Q&A: What happens when you can’t leave a job because of health insurance?

Note: This interview was originally published in Doing Well, a health news outlet from ASU Media Enterprise and ASU Learning Enterprise. Subscribe to Doing Well to get interviews with health experts delivered to your inbox weekly.

By Natasha Burrell

Most Americans depend on their job for health insurance — and, for some, that can shape everything from career choice to mental health. One in six U.S. workers report staying in an unwanted job for health insurance benefits, with Black workers and people making less than $48,000 a year most affected.

Employer-sponsored health insurance began after World War II as a way to attract and retain workers. Since employers often cover the majority of the monthly cost, the setup can save workers money on insurance and help reduce their tax bill.

But there are downfalls.

During the COVID-19 pandemic, the U.S. saw major job losses, and nearly 2.7 million people lost their health insurance in the few months between the spring and summer of 2020. In cases where someone wants to leave their job and doesn’t have something else lined up, health insurance options, such as COBRA, can be quite expensive because the worker must take on the monthly cost that their employer once covered. With few affordable alternatives, workers with health conditions or dependents can feel pressured to remain in jobs they’d otherwise leave, just to keep their health insurance.

We spoke to Tiffany Lemon, assistant professor in ASU’s College of Health Solutions and School of Technology for Public Health, who recently published a study about how “job lock” impacts health outcomes. In this conversation, she walks us through how the United States’ reliance on employer health insurance impacts job mobility and mental health.

Question: Most Americans get health insurance through their jobs. How is health insurance coverage tied to employment?

Answer: Because of the structure of the U.S. health care system, who pays for certain types of coverage is pretty fragmented, and having (insurance) through an employer is just one of those pieces.

Having insurance coverage through your employer does come with benefits. That includes not having to think that hard about what type of insurance you’re getting — the employer has advocated for those choices. Typically, the employer covers a portion of the cost, and then the employee usually pays out of their paycheck directly. It’s kind of a convenient system, and there’s a lot of savings that (go) with it.

The downsides come into play when our insurance coverage options are limited based on the lack of opportunities we have for getting coverage outside of jobs. One way that presents itself is through "job lock."

There’s a couple of reasons people can be job-locked, but one is insurance coverage. Some people who have special health care needs might opt to stay in their jobs to keep that type of insurance — maybe because they don’t have a lot of affordable options outside of their employer. Or maybe it’s because (with) the specific type of insurance coverage they have, they can go to their doctor that they love. When those options can be limited, it incentivizes people to stay in jobs that they might otherwise leave.

Q: How does this impact families who are all on the same insurance plan?

A: Sometimes, employees have dependents that are also included on these employer-sponsored insurance plans. So these decisions to keep insurance coverage expand beyond the actual employee to impact people who are considered dependents. Those dependents could be partners, they could be children — just two examples. Dependent-associated job lock is when people opt to stay in those jobs to keep insurance, not necessarily for themselves, but for the dependents they care for.

Q: That’s a really interesting term. A few years ago, my mom didn’t want to retire when she could because she had great health insurance benefits through her job. My younger sister, who has a heart condition, was a dependent and used those benefits very regularly. So I think that fits what you’re explaining.

A: That's such a great example. I’m glad you shared that story because every time I talk about this line of research, people will always share, "Oh yeah, this happened to me, or I know someone who this happened to."

We hear a lot about health insurance that people maintain for themselves. But we hear a lot less about keeping jobs for dependents who need insurance coverage or who need access to health care. Early in life, kids require a lot of health care engagement just to keep on track with those milestones of growth. Increasingly, kids and adolescents need mental health care, which is becoming more and more of a health care need in the U.S.

Q: What steps can a working person with health insurance take to protect their well-being or mental health, especially if they’re in a job they don’t like but rely on for insurance?

A: We can encourage folks to leverage the care and access they have through their insurance coverage to access their benefits and to utilize the resources within their employment environments, if they feel safe to do so.

When I was (working at) Mass General, there was an app for mental wellness for employees. They would connect you to vetted clinicians that could serve as therapists and other types of providers. I connected with someone through that app and ended up developing a really robust therapeutic relationship with that person. So I’d say that it’s also kind of a responsibility of institutions and employers to have these resources available for employees and to highlight the opportunities that exist. That was such a great program — I wouldn’t have known about it unless that newsletter email scrolled across my inbox. Often there are many resources that can be helpful for employees when they’re dealing with difficult mental and physical health situations.

If you’re in a situation where you’re job-locked, I would encourage folks to get more information on other (coverage) options. Insurance coverage is one of those difficult things; it’s so vast to hop into. One of the things that I want to follow up when it comes to my research on insurance coverage is people’s feelings about what it means to explore insurance coverage options. People don’t have the time to look up this policy that has 50 million things, and it just becomes a huge burden for people to navigate through, especially if they’re already dealing with really difficult circumstances. So one option could be talking to someone, maybe in the benefits office (or) a professional who navigates insurance coverage situations, somebody that is connected with the marketplace. Your options are often more expansive than we realize, and there could be solutions.

Then, we really need more structural interventions. The system that has a lot of benefits that are undeniable could also have unintended consequences. I’ll always go with the structural solutions and think about how we can actually change the fragmentation of our health insurance system such that we’re caring for those most vulnerable and actually helping caregivers care for the people that are most important to them.

My mom is one of those caregivers — she cares for her mom, she cares for her brother, and she still makes time to call and check on me. Now I find myself calling and checking on her: "How’d you take care of yourself today?" To the degree possible, (we need) to help caregivers understand that their health also matters.