Kirk Vartan pays more than $2,000 a month for a high-deductible health insurance plan from Blue Shield on Covered California, the state’s Affordable Care Act marketplace. He could have selected a cheaper plan from a different provider, but he wanted one that includes his wife’s doctor.

“It’s for the two of us, and we’re not sick,” said Vartan, general manager at A Slice of New York pizza shops in the Bay Area cities of San Jose and Sunnyvale. “It’s ridiculous.”

Vartan, who is in his late 50s, is one of millions of Californians struggling to keep up with health insurance premiums ballooning faster than inflation.

Average monthly premiums for families with employer-provided health coverage in California’s private sector nearly doubled over the last 15 years, from just over $1,000 in 2008 to almost $2,000 in 2023, a KFF Health News analysis of federal data shows. That’s more than twice the rate of inflation. Also, employees have had to absorb a growing share of the cost.

The spike is not confined to California. Average premiums for families with employer-provided health coverage grew as fast nationwide as they did in California from 2008 through 2023, federal data shows. Premiums continued to grow rapidly in 2024, according to KFF.

Small-business groups warn that, for workers whose employers don’t provide coverage, the problem could get worse if Congress does not extend enhanced federal subsidies that make health insurance more affordable on individual markets such as Covered California, the public marketplace that insures more than 1.9 million Californians.

Premiums on Covered California have grown about 25% since 2022, roughly double the pace of inflation. But the exchange helps nearly 90% of enrollees mitigate high costs by offering state and federal subsidies based on income, with many families paying little or nothing.

Rising premiums also have hit government workers — and taxpayers. Premiums at CalPERS, which provides insurance to more than 1.5 million of California’s active and retired public employees and family members, have risen about 31% since 2022. Public employers pay part of the cost of premiums as negotiated with labor unions; workers pay the rest.

“Insurance premiums have been going up faster than wages over the last 20 years,” said Miranda Dietz, a researcher at the University of California-Berkeley Labor Center who focuses on health insurance. “Especially in the last couple of years, those premium increases have been pretty dramatic.”

Dietz said rising hospital prices are largely to blame. Consumer costs for hospitals and nursing homes rose about 88% from 2009 through 2024, roughly double the overall inflation rate, according to data from the Department of Labor. The rising cost of administering America’s massive health care system has also pushed premiums higher, she said.

Insurance companies remain highly profitable, but their gross margins — the amount by which premium income exceeds claims costs — were fairly steady during the last few years, KFF research shows. Under federal rules, insurers must spend a minimum percentage of premiums on medical care.

Rising insurance costs are cutting deeper into family incomes and squeezing small businesses.

The average annual cost of family health insurance offered by private sector companies was about $24,000, or roughly $2,000 a month, in California during 2023, according to the U.S. Department of Health and Human Services. Employers paid, on average, about two-thirds of the bill, with workers paying the remaining third, about $650 a month. Workers’ share of premiums has grown faster in California than in the rest of the nation.

Many small-business workers whose employers don’t offer health care turn to Covered California. During the last three decades, the percentage of businesses nationwide with 10 to 24 workers offering health insurance fell from 65% to 52%, according to the Employee Benefit Research Institute. Coverage fell from 34% to 23% among businesses with fewer than 10 employees.

“When an employee of a small business isn't able to access health insurance with their employer, they're more likely to leave that employer,” said Bianca Blomquist, California director for Small Business Majority, an advocacy group representing more than 85,000 small businesses across America.

Kirk Vartan said his pizza shop employs about 25 people and operates as a worker cooperative — a business owned by its workers. The small business lacks negotiating power to demand discounts from insurance companies to cover its workers. The best the shop could do, he said, were expensive plans that would make it hard for the cooperative to operate. And those plans would not offer as much coverage as workers could find for themselves through Covered California.

“It was a lose-lose all the way around,” he said.

Mark Seelig, a spokesperson for Blue Shield of California, said rising costs for hospital stays, doctor visits, and prescription drugs put upward pressure on premiums. Blue Shield has created a new initiative that he said is designed to lower drug prices and pass on savings to consumers.

Even at California companies offering insurance, the percentage of employees enrolled in plans with a deductible has roughly doubled in 20 years, rising to 77%, federal data shows. Deductibles are the amount a worker must pay for most types of care before their insurance company starts paying part of the bill. The average annual deductible for an employer-provided family health insurance plan was about $3,200 in 2023.

During the last two decades, the cost of health insurance premiums and deductibles in California rose from about 4% of median household income to about 12%, according to the UC Berkeley Labor Center, which conducts research on labor and employment issues.

As a result, the center found, many Californians are choosing to delay or forgo health care, including some preventive care.

California is trying to lower health care costs by setting statewide spending growth caps, which state officials hope will curb premium increases. The state recently established the Office of Health Care Affordability, which set a five-year target for annual spending growth at 3.5%, dropping to 3% by 2029. Failure to hit targets could result in hefty fines for health care organizations, though that likely wouldn’t happen until 2030 or later.

Other states that imposed similar caps saw health care costs rise more slowly than states that did not, Dietz said.

“Does that mean that health care becomes affordable for people?” she asked. “No. It means it doesn’t get worse as quickly.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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SACRAMENTO, Calif. — A growing number of people — many of them older and homeless — are freezing to death during winter.

Hypothermia from exposure to cold temperatures was the underlying or contributing cause of death for 166 Californians last year, more than double the number a decade ago, according to provisional death certificate data from the U.S. Centers for Disease Control and Prevention. The age-adjusted rate of 3.7 deaths per million residents in 2023 was the highest in the state in at least 25 years.

Hypothermia deaths have also increased nationwide, with about 2,520 Americans dying last year, up about 35% from 2014, provisional CDC data shows. It was even worse in 2022: 3,500 hypothermia deaths, many of them during brutal winter storms across much of the country in January and December.

The increase in hypothermia deaths is linked to a rise in homelessness, especially in California, which has the nation’s largest homeless population, experts say.

Homeless people are particularly susceptible to hypothermia because so many older, vulnerable adults live outside, where they are exposed to the elements. Government officials have largely responded to hypothermia deaths by opening warming centers where homeless people can stay on cold nights, but advocates say more permanent housing and more programs that prevent homelessness are needed.

Sitting on a park bench near the state Capitol, Leon Winch said he has trouble staying warm as winter approaches. On cold, rainy nights, he tries to find places to stay dry but covered spots are often patrolled by private security guards who chase him away. Hypothermia often occurs in cold temperatures below 40 degrees but can also occur at warmer temperatures, especially when it’s rainy.

City officials open centers under certain conditions, including when nightime temperatures are likely to fall below 37 degrees on two or more days in a five-day period. But Winch said he does not trust the city of Sacramento and doesn’t use the city’s warming centers even as temperatures grow frigid.

“They’re not doing anything except window-dressing,” he said.

According to the California Department of Health Care Access and Information, homeless people accounted for 18% of hospitalizations and emergency room visits related to hypothermia from 2019 through 2023. Homeless Californians represent nearly 0.5% of the state’s population, suggesting they are about 40 times as likely as others to end up at the hospital for hypothermia.

Federal data shows more than two-thirds of the state’s 181,000 homeless people are unsheltered. And among those dying from hypothermia, one group has been hit particularly hard.

Older adults are most susceptible to hypothermia, with people 55 and older accounting for more than three-quarters of hypothermia deaths in California from 2021 through 2023, CDC data shows.

“There is a massive increase in the aging homeless population,” said Margot Kushel, director of the University of California-San Francisco Benioff Homelessness and Housing Initiative. She said the proportion of single homeless adult Californians who are 50 or older has increased from 11% in 1990 to nearly 50%.

And as the number of deaths from exposure to cold has risen in the state, so has the number of deaths from exposure to heat in the summer. “A changing climate, more temperature extremes, more soaking rains — people are older and thus unable to even tolerate it, so they get much sicker, faster,” Kushel said.

The trend could worsen: The proportion of the homeless population 65 or older is projected to triple in the United States between 2017 and 2030, according to UCSF researchers.

California’s hypothermia death rate is highest in its rural, mountainous, northern counties, but most deaths are occuring in urban centers.

Hypothermia was the underlying or contributing cause of death for 46 Los Angeles County residents from 2021 to 2023 — the highest number in the state. However, the death rate was below the statewide average due to the county’s large population.

Santa Clara, San Francisco, and Sacramento had the highest hypothermia death rates among the state’s most populous counties. Hypothermia was the underlying or a contributing cause of 42 deaths in Santa Clara County from 2021 through 2023, up from 11 during the previous three years, CDC data shows.

“Every year, we are worse than last year,” said Shaunn Cartwright, an advocate for homeless people in Santa Clara County.

Cartwright said local officials are not providing enough permanent shelter beds for homeless people, let alone enough temporary shelter beds on cold nights. It’s a problem that Kushel said is prevalent across the state.

Michelle Jorden, Santa Clara County’s chief medical examiner, said in an emailed statement that she is unsure why hypothermia deaths are rising but is monitoring the trend. She said the county has sent outreach teams to encampments with supplies, established warming centers, and issued cold weather safety alerts during severe conditions.

Sacramento County had 34 deaths related to hypothermia from 2021 through 2023, up from 20 hypothermia deaths from 2018 through 2020. Like many places, Sacramento has enforced homeless ordinances and conducted sweeps in the wake of a U.S. Supreme Court decision giving cities more authority to fine and remove homeless people from the streets. Nearly half of unsheltered homeless Californians report that officials have confiscated their belongings at some point, Kushel said.

Bob Erlenbusch, an advocate at the Sacramento Regional Coalition To End Homelessness, said many homeless people are cold because local authorities have confiscated items including blankets, sleeping bags, and tents during sweeps.

“They're not supposed to take people's stuff,” he said. “They're supposed to tag it and store it, but that doesn't happen.”

City of Sacramento spokesperson Jennifer Singer said city workers reach out to homeless residents before removing encampments “so they can manage their belongings before any clean-up begins.”

Kushel said the long-term solution to the rise in hypothermia deaths is to prevent people from falling into homelessness and get those who are already homeless into housing. In the meantime, she said, cities need to open more warming centers — and cooling centers in the summer — and make sure they are accessible.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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