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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. Readers of health affairs know well just how significant a presence employer sponsored insurance plays in the health care coverage landscape. And as recently as a few weeks ago on this podcast, we had KFF's Matthew Ray talking about the latest results of their annual survey of employer sponsored plans. But one thing he and I did not really discuss was how a health system like ours, built on a foundation as idiosyncratic as employer sponsored coverage, affects the people who rely on it for access to health care.
Rob Lott:Are there unintended consequences associated with a system that requires millions of Americans to depend on their employer for insurance? That is our question for the podcast today. I'm here with Doctor. Tiffany Lemmon, an epidemiologist and assistant professor in the College of Health Solutions at Arizona State University. Along with her coauthors, Doctor.
Rob Lott:Lemmon published an article in the new issue of Health Affairs describing the, quote, associations between dependent related job lock and adult mental and physical health. I can't wait to learn from her today all about their findings and the implications for policymakers. And by the way, before we jump in, I just wanted to mention to our listeners that this is gonna be our last episode of the year. Thank you all for listening. We had a great 2025, and after a break, I can't wait, to jump back into things in January 2026.
Rob Lott:All right. Well, let's get into it. Doctor. Tiffany Lemon, welcome to the Health Odyssey.
Tiffany Lemon:Thank you so much for having me. Excited to be here.
Rob Lott:Great to have you. And maybe we can start with a little bit of context. Remind our listeners, if you will, how significant is employer sponsored insurance in The United States? What proportion of people are covered by employer sponsored insurance? And then with your paper in mind, I'm curious if you could say a little bit about what that looks like for families in particular.
Tiffany Lemon:For sure. I would say significant is definitely the word to use here. Employer sponsored insurance is the most common avenue that Americans use to get their health coverage in The US. About 60% of insured individuals in The US get their coverage from their employers. And what that translates to is about one hundred and sixty five million individuals 65.
Tiffany Lemon:And these are latest numbers from 2023. And there are many reasons why people might opt to go with employer sponsored insurance. One is that it's efficient. Usually you enroll during your open enrollment period if you're a continuing employee or when you're first hired. Otherwise, if you're looking for plans at the individual level, it can get pretty complex such that there's often agents specifically assigned to people looking for coverage options at the individual level.
Tiffany Lemon:And so efficiency is a huge appeal of employer sponsored coverage. There's also the cost sharing element. Getting insurance coverage through your employer comes with significant cost sharing when it comes to those premiums. And so for individual plans, individuals are covering about 16% that deductible or start off that premium. And then for family plans, looks like 25% of that premium is covered.
Tiffany Lemon:And that's not to mention tax benefits. What we pay for our employer sponsored insurance coverage usually comes out before taxes. So that's additional savings applied to families. But yeah, you're right. In the context of this study, we were looking at household levels.
Tiffany Lemon:So when we look at the household, the little bit over half of people covered by employer sponsored insurance are the employees that we've already mentioned. But the other near half of the individuals in The US covered by employee or sponsored insurance coverage are actually other dependents. And so that's a huge pool of employer sponsored, insured individuals, which only emphasizes how much healthcare access in The US is tied to employment, including for dependents and children?
Rob Lott:Well, so you mentioned efficiency, obviously the economic benefits. There's a reason a lot of employers offer this as a benefit. There's certainly that you can look at it as a perk. Of course, there are there are potentially some downsides, and one of those is this sort of idea of job lock, the idea that people might stay in a job they might otherwise want to leave for fear of losing their coverage. And so I'm wondering if you can say a little bit about, before we get to your study, what the literature tells us about job lock as a concept more broadly, what does it say about the dynamics of job mobility, And also its impact on people's health.
Tiffany Lemon:For sure. And you're completely right. Job block is a well documented phenomenon and one of those potentially negative impacts on the side of all those positives we just chatted about. And so as mentioned, it's a well documented phenomenon within the context of economics and health policy. And job a lot to kind of give you the more standard definition describes when someone maintains employment to address the more secondary need tied to a job based benefit like insurance coverage.
Tiffany Lemon:And so over the years research has found kind of mixed evidence actually looking at job lock and the impacts on job mobility, healthcare access and the like. And honestly, just the baseline of whether or not people are job locked in the first place. And so there are a few studies that show that employer sponsored insurance can reduce job mobility about anywhere from 25 to 40%. And this especially true for people nearing retirement that could potentially have other options, maybe more normative options, but rather have that secondary need that's being addressed by those job based benefits. Also people who have chronic health needs are often finding themselves with reduced job mobility, especially in the context of jobs in which they are receiving that employer sponsored insurance coverage.
Tiffany Lemon:And now in this literature, one of the things that I'm most interested in my putting my Epi hat on is the measurement, methods. Across studies of job block, the measurement methods vary, but there are two common approaches. The first is when studies look indirectly at job mobility data, usually using statistical techniques to compare turnover rates and people leaving their jobs voluntarily or not in job context where people have or don't have employer sponsored insurance coverage. Other studies and these are more recent studies will use direct self report in the context of surveys. And these surveys simply ask people if they've ever kept the job for the sake of keeping health insurance coverage.
Tiffany Lemon:And this kind of gives us a clear sense of the personal experience of individuals and why people are deciding to keep their jobs. With the mobility data, the job mobility data, there's still some question although researchers have been really elegant in using that administrative data to come up with these inferences. But the self report survey data really kind of gets to the heart of it by asking people, has this happened to you? Have you avoided changing jobs? Have you avoided or, you know, try to keep your job to keep these secondary benefits including health insurance?
Tiffany Lemon:I mean, I think these are really helpful in a way that gets us to the mechanism. And I'm always a fan of finding out what the mechanism is because if you follow the mechanism, you'll often have a great starting point for launching off some really good interventions, right? And so these self report questions kind of confirm the existence of job lock right from the horse's mouth and actually tend to unearth the why behind why people are experiencing job luck.
Rob Lott:Got it. I like that. We should put that on a bumper sticker. Always look for the mechanism. I think that's a good advice for anyone submitting a paper to health affairs.
Tiffany Lemon:I like that too. Constantly
Rob Lott:feel like we're hearing from peer reviewers who are trying to get at that question below the surface. Now speaking of which, one other question before we kind of dig into your paper, and that is I think you've sort of coined a term, if you will, to identify a subset of folks who might be experiencing job lock, and that is dependent related job lock. Can you say just a little bit about how you make that distinction?
Tiffany Lemon:Great question. And herein lies, I think, one of the major contributions of our work. And so most, studies of job lock look at people, the actual employees that are staying in their jobs to keep their own insurance coverage. But dependent related job lock or we call it DJL, is a little bit different because it's not driven by the actual employee, but it's driven by the needs and possibly the caretaking responsibilities of the employer who's seeking to maintain that employment to protect a dependent here specifically a child's insurance coverage. And what's unique about, this approach to thinking about JobLoc is that we use, data from a national survey, which kind of gives us an insight to what this looks like at the national level.
Tiffany Lemon:And again, the questions of asking people on whose behalf are you experiencing job lock again, gets us closer to the heart of that mechanism. It's not inferred from job mobility or not identified after a specific life event or claims data. We're asking individuals about a very personal experience, and also a very transient experience too. And so DJL or dependent, related job lock essentially is job lock on behalf of something else, which is a reflection of how deeply intertwined family health and employment are in a disjointed health system like we see in The US.
Rob Lott:Great. Well, great segue then. Let's talk about your study. I know you sought to measure the association between dependent related job lock and the health of adult caregivers. What were some of your top line findings?
Tiffany Lemon:Our study set out to accomplish a few goals. The first was to estimate the prevalence of dependent related job lock in The US. And so what we found was that the prevalence among families in The US over the study period, which was from 2016 to 2023 was about eight point nine percent, which translates to about one in eleven families experiencing dependent related job lock. And so we also sought to investigate whether this prevalence varied based on the healthcare needs of youth. Our hypothesis was that parents of youth with special healthcare needs may be more likely to maintain employment to ensure that their dependent child would have the access to the healthcare that they needed.
Tiffany Lemon:So we went with a definition, used by HRSA, the Maternal and Child Health Bureau. And it defines, children with special healthcare needs as, any of the following. So children that are having health related needs that have lasted or are expected to last for twelve months or longer. These include the use of prescription medications, elevated need for or use of mental health or educational services, including any functional limitations. And basically that's conditions that limit daily activity.
Tiffany Lemon:Also the need for or the use of special therapies, including physical therapy, occupational therapy and speech therapy. And also any emotional, developmental or behavioral problem for which treatment or counseling is needed. And based on this definition, approximately twenty percent, or fourteen, about fourteen million children in The US have a special healthcare need. And that's based on data from 2019, 2020. And we're seeing this actually increase over time.
Tiffany Lemon:And so for the purposes of our study, we define three specific categories. The first was children without any special healthcare needs. And then the other two categories were children with special healthcare needs but these were defined or distinguished based on whether or not special healthcare needs included emotional, behavioral or developmental problems. So in essence, we looked at three of these subgroups. And what we found was incredibly interesting.
Tiffany Lemon:And so not only were parents or caregivers of youth with special healthcare needs more likely to report dependent related job lock, We observed basically that caregivers of youth with these emotional behavioral or developmental problems had the highest prevalence of job block. In fact, the prevalence near twenty three percent almost one in four families of children with special healthcare needs, including these emotional behavioral or developmental problems were experiencing job lock.
Rob Lott:Wow, okay, really interesting findings. I think it's fair, as someone sort of listening to that for the first time, that sort of rings true to me. It sounds right, but that you were able to sort of quantify it and capture it is pretty significant. I wanna ask you a little more about the results, but first, let's take a quick break. And we're back.
Rob Lott:I'm here talking with doctor Tiffany Lemmon about, a new research study in the pages of Health Affairs. Doctor Lemmon and her colleagues studied the associations between dependent related job lock and adult mental and physical health. Let me ask you about the scope and the time period of your study. You covered a period from 2016 to 2023, And it looks like there were increasing experiences of dependent related job luck through 2019, then a decline, and then some stabilization, I assume after the sort of darkest days of COVID. How do you explain those shifts?
Rob Lott:Was it COVID? Were there other things going on? And how does that sort of fit into the bigger picture?
Tiffany Lemon:So the figure that you're referencing is one of our exhibits that we feature in the paper, and this is a visual representation of how job block is changing over time. And, ours was the first study to estimate the national prevalence of dependent related job block, which is really interesting to see, for all of the reasons that you mentioned as well. And so looking at this graph, we basically see that dependent related, job lock drop, around the time of the public health emergency associated with the COVID nineteen pandemic. And so we hypothesize that this is due to widespread job loss and changes in employment patterns during this time. We suspect that this drop is simply because there were less jobs to be locked into around that time, right?
Tiffany Lemon:And we also highlight that this decrease could be associated with the temporary Medicaid and CHIP extensions that paused disenrollments. And so you'll see that our prevalence timeline ends at around 2023. So we're gonna need some more data points beyond this time to assess this theory and all. But I also wanted to highlight the second part of the findings that we explored in the context of our paper, which kind of gets to the question of, okay, we have job lock that's happening. We see job lock happening to different degrees depending on whether or not children are experiencing special healthcare needs.
Tiffany Lemon:But we also wanted to explore a little bit a curiosity about whether or not job lock was associated with the health conditions and their personal self rated health when it comes to adult caregivers. And this curiosity was driven by this increasing awareness that the burdens faced by parents and caregivers are growing. And this translates more often than not into health outcomes. The US Surgeon General's twenty twenty four advisory report named Parents Under Pressure really, really resonated with us as we were finalizing this work. It acknowledged something that parents and caregivers have been feeling for years.
Tiffany Lemon:The stress of providing and caring and navigating complex systems, including The US healthcare system is a growing public health challenge. And so we looked at how this dependent related job block impacted or related or was associated with caregiver health. And we broke the analysis down by those categories of special healthcare needs. We found that regardless of the child's health needs status, caregivers who felt job blocked were more likely to report being in poor or fair health themselves. Which is a huge kind of signal point for us to look deeper into.
Tiffany Lemon:For example, caregivers who weren't job locked, just to give you a reference, about four percent reported poor or fair mental health specifically. That number jumped to about eleven percent among those who were job locked, a difference about roughly seven percentage points. I mean, we saw similar patterns for physical health as well.
Rob Lott:So just to be clear, this again is sort of an association, right? There's probably multiple factors at play here of, you know, people experiencing job lock having poor health, but also perhaps people in poor health feeling job lock not only associated with their dependents, but their own their own care. So I imagine it kind of goes both ways.
Tiffany Lemon:Exactly. And so you're speaking my empty language there. We definitely get into the specifics or maybe the limitations Because what the data we looked at data from the National Survey of Children's Health, which is a really great source, of understanding trends in health care, specifically for kids in The US. The robustness of this data to give us national estimates, prevalence of job lock is top tier. However, with cross sectional studies, we do experience those limitations with temporality.
Tiffany Lemon:What came first, the chicken or the egg? And so in the context of that specific challenge, what we're highlighting here is, hey, job a lot could be a potential additional source that has been previously undocumented that we may want to pay a little closer attention to when we think about really protecting and caring for the caregivers themselves.
Rob Lott:Got it. I want to ask a little bit about sort of the policy context that all of this is taking place in. How do you think about programs like Medicaid and CHIP? Isn't there a world, in theory at least, in which the existence of these safety net programs could provide families with the protection or even the confidence to let go of their employer sponsored insurance? And maybe why isn't that happening in this world?
Tiffany Lemon:There's definitely a world in which these programs could provide, the secondary options for coverage for parents. However, as you alluded to, this might not be the world in which many job locked parents live in. And so programs like Medicaid and CHIP are essential safety nets, especially for children. And in theory, they should reduce job lock giving parents confidence that they can leave their job and their kids won't lose coverage. But unfortunately that doesn't happen.
Tiffany Lemon:I'm looking at some data, I believe it was KFF data. After initial job losses in the context of the public health emergency, we saw children lose in the condition to the employees lose that employer sponsored coverage. And I believe upwards of about eighty percent or more of kids that lost that coverage were actually eligible for Medicaid or CHIP as it would be. Unfortunately though, not all of those individuals found their way into that coverage mechanism. And we could talk about the different reasons why that is.
Tiffany Lemon:I think in some cases parents might be concerned that the programs won't meet their child's healthcare needs. And we could think about the provider networks. Will my child be able to see their same provider that they've been seeing for months, even years to address these specific healthcare concerns? We think about patient trust of providers and how important that is especially for individuals who are marginalized and find that comfort provider that can actually meet them where they are. And you also think about the more practical health services piece of having providers be familiar with the health, the comprehensive health landscape of an individual person.
Tiffany Lemon:And those things are so important to having that comprehensive and effective and valued healthcare. You think about longer wait times too. For some individuals and for some clinics and providers, the difference between being seen this week or possibly next month could be the difference between you having public coverage or private coverage. And so thinking about the longer wait times that may enter into that equation. And finally, challenges in finding specialists.
Tiffany Lemon:A lot of the kids that fall into this category of having special healthcare needs are looking and needing very specific types of care. And so will individuals and will my child get the care that they need if the insurance coverage doesn't look the same? And so I think more, awareness. There's definitely more work to do on the ground about improving the accessibility of the programs and the fit for people's lives. But I think there's also some work to be done in making people more aware of what the options are, what the nature of the options are, if care in one scenario or under one coverage option looks the same as the other.
Tiffany Lemon:And so I think those are places that we can get some leeway here. But at the end of the day, people often go with ESI, employee sponsored insurance because of the relative stability and predictability. That piece is so desirable in the context of a relatively unpredictable world and sometimes an unpredictable policy landscape as well. I'm reminded of, you know, the current government shutdown and one of the current sticking points, for democratic lawmakers is the inclusion of the tax credits, that could potentially avoid steep, increases in premiums. And so looking at the landscape as a parent, to ensure that my child has the healthcare that they need, employer sponsored insurance coverage might look like the best bet of any.
Rob Lott:Yeah, it's interesting. I was going to ask about sort of, or sort of in the same vein that, we might see Medicaid and CHIP as a protection or offering people the confidence to kind of let go of their insurance. The same is true of the marketplace for the Affordable Care Act plans. I can remember back when that bill was being debated and ultimately passed, that one of the arguments in favor of the creation of these marketplaces was that it would release people from being locked into their insurance. And yet, what you're describing is there's still a whole lot more reasons why people might still feel tied to that employer sponsored coverage.
Rob Lott:Well, I did want to ask about sort of next steps or for our listeners who might be wondering, Okay, wow, this is a really sort of sobering picture of the world today. What do we do when it comes to policy with the findings of your paper? If your paper were to inspire a concrete specific policy change or improvements in this space, what would you like to see?
Tiffany Lemon:Oh man, that's such a great question. And there's so much I would like to see. But of course, I feel like my vision for what would be a really good, maybe intervention, something to step in and fill the gap is rooted in the understanding that as a society, as a community, as families, we can go from macro level to more micro level. Our health and wellness is so intertwined. The health of parents is associated with the health of kids and vice versa.
Tiffany Lemon:And in order to really create a health landscape, a healthcare landscape in which everybody gets the care that they need, in which caregivers like parents who have a to do list of 500,000,000 things have the support that they need to really ensure that their children are getting the best possible care. We really need to make healthcare coverage more universal, more portable and more reliable. And so in the near term, expanding Medicaid and CHIP eligibility for children, simplifying reenrollment. I know right now there are a couple of projects going on where instead of having month to month or even one year periods of eligibility, those eligibility periods can expand over six years in various iterations of that which kind of eliminates possibly this fear or trepidation that people who fall in those middle income categories where income might fluctuate over time which results in fluctuations in eligibility for specific care mechanisms, having a simple, straightforward enrollment options that keep people locked in care for longer, not only stabilizes the care engagement points but also ensures that children, youth specifically, have the full access to care in those critical life stages. And also improving provider access would also help tremendously that would reassure parents, especially of kids who have these special healthcare needs, that their kid can continue to see the providers that they've come to know love and the providers who've come to know their unique health stories.
Tiffany Lemon:Longer term, we could think about more foundational reforms, universal continuous coverage across the lifespan. Basically creating a healthcare environment where families don't need to tie their employment, potentially detrimental employment, potentially forgoing opportunities like entrepreneurship to protect their children's health. By doing so, we could unlock not only job mobility and opportunities for individuals in an increasingly diversified job market, might add, but potentially provide better, care and increase or enhance caregiver well-being too.
Rob Lott:Wonderful. Well, a lot to, look out for and think about and perhaps study in the years ahead. Doctor. Tiffany Lemon, thank you so much for taking the time. I had a lot of fun chatting with you today.
Tiffany Lemon:Me too. Thanks so much for having me.
Rob Lott:Absolutely. And for our listeners, if you enjoyed this episode, please subscribe, recommend it to a friend, and, check us out, next year. Thanks everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.