August 2009 Data Brief Paying the Price: How Health Insurance Premiums Are Eating Up Middle-Class Incomes State Health Insurance Premium Trends and the Potential of National Reform The mission of The Commonwealth Cathy S choen , J ennifer L. N icholson , and S heila D. R ustgi Fund is to promote a high performance health care system. The Fund carries The Commonwealth F und out this mandate by supporting independent research on health care issues and making grants to improve ABSTRACT: The rapid rise in health insurance premiums has severely strained U.S. fami- health care practice and policy. Support lies and employers in recent years. This analysis of federal data finds that if premiums for for this research was provided by The Commonwealth Fund. The views employer-sponsored insurance grow in each state at the projected national rate of increase, presented here are those of the authors then the average premium for family coverage would rise from $12,298 (the 2008 aver- and not necessarily those of The age) to $23,842 by 2020—a 94 percent increase. However, if health system reforms were Commonwealth Fund or its directors, able to slow premium growth by 1 percentage point in all states, by 2020 employers and officers, or staff. families together would save $2,571 per premium for family coverage, compared with projected trends. If growth could be slowed by 1.5 percentage points—a target recently agreed to by a major industry coalition—yearly savings would equal $3,759. The analysis presents state-by-state data on premium costs for 2003 and 2008, as well as projections, using various assumptions, for costs in 2015 and 2020. For more information about this study, please contact:      Cathy Schoen, M.S. Senior Vice President Research & Evaluation OVERVIEW The Commonwealth Fund Across the United States, middle-income individuals and families have been los- cs@cmwf.org ing ground as the cost of health insurance continues to rise at a faster rate than incomes. Rising employer insurance premiums have forced many working fami- lies to trade off increases in their wages just to hold onto their health benefits. The To learn more about new publications expanding share of health insurance premiums paid by workers themselves has when they become available, visit the also taken a greater cut out of paychecks. In state after state, premiums are up as Fund's Web site and register to receive e-mail alerts. a share of median household income, making it difficult for many U.S. families to Commonwealth Fund pub. 1313 save for education or retirement—or simply to meet day-to-day living expenses— Vol. 17 and for employers to maintain the level of health benefits they provide. 2T he  C ommonwealth F und This data brief examines recent trends in health rate for all states. Next, we estimated the potential sav- insurance premiums and projects future premium ings in the cost of family premiums if reforms were increases state by state if the nation continues on its enacted that slowed the increase by 1 or 1.5 percentage current course. It also projects the potential savings points in each state. The tables at the end of this brief for families and employers—money on the table— provide state-specific data. if national health reform is enacted and succeeds in It is important to note that these estimates are reducing annual growth in health care costs by up to presented for illustrative purposes only; we did not 1.5 percentage points per year in each state—the same attempt to model the impact of reforms at the state target set by an industry coalition as part of a recent level, nor did we vary estimates for relatively higher- pledge to slow health spending over the next decade.1 or lower-cost states. The analysis finds that if insurance premiums for employer-sponsored health plans in each state grow at FINDINGS the projected national rate of increase, then the average Recent Trends premium for family coverage would rise from $12,298 Between 1999 and 2008, employer-sponsored fam- (the average for 2008) to $23,842 by 2020. This is an ily health insurance premiums rose by 119 percent increase of 94 percent. nationally, while median family income rose by 29 On the other hand, if health system reforms percent.2 Such a rapid increase in the cost of employer- were able to slow the annual rate of growth by 1 sponsored health benefits has forced difficult choices percentage point in all states, by 2020 an average of at workplaces across the country. Studies indicate $2,571 could be saved annually on family health plans, that slower growth in wages and lower savings for compared with projected trends. If growth could be retirement (worker and employer contributions) have slowed by 1.5 percentage points, the savings would be been part of the trade-off to preserve health benefits.3 even larger—$3,759 per year. Despite such trade-offs, the monthly cost of premiums paid by workers and their families is up—consuming HOW THIS STUDY WAS CONDUCTED an ever-greater share of any wage increases they This data brief first presents recent premium and might receive.4 income trends by state for the under-65 population. At the state level, premiums have risen rapidly, The data for these trends come from the federal gov- and far faster than average incomes. In the five years ernment’s most recent annual surveys of employ- from 2003 to 2008, total premiums for family cover- ers—conducted for the insurance component of the age under employer-sponsored plans rose a cumulative Medical Expenditure Panel Survey (MEPS)—and average of 33 percent. The five-year increase in family from U.S. Census surveys of households. The premi- premiums ranged from about 25 percent in the three ums presented include the total costs of the average lowest-growth states (Michigan, Texas, and Ohio) to 45 private group health insurance premium for employer- percent in the two highest-growth states (Indiana and sponsored coverage, including both the employer and North Carolina). Twelve states saw increases of 40 per- employee shares. For each state, we compared the total cent or more and 36 states saw increases of 30 percent premium with median household income for the under- or more—well above the rate of income growth. 65 population. By 2008, the average employer-sponsored fam- To calculate the potential costs over the next ily premium across all states was $12,298, ranging decade, we estimated premiums if all states experi- from more than $13,500 in Massachusetts, Minnesota, enced increases that conformed to projected trends in New Hampshire, and Indiana to $11,000–$11,500 in national per capita health expenditures in the absence the 14 states with the lowest average premium costs of health reform. We also assumed the same inflation (Figure 1 and Table 1).5 Average family premiums in P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 3 Figure 1. Premiums for Family Coverage, by State, 2008 Annual premium amount, in dollars $15,000 $14,000 $13,000 U.S. Average: $12,298 $12,000 $11,000 $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 0 West Virginia New Hampshire Michigan Missouri New Mexico Nebraska Idaho Hawaii Oklahoma Alabama North Dakota Louisiana Mississippi South Dakota Montana Kentucky Georgia Utah Colorado Texas South Carolina New Jersey Rhode Island New York Wisconsin Vermont Maine Alaska Connecticut Indiana Iowa Ohio Virginia California Arizona Tennessee North Carolina Minnesota Arkansas Nevada Pennsylvania Maryland Oregon Illinois Florida Wyoming Delaware Kansas Washington Massachusetts Data source: 2008 Medical Expenditure Panel Survey–Insurance Component. the highest-premium-cost states were about 25 percent 2, cost pressures are particularly acute in states in the above the lowest-cost states. South and the south-central U.S., where premium costs People with employer-sponsored insurance typi- are high relative to incomes. The high ratio of premi- cally do not see the total annual cost of the premium, ums to income often reflects both high premiums and since most employers pay a substantial share of it. median incomes that are below the national average Nevertheless, the steady increase in premiums has (see Table 2 for median incomes). Many states with been consuming resources that employers might oth- premiums above the national average have family erwise have earmarked for salary or wage increases, incomes below the national average. or for other benefits. When viewed as a percentage of With premiums increasing faster than incomes workers’ income, health insurance premiums (includ- in low- as well as higher-income states, health insur- ing both the employer and employee shares) are up for ance has become ever less affordable. Premium middle-income families across the country. By 2008, increases have occurred despite the fact that employers annual family premiums were 18 percent or more of have been raising cost-sharing or limiting benefits in median income in 18 states, compared with just three an effort to moderate annual premium growth. Thus, states in 2003 (Figure 2 and Table 2). In three states— as of 2008, premiums are often buying less in scope Mississippi, Tennessee, and West Virginia—family pre- of benefits or financial protection than they had been miums averaged 20 percent or more of median income at the start of the decade, and families are paying not for middle-income households within the under-65 only higher premiums but higher out-of-pocket costs population. for medical bills.6 Deductibles for employer-sponsored By 2008, average premiums were at or above 16 plans overall have tripled between 2000 and 2008, percent of median income in 37 of the 50 states and the and those for plans offered by firms with fewer than District of Columbia. And only three states had premi- 200 employees have more than quadrupled during this ums averaging less than 14 percent of median income, period.7 Heading into the recession that began in 2008, down from 13 states in 2003. As illustrated in Figure middle- and lower-income working families were in a 4T he  C ommonwealth F und Figure 2. Employer Premiums as Percentage of Median Household Income for Under-65 Population, 2003 and 2008 Number of referrals, by state fiscal year 2003 2008 NH ME WA VT NH ME ND WA VT MT MN MT ND OR MN NY MA WI OR NY MA ID SD RI WI MI ID SD WY MI RI PA CT WY IA NJ PA CT NE OH IA NJ IN DE NE OH NV IN DE IL WV VA MD NV UT IL MD CO DC UT WV VA CA KS MO KY CO DC CA KS MO KY NC TN NC OK TN AR SC AZ NM OK AR SC MS AL GA AZ NM MS AL GA TX LA TX LA FL FL AK AK HI 18% or more HI 16%–17.9% 14%–15.9% Less than 14% Data sources: 2003 and 2008 Medical Expenditure Panel Survey–Insurance Component (for average premiums for employer-based health insurance plans, weighted by single and family household distribution); 2004–2005 and 2008 Current Population Surveys (for median household incomes). precarious position, with millions at risk of joining the Potential Savings with National Reforms ranks of the uninsured. The current debate over national health reform is Underscoring the consequences of higher pre- centered on how to ensure affordable coverage for miums for living standards, median incomes have everyone, slow the increase in costs, and enhance generally failed to keep up with the costs of living, quality and value for those with insurance. Recent esti- not counting health care costs. From 2003 to 2007, mates indicate that a combination of insurance market before the onset of the current severe recession, median reforms, payment incentives that reward high-value incomes increased by less than 11 percent on average, care, and other health system reforms to bring about failing to keep up with the general inflation rate in 25 more patient-centered, coordinated care could reduce states (Table 2).8 Stagnant incomes have left workers national costs by an average of 1 to 1.5 percentage and their families with less money available for mort- points per year over the next decade.10 These targets gage expenses, education, or the daily cost of living.9 are also consistent with a recent pledge made by an industry coalition to slow spending by 1.5 percent- Projected Increases over the Next Decade age points annually over the next decade.11 If reforms Absent significant reforms, current projections esti- were to succeed in “bending the cost curve” within mate that national per-person spending on health insur- this range, the result would be much-lower premium ance premiums will increase by 94 percent from 2009 increases and potentially substantial increases in to 2020, increasing an average of 5.7 percent annually. incomes if savings accrued to families in the form of In recent years, per-person spending increases in most higher wages or salaries. states have followed national trends. To project the potential savings in each state, Using these national projections, and applying we calculated the differences in premiums under the the same rate of increase to all states, average total following three scenarios: 1) if premium growth con- family premiums would reach $17,599 by 2015 and tinues at current rates; 2) if premium growth slowed to $23,842 by 2020 (Figure 3 and Table 3). Projections 1 percentage point lower than current rates; and 3) if for family premiums in 2020 range from $21,009 in premium growth slowed to 1.5 percentage points lower Idaho to $26,730 in Massachusetts. P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 5 family coverage premiums would range from $3,312 Figure 3. Premiums for Family Coverage, 2003, 2008, 2015, and 2020 in Idaho in 2020 to $4,214 in Massachusetts (Tables 4 and 5) compared with premium costs by 2020 if trends Health insurance premiums for family coverage continue as projected. 2003 2008 2015 2020 Because this analysis did not model the impact $30,000 26,730 $25,000 23,842 of potential reforms at the state level, the projected sav- 21,009 19,731 ings for each state must be viewed with caution. To the $20,000 17,599 15,508 extent that there might be more room to achieve sav- $15,000 13,788 12,298 10,837 10,748 ings from delivering more cost-effective and efficient $10,000 9,249 7,866 care in higher-cost states, the potential gains might be $5,000 greater in these states than those starting the decade $0 with relatively lower costs. Regardless of the starting U.S. average Lowest state1 Highest state point, however, the contrast in the cost consequences 1 2003: Lowest is North Dakota; highest is District of Columbia. 2008, 2015, and 2020: Lowest is Idaho; highest is Massachusetts. of possible premium growth rates illustrate the high Data sources: Medical Expenditure Panel Survey–Insurance Component (for 2003 and 2008 premiums); Centers for Medicare and Medicaid Services, Office of the Actuary, National Health risk the nation faces if current trends persist, as well Statistics Group, national health expenditures per capita annual growth rate (for premium estimates for 2015 and 2020). as the potential gains for families and employers in all states if comprehensive reforms are enacted. than current rates. Rather than projecting the premium savings to households and employers that might be possible in each state given its particular starting point, For state-specific data: Starting on page 8, savings in each state were projected for both 2015 and see Tables 1 and 2, for average premiums for 2020 using the same percentage reductions for single and family coverage and premiums as all states. a percentage of median household income for nonelderly households, by state, for 2003 and In all states, reducing the rate of premium 2008. See Table 3 for projected increases by state increase by 1 or 1.5 percent per year would yield sub- and Tables 4 and 5 for potential savings if reforms stantial savings compared with projected trends. If pre- successfully moderate cost growth. mium growth were to slow to 1 percentage point lower than the projected national growth rate, an average of $1,138 would be saved annually on family coverage CONCLUSIONS AND POLICY IMPLICATIONS by 2015 (Figure 4 and Table 5). The annual savings for Over the last several years, the combination of ris- families and employers would increase to $2,571 by ing health care costs and slow growth in real incomes 2020. Average savings from family coverage premiums has left individuals and working families spending a would range from $2,265 in Idaho in 2020 to $2,882 in greater percentage of their income and total compensa- Massachusetts (Table 5). These savings could be used tion from work on health insurance premiums, often by employers to increase wages, contribute to retire- with greater out-of-pocket cost-sharing and less-com- ment savings plans, or add workers. prehensive benefits. With rising costs and eroding cov- Even greater amounts could be saved if the erage, much is at stake for the insured and uninsured annual premium growth rates were to slow by 1.5 alike as the nation debates health care reform. percentage points over the decade. An average $1,682 To ensure that coverage is more affordable could be saved annually on family coverage by 2015 now and in the future, it is critical that any reforms with a 1.5-percentage-point-lower growth rate in pre- enacted address long-term growth in health care costs. miums (Figure 4 and Table 5). The savings would more Proposals in Congress include several measures that than double to $3,759 annually by 2020. Savings from would provide insurance coverage for everyone and 6T he  C ommonwealth F und significantly slow the rate of cost increases, while at premiums and out-of-pocket health care spending. The the same time improving quality. For example, hav- Congressional Budget Office estimates that premiums ing the choice of a publicly sponsored insurance under a public health plan would be 10 percent lower option that competes with private insurance plans— than those of typical private plans—a cost break that in addition to reforms that support a more patient- would provide much-needed relief to families and busi- centered, effective, and efficient health care delivery nesses, with greater potential gains in future years.13 system—could yield gains for people in every state. The stakes are high in the health reform debate. Commonwealth Fund analysis indicates that reorient- Without a change in course, projections of premium ing the health insurance market so that it fosters greater trends indicate that middle- as well as lower-income value in health care—higher quality at lower cost— families may well be priced out of the insurance mar- could result in $2 trillion to $3 trillion in health system ket, or forced to sacrifice future wage increases to hold savings between 2010 and 2020 (a reduction in annual onto shrinking health benefits. spending growth of 1 to 1.5 percent), if paired with There is now an opportunity for comprehensive provider payment and health system reforms.12 These health reform—focused on better access, better qual- reforms include leveraging public purchasing power, ity, and slower cost growth—to put the country on a reducing administrative waste, creating incentives for path of rising family income, savings for education and better health and cost outcomes, and having insur- retirement, and health security. Our analysis suggests ance companies work in the public interest. The bulk that in every state—regardless of size or geographic of the savings would benefit families and individuals, region—insured people stand to gain when reform is who would see slower growth in their health insurance truly in the public interest. Figure 4. Projected Annual Savings in Family Premiums, 2015 and 2020 2015 2020 1% Savings 1.5% Savings 1% Savings 1.5% Savings Average of highest 10 premium states $1,245 $1,842 $2,814 $4,114 (MA, MN, NH, IN, CT, DC, DE, AK, RI, ME) U.S. average $1,138 $1,682 $2,571 $3,759 Average of lowest 10 premium states $1,029 $1,522 $2,327 $3,401 (ID, IA, HI, OK, AL, ND, LA, AR, MI, MS) Data sources: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2008 Medical Expenditure Panel Survey–Insurance Component (2008 premiums); Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, national health expenditures per capita annual growth rate (premium estimates for 2015 and 2020). P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 7 6 N otes C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, “How Many Are Underinsured? Trends 1 The coalition comprises the American Hospital Among U.S. Adults, 2003 and 2007,” Health Affairs Association (AHA), the American Medical Web Exclusive, June 10, 2008:w298–w309; Association (AMA), America’s Health Insurance D. Rowland, C. Hoffman, and M. McGinn-Shapiro, Plans (AHIP), the Pharmaceutical Research Health Care and the Middle Class: More Costs and and Manufacturers of Americas (PhRMA), the Less Coverage, (Menlo Park, Calif.: Henry J. Kaiser Advanced Medical Technology Association Family Foundation, July 2009). (AdvaMed), and the Service Employees 7 The Kaiser Family Foundation and Health Research International Union (SEIU). Letter to President & Educational Trust Employer Health Benefits 2008 Obama, May 11, 2009. Accessed at http://www. Annual Survey. Available at: http://ehbs.kff.org/. whitehouse.gov/assets/documents/05-11-09_ 8 Health_Costs_Letter_to_the_President.pdf. For General inflation between 2003 and 2007 was discussion, see fact sheet at http://www.whitehouse. 12.7 percent. Economic Report of the President gov/assets/documents/Fact_Sheet-Health_Reform_ (Washington, D.C.: United States Government Stakeholders_5-11-09.pdf. Printing Office, Jan. 2009). 9 2 Family premiums from Kaiser/HRET Survey of R. Helman, C. Copeland, and J. VanDerhei, The Employer-Sponsored Health Benefits, 1999–2008; 2009 Retirement Confidence Survey: Economy median family income from U.S. Census Bureau, Drives Confidence to Record Lows; Many Current Population Survey. Looking to Work Longer, EBRI Issue Brief #328 3 (Washington, D.C.: Employee Benefit Research K. Baicker and A. Chandra, The Labor Market Institute, April 2009). Effects of Rising Health Insurance Premiums, 10 NBER Working Paper No. 11160 (Cambridge, C. Schoen, K. Davis, S. Guterman, and K. Mass.: National Bureau of Economic Research, Feb. Stremikis, Fork in the Road: Alternative Paths to a 2005); D. Goldman, N. Sood, and A. Leibowitz, High Performance U.S. Health System (New York: Wage and Benefit Changes in Response to Rising The Commonwealth Fund, June 2009). Health Insurance Costs, NBER Working Paper 11 See note 1. No. 11063 (Cambridge, Mass.: National Bureau of 12 Economic Research, Jan. 2005); N. Sood, A. Ghosh, Schoen et al., Fork in the Road, 2009. and J. J. Escarce, “Employer-Sponsored Insurance, 13 D. W. Elmendorf (Congressional Budget Office), Health Care Cost Growth, and the Economic letter to Charles B. Rangel, July 14, 2009; accessed Performance of U.S. Industries,” Health Services at http://www.cbo.gov/ftpdocs/104xx/doc10430/ Research, published online June 3, 2009. House_Tri-Committee-Rangel.pdf. 4 Analysis of data from Henry J. Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. 5 Idaho, Iowa, Hawaii, Oklahoma, Alabama, North Dakota, Louisiana, Arkansas, Michigan, Mississippi, South Dakota, Ohio, Montana, and Nevada. 8T he  C ommonwealth F und Click here to see Table 1 ranked by 2008 family premium Table 1. Single and Family Average Health Insurance Premiums, by State, 2003 and 2008 Percent Increase: 2003 2008 2003–08 Single Family Single Family Single Family United States 3,481 9,249 4,386 12,298 26% 33% Alabama 3,156 8,045 4,139 11,119 31% 38% Alaska 4,011 10,564 5,293 13,383 32% 27% Arizona 3,209 8,972 4,214 12,292 31% 37% Arkansas 3,127 7,977 3,923 11,220 25% 41% California 3,293 9,091 4,280 12,254 30% 35% Colorado 3,645 9,522 4,303 11,952 18% 26% Connecticut 3,676 10,119 4,740 13,436 29% 33% Delaware 3,854 10,499 4,733 13,386 23% 27% District of Columbia 3,740 10,748 4,890 13,427 31% 25% Florida 3,592 9,331 4,517 12,697 26% 36% Georgia 3,624 8,641 4,160 11,659 15% 35% Hawaii 3,020 7,887 3,831 11,044 27% 40% Idaho 3,331 8,563 4,104 10,837 23% 27% Illinois 3,692 9,693 4,643 12,603 26% 30% Indiana 3,493 9,315 4,495 13,504 29% 45% Iowa 3,270 8,436 4,146 10,947 27% 30% Kansas 3,401 8,907 4,197 11,662 23% 31% Kentucky 3,437 9,118 4,009 11,506 17% 26% Louisiana 3,317 8,735 4,055 11,207 22% 28% Maine 3,852 10,308 4,910 13,102 27% 27% Maryland 3,427 9,217 4,360 12,541 27% 36% Massachusetts 3,496 9,867 4,836 13,788 38% 40% Michigan 3,671 9,449 4,388 11,321 20% 20% Minnesota 3,679 10,066 4,432 13,639 20% 35% Mississippi 3,305 8,075 4,124 11,363 25% 41% Missouri 3,305 8,984 4,124 11,557 25% 29% Montana 3,506 8,542 4,355 11,438 24% 34% Nebraska 3,506 9,139 4,392 11,648 25% 27% Nevada 3,578 8,831 3,927 11,487 10% 30% New Hampshire 3,563 9,776 5,247 13,592 47% 39% New Jersey 3,814 10,168 4,798 12,789 26% 26% New Mexico 3,361 9,299 4,074 12,071 21% 30% New York 3,592 9,439 4,638 12,824 29% 36% North Carolina 3,411 8,463 4,460 12,308 31% 45% North Dakota 2,999 7,866 3,830 11,178 28% 42% Ohio 3,416 9,136 4,089 11,425 20% 25% Oklahoma 3,285 8,739 4,072 11,053 24% 26% Oregon 3,362 8,861 4,384 12,585 30% 42% Pennsylvania 3,449 9,133 4,499 12,339 30% 35% P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 9 Rhode Island 3,725 9,460 4,930 13,363 32% 41% South Carolina 3,371 8,918 4,477 12,068 33% 35% South Dakota 3,361 8,499 4,233 11,382 26% 34% Tennessee 3,597 9,261 4,276 12,302 19% 33% Texas 3,400 9,575 4,205 11,967 24% 25% Utah 3,352 8,349 4,197 11,783 25% 41% Vermont 3,596 9,483 4,900 13,091 36% 38% Virginia 3,322 9,176 4,202 11,935 26% 30% Washington 3,520 9,212 4,404 13,036 25% 42% West Virginia 3,809 9,164 4,892 12,887 28% 41% Wisconsin 3,749 9,562 4,777 12,956 27% 35% Wyoming 3,706 9,612 4,622 12,734 25% 32% Note: Premiums are for insurance policies offered by private-sector employers in the U.S. Data: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2003 and 2008 Medical Expenditure Panel Survey-Insurance Component. 10T he  C ommonwealth F und Click here to see Table 2 ranked by 2008 premium as a percentage of median household income Table 2. Health Insurance Premiums as Percentage of Median Household Income, 2003 and 2008 Median household income for Employer premiums as percent of median under-65 population household income for under-65 population 2003–04 2007 2003 2008 United States $48,442 $53,685 15.0 17.2 Alabama 46,000 48,000 14.9 17.5 Alaska 56,108 65,850 15.5 16.2 Arizona 42,500 49,600 16.3 18.9 Arkansas 37,899 49,090 17.3 18.8 California 46,030 52,000 14.8 17.1 Colorado 53,430 64,830 13.8 13.9 Connecticut 65,032 69,150 12.6 14.3 Delaware 52,000 60,000 15.4 16.7 District of Columbia 40,000 42,904 16.9 19.0 Florida 45,000 50,000 16.2 18.5 Georgia 45,000 54,202 14.9 16.1 Hawaii 48,084 53,680 12.1 14.1 Idaho 47,322 56,834 15.5 16.1 Illinois 52,016 57,000 14.7 16.9 Indiana 50,000 56,611 15.0 18.1 Iowa 53,650 58,050 13.1 14.8 Kansas 51,082 55,000 14.5 16.0 Kentucky 42,419 46,000 16.8 19.5 Louisiana 38,700 45,000 17.8 18.7 Maine 45,840 55,045 17.7 19.0 Maryland 60,000 69,500 11.8 13.3 Massachusetts 60,432 63,867 12.4 15.6 Michigan 52,490 60,000 14.7 15.3 Minnesota 63,510 68,000 12.9 15.4 Mississippi 39,018 43,094 16.8 20.0 Missouri 50,967 50,000 14.1 17.3 Montana 37,457 50,000 17.8 17.4 Nebraska 52,082 57,000 14.4 16.5 Nevada 45,000 52,000 15.0 16.9 New Hampshire 66,078 74,317 12.3 14.9 New Jersey 65,000 69,560 12.2 13.9 New Mexico 36,300 45,000 19.7 19.0 New York 47,000 51,101 15.1 17.6 North Carolina 43,662 46,002 15.6 19.9 North Dakota 49,750 56,250 13.3 15.9 Ohio 51,084 55,025 14.5 16.1 Oklahoma 42,162 48,000 17.1 18.3 Oregon 45,350 52,305 15.1 18.1 Pennsylvania 52,178 56,500 13.8 16.5 P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 11 Median household income for Employer premiums as percent of median under-65 population household income for under-65 population 2003–04 2007 2003 2008 Rhode Island 52,031 58,800 14.2 16.8 South Carolina 44,488 50,000 16.2 18.6 South Dakota 49,818 54,922 14.6 15.8 Tennessee 44,064 46,000 17.4 20.3 Texas 40,050 45,640 18.4 19.3 Utah 52,033 60,090 14.0 16.5 Vermont 52,606 55,506 14.1 18.5 Virginia 56,000 61,000 12.9 14.7 Washington 54,400 62,300 13.7 15.7 West Virginia 38,400 46,066 19.3 23.1 Wisconsin 52,760 62,485 14.8 17.3 Wyoming 51,560 59,136 16.0 17.4 Data: Average premiums for employer-based health insurance plans (weighted by single and family household distribution)—2003 and 2008 Medical Expenditure Panel Survey- Insurance Component; Median household incomes—2004-2005 and 2008 Current Population Surveys. Table 3. Average Total Premium (in dollars) for Employer-Sponsored Health Insurance at Current Growth Rate and at 1% and 1.5% Below Current Growth Rate, 2015 and 2020 At Current Growth Rate At 1% Below Current Growth Rate At 1.5% Below Current Growth Rate Single Family Single Family Single Family State 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 United States $6,289 $8,519 $17,599 $23,842 $5,882 $7,601 $16,461 $21,271 $5,688 $7,176 $15,917 $20,083 Alabama 5,934 8,039 15,912 21,556 5,551 7,173 14,883 19,232 5,367 6,772 14,391 18,158 Alaska 7,589 10,281 19,152 25,945 7,099 9,172 17,914 23,147 6,864 8,660 17,321 21,855 Arizona 6,042 8,185 17,590 23,830 5,651 7,303 16,453 21,260 5,464 6,895 15,909 20,073 Arkansas 5,625 7,620 16,056 21,752 5,261 6,798 15,018 19,406 5,087 6,419 14,521 18,323 California 6,137 8,313 17,536 23,756 5,740 7,417 16,403 21,195 5,550 7,003 15,860 20,011 Colorado 6,170 8,358 17,104 23,171 5,771 7,457 15,998 20,672 5,580 7,040 15,469 19,518 Connecticut 6,796 9,207 19,228 26,048 6,357 8,214 17,985 23,239 6,147 7,755 17,390 21,941 Delaware 6,786 9,193 19,156 25,951 6,347 8,202 17,918 23,153 6,137 7,744 17,325 21,860 District of Columbia 7,011 9,498 19,215 26,030 6,558 8,474 17,973 23,224 6,341 8,001 17,378 21,927 Florida 6,476 8,774 18,170 24,615 6,058 7,828 16,995 21,961 5,857 7,391 16,433 20,735 Georgia 5,964 8,080 16,685 22,603 5,579 7,209 15,606 20,166 5,394 6,807 15,090 19,040 Hawaii 5,493 7,441 15,805 21,411 5,138 6,639 14,783 19,102 4,968 6,268 14,294 18,035 Idaho 5,884 7,971 15,508 21,009 5,504 7,112 14,506 18,744 5,322 6,715 14,026 17,697 Illinois 6,657 9,018 18,036 24,433 6,227 8,046 16,870 21,798 6,021 7,597 16,311 20,581 Indiana 6,445 8,731 19,325 26,180 6,028 7,790 18,076 23,357 5,829 7,355 17,478 22,052 Iowa 5,944 8,053 15,666 21,223 5,560 7,185 14,653 18,934 5,376 6,784 14,168 17,877 Kansas 6,018 8,152 16,689 22,609 5,629 7,273 15,610 20,171 5,442 6,867 15,094 19,044 Kentucky 5,748 7,787 16,466 22,306 5,377 6,947 15,401 19,901 5,199 6,559 14,892 18,790 Louisiana 5,814 7,876 16,038 21,727 5,438 7,027 15,001 19,384 5,258 6,635 14,505 18,301 Maine 7,040 9,537 18,750 25,400 6,585 8,509 17,538 22,661 6,367 8,034 16,957 21,396 Maryland 6,251 8,469 17,947 24,313 5,847 7,556 16,787 21,691 5,654 7,134 16,231 20,480 Massachusetts 6,934 9,393 19,731 26,730 6,486 8,380 18,456 23,848 6,271 7,913 17,845 22,516 Michigan 6,291 8,523 16,201 21,948 5,885 7,604 15,154 19,581 5,690 7,180 14,652 18,488 12T he  C ommonwealth F und Minnesota 6,354 8,609 19,518 26,441 5,944 7,680 18,256 23,590 5,747 7,252 17,652 22,273 Mississippi 5,913 8,010 16,261 22,029 5,531 7,147 15,210 19,654 5,348 6,748 14,707 18,556 At Current Growth Rate At 1% Below Current Growth Rate At 1.5% Below Current Growth Rate Single Family Single Family Single Family P aying State 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 the Missouri 5,913 8,010 16,539 22,405 5,531 7,147 15,470 19,989 5,348 6,748 14,958 18,873 Montana 6,244 8,459 16,368 22,174 5,841 7,547 15,310 19,783 5,647 7,126 14,804 18,679 Nebraska 6,297 8,531 16,669 22,582 5,890 7,611 15,591 20,147 5,695 7,186 15,075 19,022 Nevada 5,630 7,628 16,438 22,269 5,267 6,805 15,376 19,868 5,092 6,425 14,867 18,759 New Hampshire 7,523 10,192 19,451 26,350 7,037 9,093 18,193 23,509 6,804 8,585 17,591 22,196 New Jersey 6,879 9,319 18,302 24,794 6,435 8,315 17,119 22,120 6,222 7,850 16,552 20,885 New Mexico 5,841 7,913 17,274 23,402 5,464 7,060 16,158 20,878 5,283 6,666 15,623 19,712 New York 6,650 9,009 18,352 24,861 6,220 8,037 17,165 22,181 6,014 7,589 16,597 20,942 North Carolina 6,395 8,663 17,613 23,861 5,981 7,729 16,475 21,288 5,783 7,297 15,930 20,099 North Dakota 5,491 7,439 15,996 21,670 5,136 6,637 14,962 19,334 4,967 6,267 14,467 18,254 Ohio 5,863 7,942 16,350 22,149 5,484 7,086 15,293 19,761 5,302 6,690 14,787 18,657 Oklahoma 5,838 7,909 15,817 21,428 5,461 7,057 14,795 19,117 5,280 6,663 14,305 18,050 Oregon 6,286 8,515 18,010 24,398 5,879 7,597 16,846 21,767 5,685 7,173 16,288 20,552 Pennsylvania 6,451 8,739 17,658 23,921 6,034 7,796 16,516 21,342 5,834 7,361 15,970 20,150 Rhode Island 7,068 9,576 19,123 25,906 6,612 8,543 17,887 23,113 6,393 8,066 17,295 21,822 South Carolina 6,419 8,696 17,270 23,396 6,004 7,758 16,154 20,873 5,806 7,325 15,619 19,707 South Dakota 6,069 8,222 16,288 22,066 5,677 7,336 15,235 19,686 5,489 6,926 14,731 18,587 Tennessee 6,131 8,305 17,605 23,849 5,735 7,410 16,467 21,278 5,545 6,996 15,922 20,090 Texas 6,029 8,168 17,125 23,200 5,639 7,287 16,018 20,698 5,453 6,880 15,488 19,542 P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes Utah 6,018 8,152 16,862 22,843 5,629 7,273 15,772 20,380 5,442 6,867 15,250 19,242 Vermont 7,025 9,518 18,734 25,379 6,571 8,491 17,523 22,642 6,354 8,017 16,943 21,378 Virginia 6,025 8,162 17,080 23,138 5,635 7,282 15,976 20,643 5,449 6,875 15,447 19,490 Washington 6,314 8,554 18,655 25,272 5,906 7,632 17,449 22,547 5,711 7,206 16,872 21,288 West Virginia 7,014 9,502 18,442 24,984 6,561 8,478 17,250 22,290 6,344 8,004 16,679 21,045 Wisconsin 6,849 9,279 18,541 25,117 6,407 8,278 17,342 22,409 6,195 7,816 16,768 21,158 Wyoming 6,627 8,978 18,223 24,687 6,199 8,010 17,045 22,025 5,994 7,562 16,481 20,795 13 Data: Calculated based on 2008 premium data from Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2008 Medical Expenditure Panel Survey-Insurance Component; Premium estimates for 2015 and 2020 based on Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group, national health expenditures per capita annual growth rate. 14T he  C ommonwealth F und Table 4. Annual Amount Saved on Single Premiums, at 1% and 1.5% Below Current Growth Rate, 2015 and 2020 Amount Saved Annually Amount Saved Annually with 1% Savings with 1.5% Savings State 2015 2020 2015 2020 United States $406 $919 $601 $1,343 Alabama 384 867 567 1,267 Alaska 490 1,108 725 1,621 Arizona 390 882 577 1,290 Arkansas 363 822 538 1,201 California 397 896 586 1,310 Colorado 399 901 590 1,317 Connecticut 439 993 649 1,451 Delaware 439 991 649 1,449 District of Columbia 453 1,024 670 1,497 Florida 419 946 619 1,383 Georgia 385 871 570 1,274 Hawaii 355 802 525 1,173 Idaho 380 859 562 1,257 Illinois 430 972 636 1,422 Indiana 416 941 616 1,376 Iowa 384 868 568 1,269 Kansas 389 879 575 1,285 Kentucky 371 840 549 1,227 Louisiana 376 849 556 1,242 Maine 455 1,028 673 1,503 Maryland 404 913 597 1,335 Massachusetts 448 1,013 663 1,481 Michigan 407 919 601 1,343 Minnesota 411 928 607 1,357 Mississippi 382 864 565 1,263 Missouri 382 864 565 1,263 Montana 404 912 597 1,333 Nebraska 407 920 602 1,345 Nevada 364 822 538 1,202 New Hampshire 486 1,099 719 1,606 New Jersey 445 1,005 657 1,469 New Mexico 377 853 558 1,247 New York 430 971 636 1,420 North Carolina 413 934 611 1,366 North Dakota 355 802 525 1,173 Ohio 379 856 560 1,252 Oklahoma 377 853 558 1,247 Oregon 406 918 601 1,342 Pennsylvania 417 942 616 1,377 P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 15 Amount Saved Annually Amount Saved Annually with 1% Savings with 1.5% Savings State 2015 2020 2015 2020 Rhode Island 457 1,032 676 1,509 South Carolina 415 938 613 1,371 South Dakota 392 886 580 1,296 Tennessee 396 895 586 1,309 Texas 390 881 576 1,287 Utah 389 879 575 1,285 Vermont 454 1,026 671 1,500 Virginia 389 880 576 1,287 Washington 408 922 603 1,348 West Virginia 453 1,024 670 1,498 Wisconsin 443 1,000 655 1,463 Wyoming 428 968 633 1,415 Data: Calculated based on 2008 premium data from Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2008 Medical Expenditure Panel Survey-Insurance Component; Premium estimates for 2015 and 2020 based on Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group, national health expenditures per capita annual growth rate. 16T he  C ommonwealth F und Table 5. Annual Amount Saved on Family Premiums, at 1% and 1.5% Below Current Growth Rate, 2015 and 2020 Amount Saved Annually Amount Saved Annually with 1% Savings with 1.5% Savings State 2015 2020 2015 2020 United States $1,138 $2,571 $1,682 $3,759 Alabama 1,029 2,324 1,521 3,398 Alaska 1,238 2,798 1,831 4,090 Arizona 1,137 2,570 1,682 3,757 Arkansas 1,038 2,346 1,535 3,429 California 1,134 2,562 1,676 3,745 Colorado 1,106 2,499 1,635 3,653 Connecticut 1,243 2,809 1,838 4,107 Delaware 1,238 2,798 1,831 4,091 District of Columbia 1,242 2,807 1,837 4,104 Florida 1,175 2,654 1,737 3,881 Georgia 1,079 2,437 1,595 3,563 Hawaii 1,022 2,309 1,511 3,375 Idaho 1,002 2,265 1,483 3,312 Illinois 1,166 2,635 1,724 3,852 Indiana 1,249 2,823 1,847 4,127 Iowa 1,013 2,288 1,498 3,346 Kansas 1,079 2,438 1,595 3,564 Kentucky 1,064 2,405 1,574 3,517 Louisiana 1,037 2,343 1,533 3,425 Maine 1,212 2,739 1,792 4,004 Maryland 1,160 2,622 1,716 3,833 Massachusetts 1,275 2,882 1,886 4,214 Michigan 1,047 2,367 1,549 3,460 Minnesota 1,262 2,851 1,866 4,169 Mississippi 1,051 2,375 1,554 3,473 Missouri 1,069 2,416 1,581 3,532 Montana 1,058 2,391 1,565 3,496 Nebraska 1,077 2,435 1,593 3,560 Nevada 1,063 2,401 1,571 3,511 New Hampshire 1,257 2,841 1,859 4,154 New Jersey 1,183 2,674 1,750 3,909 New Mexico 1,117 2,523 1,651 3,689 New York 1,186 2,681 1,754 3,919 North Carolina 1,139 2,573 1,684 3,762 North Dakota 1,034 2,337 1,529 3,416 Ohio 1,057 2,388 1,563 3,492 Oklahoma 1,022 2,311 1,512 3,378 Oregon 1,164 2,631 1,722 3,846 P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 17 Amount Saved Annually Amount Saved Annually with 1% Savings with 1.5% Savings State 2015 2020 2015 2020 Pennsylvania 1,141 2,579 1,688 3,771 Rhode Island 1,236 2,794 1,828 4,084 South Carolina 1,116 2,523 1,651 3,688 South Dakota 1,053 2,379 1,557 3,479 Tennessee 1,138 2,572 1,683 3,760 Texas 1,107 2,502 1,637 3,658 Utah 1,090 2,463 1,612 3,601 Vermont 1,211 2,737 1,791 4,001 Virginia 1,104 2,495 1,633 3,648 Washington 1,206 2,725 1,783 3,984 West Virginia 1,192 2,694 1,763 3,939 Wisconsin 1,198 2,708 1,772 3,960 Wyoming 1,178 2,662 1,742 3,892 Data: Calculated based on 2008 premium data from Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2008 Medical Expenditure Panel Survey-Insurance Component; Premium estimates for 2015 and 2020 based on Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group, national health expenditures per capita annual growth rate. 18T he  C ommonwealth F und M ethodology Data for single and family premiums for 2003 and 2008 by state are from the Medical Expenditure Panel Survey–Insurance Component, which is reported by private and public sector employers and is representative by state. State median incomes for 2003–04 and 2007 are from the Current Population Survey. We estimated aver- age premiums from 2008 to 2020 for each state, applying the same rate to all states. To estimate premiums by 2010, we used the average growth rate for single and family insurance premiums over the 2006–08 period from the Kaiser/HRET Survey of Employer-Sponsored Health Benefits and applied this average rate to inflate to 2009 and 2010. We estimated potential premiums from 2011 through 2020 using the average annual growth rate in the Centers for Medicare and Medicaid Services’ estimates of growth in national health expenditures per capita. We then estimated potential savings with slower growth by projected annual growth rates minus 1 percentage point and minus 1.5 percentage points for each year through 2020. P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 19 A bout the A uthors Cathy Schoen, M.S., is senior vice president for research and evaluation at The Commonwealth Fund and research director for The Commonwealth Fund Commission on a High Performance Health System, overseeing the Commission’s Scorecard project and surveys. From 1998 through 2005, she directed the Fund’s Task Force on the Future of Health Insurance. She has authored numerous publications on policy issues, insurance, and health system performance (national and international), and coauthored the book Health and the War on Poverty. She has also served on many federal and state advisory and Institute of Medicine committees. Ms. Schoen holds an under- graduate degree in economics from Smith College and a graduate degree in economics from Boston College. She can be e-mailed at cs@cmwf.org. Jennifer L. Nicholson, M.P.H., is associate program officer for the Affordable Health Insurance program at The Commonwealth Fund, where she is responsible for project development and grants management, and is also involved in researching emerging policy issues regarding the extent and quality of health insurance coverage and access to care in the United States, researching and writing reports and articles, and survey development and analysis. She holds a B.S. in public health from the University of North Carolina at Chapel Hill and an M.P.H. in epidemiology from Columbia University's Mailman School of Public Health. Sheila D. Rustgi is program associate for the Affordable Health Insurance program at The Commonwealth Fund. She is a graduate of Yale University with a B.A. in economics. While in school, she volunteered in several local and international health care organizations, including Yale New Haven Hospital and a Unite for Sight eye clinic. Prior to joining the Fund, she worked as an analyst at a management consulting firm. A cknowledgments The authors thank Sabrina How for initial analysis of premiums compared with median incomes and Bisundev Mahato and Nicholas Tilipman of Columbia University for providing median income data by state based on anal- ysis of CPS data. Editorial support was provided by Christopher Hollander. P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 20 Table 1. Single and Family Average Health Insurance Premiums, by State, 2003 and 2008, Ranked by 2008 Family Premium Percent Increase: 2003 2008 2003–08 Single Family Single Family Single Family United States 3,481 9,249 4,386 12,298 26% 33% Massachusetts 3,496 9,867 4,836 13,788 38% 40% Minnesota 3,679 10,066 4,432 13,639 20% 35% New Hampshire 3,563 9,776 5,247 13,592 47% 39% Indiana 3,493 9,315 4,495 13,504 29% 45% Connecticut 3,676 10,119 4,740 13,436 29% 33% District of Columbia 3,740 10,748 4,890 13,427 31% 25% Delaware 3,854 10,499 4,733 13,386 23% 27% Alaska 4,011 10,564 5,293 13,383 32% 27% Rhode Island 3,725 9,460 4,930 13,363 32% 41% Maine 3,852 10,308 4,910 13,102 27% 27% Vermont 3,596 9,483 4,900 13,091 36% 38% Washington 3,520 9,212 4,404 13,036 25% 42% Wisconsin 3,749 9,562 4,777 12,956 27% 35% West Virginia 3,809 9,164 4,892 12,887 28% 41% New York 3,592 9,439 4,638 12,824 29% 36% New Jersey 3,814 10,168 4,798 12,789 26% 26% Wyoming 3,706 9,612 4,622 12,734 25% 32% Florida 3,592 9,331 4,517 12,697 26% 36% Illinois 3,692 9,693 4,643 12,603 26% 30% Oregon 3,362 8,861 4,384 12,585 30% 42% Maryland 3,427 9,217 4,360 12,541 27% 36% Pennsylvania 3,449 9,133 4,499 12,339 30% 35% North Carolina 3,411 8,463 4,460 12,308 31% 45% Tennessee 3,597 9,261 4,276 12,302 19% 33% Arizona 3,209 8,972 4,214 12,292 31% 37% California 3,293 9,091 4,280 12,254 30% 35% New Mexico 3,361 9,299 4,074 12,071 21% 30% South Carolina 3,371 8,918 4,477 12,068 33% 35% Texas 3,400 9,575 4,205 11,967 24% 25% Colorado 3,645 9,522 4,303 11,952 18% 26% Virginia 3,322 9,176 4,202 11,935 26% 30% Utah 3,352 8,349 4,197 11,783 25% 41% Kansas 3,401 8,907 4,197 11,662 23% 31% Georgia 3,624 8,641 4,160 11,659 15% 35% Nebraska 3,506 9,139 4,392 11,648 25% 27% Missouri 3,305 8,984 4,124 11,557 25% 29% Kentucky 3,437 9,118 4,009 11,506 17% 26% Nevada 3,578 8,831 3,927 11,487 10% 30% Montana 3,506 8,542 4,355 11,438 24% 34% Ohio 3,416 9,136 4,089 11,425 20% 25% South Dakota 3,361 8,499 4,233 11,382 26% 34% P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 21 Mississippi 3,305 8,075 4,124 11,363 25% 41% Michigan 3,671 9,449 4,388 11,321 20% 20% Arkansas 3,127 7,977 3,923 11,220 25% 41% Louisiana 3,317 8,735 4,055 11,207 22% 28% North Dakota 2,999 7,866 3,830 11,178 28% 42% Alabama 3,156 8,045 4,139 11,119 31% 38% Oklahoma 3,285 8,739 4,072 11,053 24% 26% Hawaii 3,020 7,887 3,831 11,044 27% 40% Iowa 3,270 8,436 4,146 10,947 27% 30% Idaho 3,331 8,563 4,104 10,837 23% 27% Note: Premiums are for insurance policies offered by private-sector employers in the U.S. Data: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends, 2003 and 2008 Medical Expenditure Panel Survey-Insurance Component. 22T he  C ommonwealth F und Table 2. Health Insurance Premiums as Percentage of Median Household Income, 2003 and 2008, Ranked by 2008 Premium as Percentage of Median Household Income Median household income for Employer premiums as percent of median under-65 population household income for under-65 population 2003–04 2007 2003 2008 United States $48,442 $53,685 15.0 17.2 West Virginia 38,400 46,066 19.3 23.1 Tennessee 44,064 46,000 17.4 20.3 Mississippi 39,018 43,094 16.8 20.0 North Carolina 43,662 46,002 15.6 19.9 Kentucky 42,419 46,000 16.8 19.5 Texas 40,050 45,640 18.4 19.3 District of Columbia 40,000 42,904 16.9 19.0 Maine 45,840 55,045 17.7 19.0 New Mexico 36,300 45,000 19.7 19.0 Arizona 42,500 49,600 16.3 18.9 Arkansas 37,899 49,090 17.3 18.8 Louisiana 38,700 45,000 17.8 18.7 South Carolina 44,488 50,000 16.2 18.6 Florida 45,000 50,000 16.2 18.5 Vermont 52,606 55,506 14.1 18.5 Oklahoma 42,162 48,000 17.1 18.3 Indiana 50,000 56,611 15.0 18.1 Oregon 45,350 52,305 15.1 18.1 New York 47,000 51,101 15.1 17.6 Alabama 46,000 48,000 14.9 17.5 Montana 37,457 50,000 17.8 17.4 Wyoming 51,560 59,136 16.0 17.4 Missouri 50,967 50,000 14.1 17.3 Wisconsin 52,760 62,485 14.8 17.3 California 46,030 52,000 14.8 17.1 Illinois 52,016 57,000 14.7 16.9 Nevada 45,000 52,000 15.0 16.9 Rhode Island 52,031 58,800 14.2 16.8 Delaware 52,000 60,000 15.4 16.7 Nebraska 52,082 57,000 14.4 16.5 Pennsylvania 52,178 56,500 13.8 16.5 Utah 52,033 60,090 14.0 16.5 Alaska 56,108 65,850 15.5 16.2 Georgia 45,000 54,202 14.9 16.1 Idaho 47,322 56,834 15.5 16.1 Ohio 51,084 55,025 14.5 16.1 Kansas 51,082 55,000 14.5 16.0 North Dakota 49,750 56,250 13.3 15.9 South Dakota 49,818 54,922 14.6 15.8 Washington 54,400 62,300 13.7 15.7 Massachusetts 60,432 63,867 12.4 15.6 P aying the P rice : H ow H ealth I nsurance P remiums A re E ating U p M iddle -C lass I ncomes 23 Median household income for Employer premiums as percent of median under-65 population household income for under-65 population 2003–04 2007 2003 2008 Minnesota 63,510 68,000 12.9 15.4 Michigan 52,490 60,000 14.7 15.3 New Hampshire 66,078 74,317 12.3 14.9 Iowa 53,650 58,050 13.1 14.8 Virginia 56,000 61,000 12.9 14.7 Connecticut 65,032 69,150 12.6 14.3 Hawaii 48,084 53,680 12.1 14.1 Colorado 53,430 64,830 13.8 13.9 New Jersey 65,000 69,560 12.2 13.9 Maryland 60,000 69,500 11.8 13.3 Data: Average premiums for employer-based health insurance plans (weighted by single and family household distribution)—2003 and 2008 Medical Expenditure Panel Survey- Insurance Component; Median household incomes—2004-2005 and 2008 Current Population Surveys.