Employer-sponsored Health Insurance Coverage Research Articles

“No room for error”: a qualitative interview study of experiences with health insurance coverage loss and COVID-19 pandemic relief policies among people with asthma

Objectives The COVID-19 pandemic led to unemployment and associated health insurance loss, prompting an unprecedented adoption of emergency policies, including economic relief efforts and health insurance coverage expansion. We sought to understand pandemic-related challenges for people with asthma and how emergency policies served families facing both chronic disease management and health insurance loss. Study design Qualitative interview study. Methods In 2021, we conducted semi-structured telephone interviews with 21 adults who had asthma and lost employment and employer-sponsored health insurance coverage during the COVID-19 pandemic. We used thematic analysis to assess how health and economic policies affected participants’ ability to access care and manage their asthma. Results Participants reported reduced access to care, as well as worry about heightened susceptibility to COVID-19 due to their asthma. While insurance loss exacerbated these challenges, participants indicated that economic relief efforts, including direct stimulus payments, helped them afford needed asthma care. Participants were more critical of enhancements to existing coverage policies such as the Affordable Care Act (ACA) Marketplace and Consolidated Omnibus Budget Reconciliation Act (COBRA) due to difficulty understanding, accessing, and affording such coverage. Conclusions Our findings underscore that people affected by asthma and health insurance loss benefit from policies that provide flexible and easy-to-use assistance, such as direct payments, for meeting the diverse challenges posed by living with a chronic disease. Although policies that expand health insurance coverage are critical, more attention is needed to help people with chronic conditions access these programs in a timely way.

Health Benefits In 2023: Premiums Increase With Inflation And Employer Coverage In The Wake Of Dobbs.

In 2023 the average annual premium for employer-sponsored family health insurance coverage was $23,968-an increase of $1,505 (7percent) from 2022. Both single and family premiums increased faster in 2023 than in 2022, in a period of generally high inflation throughout the US economy. On average, covered workers contributed 17percent ($1,401) of the cost of single coverage and 29percent ($6,575) of the cost of family coverage. When compared to employers' perceptions of the number of primary care providers in their networks, a smaller share of employers believed that their provider networks had a sufficient number of mental health and substance abuse providers to provide timely access to services. One-quarter of employers indicated that their employees had a "high" level of concern with the level of cost sharing required by their plans. When asked about abortion coverage in the wake of the Supreme Court Dobbs decision, almost a third of large employers reported that their largest plan covered abortion in most or all circumstances.

Trends in Reported Health Care Affordability for Men and Women With Employer-Sponsored Health Insurance Coverage in the US, 2000 to 2020

This study uses National Health Interview Survey data from 2000 to 2020 to examine reported differences between US men and women aged 19 to 64 years with employer-sponsored insurance in obtaining affordable health care.

Trends in Enrollment in Employer-Sponsored Health Insurance in the US Before and During the COVID-19 Pandemic, January 2019 to June 2021

This cross-sectional study compares trends in employer-sponsored health insurance coverage in the US before and during the COVID-19 pandemic.

Market Facilitation Program Payments, Employer-Sponsored Health Insurance Coverage and Off-Farm Employment

Market Facilitation Program Payments, Employer-Sponsored Health Insurance Coverage and Off-Farm Employment

Did the affordable care act increase the availability of employer‐sponsored health insurance?

AbstractThe 2010 Affordable Care Act (ACA) included two provisions, the Employer Shared Responsibility Provision (the “employer mandate”) and the Small Business Health Options Program (“SHOP”), aimed at increasing the availability of employer‐sponsored health insurance (ESI) among workers at small firms. To examine whether these provisions led to greater ESI availability, I use 2011–2017 Medical Expenditure Panel Survey (MEPS) data in a difference‐in‐difference framework that compares changes in ESI availability among workers at small and large firms before and after the ACA's provisions come into effect. My estimates show that there is a 3.5 percentage point increase in ESI availability among workers at smaller firms after 2013. When focusing on workers most likely to be affected by the employer mandate, I find a larger 5.2 percentage point increase in ESI availability, amounting to a 39% decline in the proportion who do not have ESI available. However, I find no evidence that greater ESI availability led to increases in ESI coverage rates. Instead, descriptive estimates suggest that gains in health insurance coverage after 2013 consist of significant increases in the number of working adults who report having Medicaid coverage, including among workers who are offered ESI. I use MEPS data for my analysis because, along with employment, firm size, and health insurance details, MEPS also provides health status and healthcare access/utilization information. Looking at changes in these health measures, I find only limited evidence to suggest that the ACA's provisions improved access to care or measures of health status for workers.

Keeping what you like: grandfathering and health insurance coverage take-up rates under the ACA

According to various reports, between 1.8 million and 4.7 million health insurance plans were replaced shortly after passage of the Affordable Care Act of 2010 with new ACA-compliant plans. In order to limit this occurrence, provisions in the ACA included “grandfathering,” which allowed many Americans to retain health insurance coverage that was in place on or before the ACA was signed into law. These health insurance plans were in many cases favored by individuals and employees because they had been customized, unlike many of the new non-grandfathered plans. This study explores the effect of grandfathering on health insurance coverage take-up rates by employees, given that there are some key differences between grandfathered and non-grandfathered plans that perhaps make the former relatively more attractive to employees. Using survey data from the Kaiser Family Foundation and the Health Research Educational Trust, difference-in-difference regressions reported here suggest that take-up rates for grandfathered health insurance plans are generally higher than those for non-grandfathered plans. Estimates generally place these take-up rate differences, favoring grandfathered plans, somewhere between 2.9 and 8.2 percentage points, depending on plan type, firm size and firm location. This finding suggests that more flexible plans are needed to increase employer-sponsored health insurance coverage.

How the COVID-19 Recession Could Affect Health Insurance Coverage

Thirty million workers filed initial unemployment claims between March 15 and April 25. As workers lose their jobs, many will also lose their employer-sponsored health insurance (ESI), as will their dependents. Some of these workers and dependents will qualify for Medicaid coverage, particularly in states that expanded Medicaid eligibility under the Affordable Care Act (ACA). Others will purchase individual coverage on the health insurance Marketplaces, possibly with a subsidy to offset the premium cost. And many will be unable to replace their ESI coverage and become uninsured. In this brief, we estimate how health insurance coverage could change as millions of workers lose their jobs during the COVID-19 recession. We present national and state-level estimates of coverage changes if unemployment rates rise from precrisis levels (around 3.5 percent nationally) to 15 percent, 20 percent, or 25 percent. For each unemployment level, we provide a base case scenario of coverage changes and a high scenario, derived from two different estimation methods. In our base scenario, we estimate that at 20 percent unemployment, approximately 25 million people will lose ESI coverage, and of them, 12 million would gain Medicaid coverage, 6 million would gain Marketplace or other private coverage, and 7 million would become uninsured. In the high scenario, we estimate that 43 million people would lose ESI coverage. The increase in Medicaid coverage and uninsurance rates will be uneven across the country, with a greater share of those estimated to lose ESI gaining Medicaid coverage and a lower share becoming uninsured in states that expanded Medicaid under the ACA.

Same-Sex Marriage and Gains in Employer-Sponsored Insurance for US Adults, 2008-2017.

Objectives. To estimate the effects of same-sex marriage recognition on health insurance coverage.Methods. We used 2008-2017 data from the American Community Survey that represent 18 416 674 adult respondents in the United States. We estimated changes to health insurance outcomes using state-year variation in marriage equality recognition in a difference-in-differences framework.Results. Marriage equality led to a 0.61 percentage point (P = .03) increase in employer-sponsored health insurance coverage, with similar results for men and women.Conclusions. US adults gained employer-sponsored coverage as a result of marriage equality recognition over the study period, likely because of an increase in dependent coverage for newly recognized same-sex married partners.

Price elasticity of demand for buprenorphine/naloxone prescriptions

Although there have been supply-side efforts in response to the opioid crisis (e.g., prescription drug monitoring programs), little information exists on demand-side approaches related to patient cost sharing that may affect utilization of and adherence to pharmacotherapy by individuals with opioid use disorder. Among individuals who had initiated pharmacotherapy, we estimated the price elasticity of demand of prescription fills of buprenorphine/naloxone, a common pharmacotherapy drug, overall and by patient characteristics. Using the IBM MarketScan® Commercial Claims and Encounters Database for individuals with employer-sponsored private health insurance coverage, we examined the relationship between cost sharing and the number of buprenorphine/naloxone prescription fills using enrollee-level longitudinal fixed effects models. Cost sharing was expressed as a price index for each employer-plan. By including enrollee-level fixed effects, the identification of the effect of interest comes from longitudinal variation in prices across multiple time points for each enrollee. Overall, the demand for buprenorphine/naloxone was price inelastic (p = 0.191). However, some subgroups were responsive to price. A doubling of price was associated with a decrease in fills by 3.0% for enrollees aged 45–64 years (p = 0.029); 5.7% for those in rural areas (p = 0.033); 5.8% for residents of the South (p ≤0.001); and 3.0% for those enrolled in an HMO (p = 0.004). Insurers should consider the effects on these groups before increasing beneficiary out-of-pocket costs for pharmacotherapy and efforts to increase adherence should consider that price may be a barrier for some subgroups with OUD.

Mental health outcomes for individuals with chronic hepatitis C infection.

ObjectiveUsing data from the 2011–2015 IBM MarketScan® Commercial Claims and Encounters, we sought to assess the relationship between mental health outcomes and chronic hepatitis C infection after adjusting for important confounders. Persons with HCV antibody and RNA test results between 2011 and 2015 and continuous enrollment in fee-for-service plans were included in the analysisIntroductionHepatitis C virus (HCV) infection is a leading cause of liver disease-related morbidity and mortality in the United States and HCV incidence has been increasing. Mental illness may impact the likelihood of initial HCV infection, progress and adherence to treatment along the hepatitis C care cascade, and risk of subsequent reinfection for those cured of hepatitis C. The relationship between HCV infection and mental illness is not well understood and many studies have lacked sufficient sample size to adjust for important confounders. We sought to explore the association between chronic HCV infection and mental illness after adjusting for important confounders.MethodsWe obtained data from the 2011–2015 IBM MarketScan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. These data consist of inpatient and outpatient service claims for persons with employer-sponsored health insurance coverage and their dependents. Persons with HCV antibody and RNA test results between 2011 and 2015 and continuous enrollment in a fee-for-service plan were included in the analysis. Chronic HCV infection was defined by a positive HCV RNA test result. Controls without chronic HCV infection had a negative HCV antibody test result and no positive HCV antibody or RNA test result in the preceding or following year. The index date was defined by the date of the earliest positive HCV RNA or negative HCV antibody test. Demographic characteristics were obtained from the MarketScan® enrollment tables. All enrollees in the study population were at least 18 years old during the year of the index date. The analysis sample was restricted to persons who were identified as receiving outpatient prescription drug claims data feeds. We estimated adjusted odds ratios (OR) for the association between mental illness (ICD-9 code 295 or 296) and HCV RNA status. Multivariate models included age (18-44, 45-64, 65+ years), sex, region, and an adjusted Charlson Comorbidity Index which excluded liver disease and hepatocellular carcinoma.ResultsWe identified 2,847 individuals with chronic HCV infection (HCV RNA+) and 57,418 controls who were HCV antibody negative. With respect to age, 83% of HCV RNA+ individuals were aged 45-64 years while only 43% of the HCV antibody negative individuals were in the same age range. Similarly, for sex, 62% and 40% of HCV RNA+ individuals and controls, respectively, were male. For unadjusted analyses, age, sex, region, comorbid conditions, and mental illness (OR= 2.25 [95% CI; 1.52 - 3.34]) were all statistically associated with HCV RNA+. For the multivariate adjusted models, these same variables remained statistically significant. For the multivariate model, individuals with a mental illness were more likely to be HCV RNA+ relative to HCV antibody negative controls. (OR= 1.95 [95% CI; 1.30 - 2.93]).ConclusionsThis study demonstrated a strong association between mental illness and HCV chronic infection after adjusting for important confounders including other comorbid conditions. A growing body of research suggests that persons with mental illness are at increased risk for contracting and transmitting HCV due to high rates of substance use and high-risk sexual behavior among infected persons as well as high rates of sexual victimization. HCV prevention efforts should be directed toward individuals with mental illness or seeking treatment for mental illness.

Hepatitis C testing trends among large commercially insured populations, 2011–2017

ObjectiveWe estimated the rate of hepatitis C testing between 2011 and 2017 among persons with commercial health insurance coverage and compared rates by birth cohort.IntroductionHepatitis C virus (HCV) infection is the most common blood-borne infection in the US, and a leading cause of liver-related morbidity and mortality. Approximately 3.5 million individuals in the US were estimated to have been living with hepatitis C in 2010, and approximately half of them were unaware that they were infected. Among HCV infected individuals, those born between 1945 and 1965 (usually referred to as the baby boomer cohort) represent approximately 75% of current cases. Because of the substantial burden of disease among this age group, CDC expanded its existing hepatitis C risk-based testing recommendations to include a one-time HCV antibody test for all persons born between 1945 and 1965. The United States Preventive Services Task Force (USPSTF) subsequently made the same recommendation in June 2013.DescriptionWe obtained data from the 2011–2017 IBM MarketScan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. These data consist of inpatient and outpatient service claims for persons with employer-sponsored health insurance coverage and their dependents. This analysis was restricted to adults 18 years of age and older with continuous enrollment in a commercial or Medicare Supplemental plan for at least one calendar year during the study period (a 45-day gap in coverage was allowed) who received outpatient prescription drug claims data feeds. Claims for hepatitis C antibody testing were identified using Current Procedural Terminology (CPT) codes (80074, 86803). We defined the annual hepatitis C testing rate as the number of patients with an HCV antibody test claim divided by the total number of study-eligible enrollees in a given calendar year. Testing rates were calculated for persons born between 1945 and 1965 and all other adults.There were 54,298,561 unique adults who were continuously enrolled for at least one calendar year during the study period. Among these, 4,629,040 (9%) had one or more inpatient or outpatient service claim with a CPT code for hepatitis C antibody testing during the study period. The overall estimated annual testing rate increased from 2.2% in 2011 to 5.3% in 2017. The testing rate increased from 1.7% to 7.8% among the 1945–1965 birth cohort and 2.5% to 4.0% in other birth cohorts. The average annual percent change in testing was 30.1% among the 1945–1965 birth cohort and 8.2% among other birth cohorts. Testing rate increased markedly (64.1%) between 2016 and 2017 in the 1945–1965 birth cohort, but not in other birth cohorts (7.7%).In this sample of individuals covered by commercial insurance, hepatitis C testing rates have increased slowly between 2011 and 2016. In 2017, there was a substantial increase in testing rates among the Baby Boomer cohort due most likely to an increase in awareness of CDC and USPSTF recommendations by both providers and individual patients associated with CDC health promotion efforts and increased marketing efforts by drug manufacturers. Efforts should continue to promote and increase the awareness of these recommendations and have people tested and treated for HCV.How the Moderator Intends to Engage the Audience in Discussions on the TopicThis panel will discuss strengths and weaknesses for monitoring hepatitis C testing using alternative data sources including self-reported data, insurance claims data, and laboratory testing data.

A Comparative Analysis of the Health System Financing in Poland and Selected Countries

IntroductionHealthcare is a very important and, at the same time, difficult element of each state's policy. For many countries, the issue of financing the healthcare system is a delicate matter and one of the basic economic and social issues. Nevertheless, decisions concerning the sources and principles of healthcare financing influence the quality of the entire system (Hady and Lesniowska, 2013, p. 1).The development of medical technologies, as well as the introduction of new generations of drugs, cause that currently there are opportunities of effectively treating cases which until recently were beyond doctors' reach. Another problem which is connected with the functioning of systems of health care is ageing population observed practically in all developed countries as well as new challenges connected with it. These circumstances cause that maintaining domestic systems of health services is generating higher and higher costs (Kujawska, 2015, p. 113).Every health system is aimed at satisfying the specific health needs of the population.Health systems can be described using models of service delivery, financing, and economic policy. Much of the literature depicts health delivery systems in terms of a national health system, social insurance or private insurance model. Within each model, there are various forms of financing including general taxation, specific taxation, and private financing (Kulesher, Forrestal, 2014, p. 127).The cost of delivering health care imposes a large, and often growing, burden in nearly all countries. Increasingly, health care decision-makers are being asked to improve performance by containing expenditures while maintaining steady improvements in access and quality (Anell and Willis, 2000, p. 770).This article presents a comparative analysis of the health system financing in Poland and selected countries: The Netherlands, Germany, United Kingdom, USA. Analysis will cover the period from 2011 to 2013. Data deriving from the OECD Health Data database were used.1.Characteristics of Foreign Health SystemsTraditional models of health systems are treated as benchmarks describing the desired and ideal shape of the system. They represent a collection of potentially possible solutions from which one can choose those best suited in specific conditions. There are three health systems defined in literature:- model of national health service, also known as the Beveridge model,- social insurance system, the so-called Bismarck model,- the system of non-regulated insurance market, the so-called residual model.Britain's National Helath Service (NHS) came into existence on 5 July 1948. It was the first health system in any western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone (Fincham, 2011, p. 27).The Bismarck model of health care structure, financing, and delivery is named in honor of Prussian Chancellor Otto von Bismarck, who unified Germany in the 19th century the system incorporates sickness funds which are jointly financed by employers and employees via payroll deductions. In this instance, the Bismarc model represent what is available to employees via employer-sponsored health insurance coverage. The major difference in the German system is that the sickness funds companies are not profit-generating entities. These sickness fund companies do not make o profit (Fincham, 2011, p. 29).A model of private health insurance in which access to benefits is conditioned on having a private insurance policy. Monies allotted to financing the benefits derive from private insurance premiums, health service manufacturers are private entities (Lyszczarz, 2014, p. 92).The European Union Member States and the United States built their health systems on the basis of these models. …

Public insurance is increasingly crucial to American families even as employer-sponsored health insurance coverage ends its steady decline.

Americans under age 65 rely on a healthy labor market for almost all facets of economic security. While 2012 marked the first year in more than a decade that the employer-sponsored health insurance (ESI) coverage rate for the under-65 population did not decline, employer-sponsored health insurance continues to fail American families. If the coverage rate had not fallen 10.8 percentage points as it did from 2000 to 2012, as many as 29 million more people under age 65 would have had ESI in 2012. Even with the end of its longstanding decline, ESI coverage rates among men and women, white and non-white, high and low income, white and blue collar, young and old remain far lower than they were in 2000. Over this period, the increase in uninsured Americans was not as steep as the fall in ESI because of increases in public coverage, including Medicaid, the Children's Health Insurance Program, and Medicare. These programs were particularly effective in reducing the share of children uninsured over the 2000s. Additionally, key components in the Patient Protection and Affordable Care Act shielded young adults from further coverage losses.

Employer-Sponsored Health Insurance Coverage Continues to Decline in a New Decade

Most Americans, particularly those under age 65, rely on health insurance offered through the workplace. Given continuing high unemployment, it comes as no surprise that the share of Americans under age 65 covered by employer-sponsored health insurance (ESI) eroded for the 11th year in a row in 2011, falling from 58.6 percent in 2010 to 58.3 percent. The situation started deteriorating long before the Great Recession: the share of Americans under age 65 covered by ESI eroded every year from 2000 to 2011, decreasing by a total of 10.9 percentage points. As many as 29 million more people under age 65 would have had ESI in 2011 if the coverage rate had remained at the 2000 level. The decline in ESI coverage has been accompanied by an overall decline in health insurance coverage. The number of uninsured non-elderly Americans was 47.9 million in 2011--11.7 million higher than in 2000. Increasing public insurance coverage, particularly among children, is the only reason the uninsured rate did not rise one-for-one with losses in ESI. In addition, key components in the Patient Protection and Affordable Care Act took effect in 2010, shielding young adults from further coverage losses.

Employer-sponsored health insurance coverage limitations: results from the Childhood Cancer Survivor Study

The Affordable Care Act (ACA) will expand health insurance options for cancer survivors in the USA. It is unclear how this legislation will affect their access to employer-sponsored health insurance (ESI). We describe the health insurance experiences for survivors of childhood cancer with and without ESI. We conducted a series of qualitative interviews with 32 adult survivors from the Childhood Cancer Survivor Study to assess their employment-related concerns and decisions regarding health insurance coverage. Interviews were performed from August to December 2009 and were recorded, transcribed, and content analyzed using NVivo 8. Uninsured survivors described ongoing employment limitations, such as being employed at part-time capacity, which affected their access to ESI coverage. These survivors acknowledged they could not afford insurance without employer support. Survivors on ESI had previously been denied health insurance due to their preexisting health conditions until they obtained coverage through an employer. Survivors feared losing their ESI coverage, which created a disincentive to making career transitions. Others reported worries about insurance rescission if their cancer history was discovered. Survivors on ESI reported financial barriers in their ability to pay for health care. Childhood cancer survivors face barriers to obtaining ESI. While ACA provisions may mitigate insurance barriers for cancer survivors, many will still face cost barriers to affording health care without employer support.

Declines in Employer‐Sponsored Insurance between 2000 and 2008: Examining the Components of Coverage by Firm Size

To examine trends in employer-sponsored health insurance coverage rates and its associated components between 2000 and 2008, to provide a baseline for later evaluations of the Affordable Care Act, and to provide information to policy makers as they design the implementation details of the law. Private sector employer data from the 2000, 2001, and 2008 Medical Expenditure Panel Survey-Insurance Component (MEPS-IC). We examine time trends in employer offer, eligibility, and take-up rates. We add a new dimension to the literature by examining dependent coverage and decomposing its trends. We investigate heterogeneity in trends by firm size. The MEPS-IC is an annual survey, sponsored by the Agency for Healthcare Research and Quality and conducted by the U.S. Census Bureau. The MEPS-IC obtains information on establishment characteristics, whether an establishment offers health insurance, and details on up to four plans. We find that coverage rates for workers declined in both small and large firms. In small firms, coverage declined due to a drop in both offer and take-up rates. In the largest firms, offer rates were stable and the decline was due to falling take-up rates. In addition, enrollment shifted toward single coverage and away from dependent coverage in both small and large firms. For small firms, this shift was due to declining offer and take-up rates for dependent coverage. In large firms, offers of dependent coverage were stable but take-up rates dropped. Within the category of dependent coverage, the availability of employee-plus-one plans increased in all firm size categories, but take-up rates for these plans declined in small firms.

Employer-Sponsored Health Insurance Erosion Continues in 2008 and is Expected to Worsen

Although employer-sponsored health insurance (ESI) is the primary source of health coverage in the United States, at 61.9 percent of the under-65 population, the rate of this coverage has decreased every year since 2000, when 68.3 percent had ESI. By 2008, the rate of ESI coverage had fallen 6.4 percentage points, and 5 million fewer people under the age of 65 had ESI in 2008 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates; more than 7.5 million more Americans became uninsured after 2000. Uninsured workers are disproportionately young, Hispanic, lower educated, and lower income; however, workers across all socioeconomic groups have experienced declines in coverage since 2000. Children's coverage also fell 7.0 percentage points over the 2000s, and the gap in ESI access by income substantially widened over this period. The only reason the drop in ESI did not translate into a larger increase in the overall number of uninsured is that 3.4 million additional non-elderly people were covered by public insurance from 2007 to 2008. Because of the rise in unemployment between 2008 and 2010, the number without ESI and without any coverage at all is likely to swell in the coming years.

Labor Markets and Employer-Sponsored Health Insurance Coverage

Labor Markets and Employer-Sponsored Health Insurance Coverage

The Erosion of Employer-Sponsored Health Insurance: Declines Continue for the Seventh Year Running

Employer-sponsored health insurance (ESI) remains the most prominent form of health coverage in the United States, at 62.9 percent of the under-65 population; however, the rate of this coverage has fallen every year since 2000, when 68.3 percent had ESI. By 2007, this rate had fallen 5.4 percentage points, and 3 million fewer people under the age of 65 had ESI in 2007 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates. Despite a small gain in overall coverage for workers from 2006 to 2007, there were over 4 million more uninsured workers in 2007 than in 2000. Uninsured workers are disproportionately young, nonwhite, less educated, and low wage; however, workers across the socioeconomic spectrum experienced losses in coverage over the 2000-2007 period. Even the most highly educated and highest-wage workers had lower rates of insurance coverage in 2007 than in 2000. As with workers, the downward trend in ESI coverage for children (through their parents' employers) continued into 2007: 3.4 million fewer children had ESI in 2007 than in 2000, cutting across all race and income groups. Even as employment-based coverage has declined, the share of Americans who receive coverage through private purchase (non-group market) has also declined. The safety net programs--Medicaid and the State Children's Health Insurance Program--have kept millions of families insured as employment-based coverage fell.