Read more: How deductibles contribute to health care inequity and discrimination

Although there is limited research on the relationship between wage levels and health care use in commercially insured populations, published studies indicate there is clear cause for concern. One study showed higher ER visit rates and hospitalizations, with reduced use of preventive services and medication adherence among low-wage workers. Other studies have shown that total health care costs are higher among low-wage workers, likely due to their more reactive approach to care. Given these findings, it is important to ensure that employees at all wage levels have affordable access to health care.

High-deductible health plans have been an increasingly prevalent option for employer benefits personnel as a means to promote greater health care consumerism and reduce employer plan costs. While low-wage workers may find the lower premium expense to be manageable, they could have difficulty affording the high deductibles associated with these plans. These affordability concerns are an important contributor to avoided or delayed health care services for all employees, but they may be especially challenging for low-wage workers.

Further, employers that implement copay accumulator adjustment programs—where the purpose is to prevent pharmaceutical industry subsidies from accruing to employee deductibles—may create even greater affordability challenges for low-wage workers.

Moving toward more equitable benefit design

If your employer clients are truly committed to DEI as a workplace priority, reevaluating benefit design represents an important component of that approach. Researching the answers to the following questions may be helpful:

• Do low-wage workers have equitable plan design options that include premium and/or health savings account (HSA) contribution subsidies?
• Are there differences in the use of preventive care services by enrollees in different wage categories?
• Are there disparities in hospitalization rates, emergency department use, or medication use among individuals in different wage groups that may reflect affordability concerns?

Employers can take steps to address disparities

To find the answers to these questions, employers can look at their claims, disability and/or family medical leave program data to evaluate the differences in use by wage category. Based on experience, separation of the data into at least three different wage groups based on employee numbers is likely to provide meaningful insights.

Well-being program participation is another benefits area where employers are likely to identify differences in wage-based services use. Research has shown that lower-income individuals are less likely to participate in these programs, despite having a higher prevalence of unhealthy lifestyle behaviors.

Equipped with insights from data analysis, employers may then benefit from employee focus group discussions to gain a better understanding of employee needs and priorities, as well as barriers to accessing existing offerings. Most employers can improve benefits affordability for lower-income individuals by providing subsidies in the form of premium reductions, wage-based HSA contributions, or other options.

Employers and their brokers can also model the potential increase in benefits subsidy-associated expenditures and determine if the costs are manageable. It is important to note that cost savings may be created by benefits subsidies for low-wage workers. More affordable care can enhance use of health care services (including chronic condition care, particularly where specialty medications are used in treatment), resulting in improved employee health, lower subsequent health care costs and reduced illness-related absences and disability, as well as enhanced employee engagement and retention rates. Actuarial modeling can help to quantify these potential impacts and help to establish the business case for more equitable benefit design.

The emerging employer focus on DEI is timely and long overdue. Employers and their broker partners are encouraged to take a close look at their current health benefits strategies through this new lens to ensure that benefits are equitable and affordable for all employees. The path toward more equitable health benefits for lower-wage workers can include premium and/or HSA subsidies, pre-deductible coverage of medications for chronic conditions, elimination of copay accumulator adjustment programs, or other approaches. Open conversation with employees can help to identify the best options.

It's clear that in today's environment, doing nothing to improve access to equitable benefits design should no longer be a viable option.

Bruce Sherman, MD, is a medical advisor for the National Alliance of Healthcare Purchaser Coalitions. Kimberly Westrich, MA, is the vice president for health services research for the National Pharmaceutical Council.

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