Employees need more support and education to understand their high deductible health plan (HDHP) and health savings account (HSA) options as well as mitigate longer-term health risks, according to research from The Guardian Life Insurance Company of America.

“A Crack in the Foundation,” the first set of findings from the fourth annual Guardian Workplace Benefits Study, suggests the greatest need to improve benefits satisfaction is among smaller companies and that brokers can play a critical role in accomplishing this goal.

Three in five employers were found to not offer an HSA alongside their HDHP, driven largely by firms with fewer than 50 employees. Respondents included 1,204 employers and 1,700 employees who were polled online in the spring of 2016.

Another alarming finding was that three in five respondents admitted they’re unable to pay a $3,000 out-of-pocket medical expense, triggering concern that neglected care could develop into catastrophic medical and disability claims. Most respondents said they would have to set up a payment plan with their provider (37%), charge the services to a credit card (34%), ask for a loan from friends or family members (9%) or take out a bank loan (6%).

A chief objective of this annual survey in 2012 was to create an index to measure how working Americans feel about the value of their benefits, explains Gene Lanzoni, assistant vice president for group and worksite marketing at Guardian, one of the nation’s largest mutual life insurers and an employee benefits provider. In doing so, researchers anticipated that both the consumer-driven health movement and Affordable Care Act (ACA) would affect employee attitudes about how their benefit programs were evolving.

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While the metric remained the same or improved slightly during the first three years, it fell substantially in 2016. The chief culprit of this disenchantment was traced to HDHPs. About 60% of respondents have an annual deductible of $1,200 or more and 25% noted that theirs is $3,000 or more, while one-third of HDHP participants admitted to placing their health at risk.

Examples include delaying a doctor visit or recommended medical procedure or surgery, as well as not filling a prescription and avoiding a blood test or X-rays.

“There seems to be a financial strain on working Americans like we hadn’t seen in the prior couple of years,” says Lanzoni. He suggests that employee communication and education must be improved, especially among smaller companies. Advisers can take the lead on helping their employer clients shape this strategy, he adds.

As many brokers and advisers have turned their attention to selling more than medical coverage post-ACA, Lanzoni sees a gradual shift toward some supplemental health products. The objective is twofold, he says: fill coverage gaps for employees and diversify their own business. Those solutions include hospital indemnity, accident, or critical-illness insurance.

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