
"All around, they are getting more bang for their buck," he said.
Even with a salary of
"It doesn't get me a lot," she said, noting that bills for seeing a therapist and filling prescriptions quickly deplete the HSA and force her to ration her care.
"I feel pretty stressed about health insurance all the time."