While these findings were drawn from employment-based health coverage, they provide useful context for ongoing discussions about enrollment and utilization patterns in the Patient Protection and Affordable Care Act (ACA) Marketplace, where similar questions about spending concentration and low utilization have emerged. January 22, 2026, #550 Spending Concentration in the ACA Marketplace Recent analyses of the individual market have highlighted that a sizable share of Marketplace enrollees do not submit health care claims in a given year. A 2025 report found that the percentage of individual-market enrollees Most Insured Individuals Use 1 with no health care claims increased from 19 percent in 2021 to 35 percent in 2024. This has prompted debate over whether such patterns reflect enrollment anomalies, short-term or transitional coverage, or simply the Relatively Little Health Care expected outcome of insuring a population that includes many younger and healthier individuals. As in employment-based coverage, the presence of enrollees with little or no utilization is a predictable feature of The use of health care services — and the spending associated with those services — is far from evenly insurance markets that rely on broad risk pooling. distributed across the population. It has long been known that a small portion of the population accounts for a disproportionately large share of health care spending, with 20 percent of the population typically accounting for At the same time, the individual market differs from employment-based health coverage in ways that complicate 80 percent of total health care spending. interpretation. Marketplace coverage experiences higher enrollee churn, more frequent midyear coverage changes, and greater reliance on income-based subsidies. As a result, zero-claim enrollment in the ACA Marketplace may This uneven distribution of health care spending across the population is generally true among the sub-population reflect a mix of factors, including partial-year coverage, changes in eligibility, or transitions to other sources of with employment-based health benefits as well. In prior EBRI research, we looked at how a small share of insurance, in addition to low underlying health care needs. workers drives the majority of health care spending in employment-based health plans and found that 20 percent of the population accounted for 84 percent of spending. In other words, most people account for relatively little From a policy perspective, distinguishing between these explanations is important for accurately assessing health care spending. enrollment levels, risk pool composition, and premium trends in the non-group market. Evidence from employment-based plans shows that a large share of insured individuals routinely account for little spending in In this Fast Fact, we examine the entire distribution of health care spending, focusing on the large percentage of any given year, consistent with the risk-protection role of insurance. This pattern highlights the core insurance the population who uses no or very little health care. function of protecting against high-cost, low-probability health events — an issue central to both employment- based health coverage and the ACA Marketplace. The health care claims of 20.8 million individuals with employment-based health benefits in 2023 were examined ® using the MarketScan Commercial Database. This database contains information on inpatient, outpatient, and Summary pharmacy claims for workers and their dependents. Health care spending is highly concentrated across insured populations, with a relatively small share of Key Findings: individuals accounting for most expenditures, while a large majority incur little or no spending in a given year. Evidence from employment-based health coverage shows that low or zero utilization is common and reflects the • Twenty percent of individuals with fundamental risk-pooling role of insurance rather than an anomaly. As similar utilization patterns are observed in Figure 1 employment-based health benefits the ACA Marketplace, careful interpretation is needed to distinguish normal insurance dynamics from accounted for roughly 84 percent of Distribution of Health Spending, Among Individuals With administrative or market-specific factors when evaluating enrollment, costs, and premium trends. overall spending, and 80 percent of the Employment-Based Health Coverage, 2023 population accounted for only 16 percent Average Percentage of Proportion of A Thank You to Members: This study was conducted through the EBRI Center for Research on Health Benefits Spending of spending. Spending Spending Enrollees Innovation (EBRI CRHBI), with the funding support of the following organizations: Blue Cross Blue Shield • Within the 80 percent, there were Overall $6,268 100% 100% Association, JP Morgan Chase, and PhRMA. individuals who used some health care No Claims — — 20% and others who used no health care. Under $500 $234 1% 20% The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute based in Overall, 50 percent of the population used $500 to Under $887 $680 1% 10% Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby no or next to no health care in 2023. $887 to Under $5,000 $2,293 11% 30% and does not take policy positions. The work of EBRI is made possible by funding from its members and $5,000 to Under $10,000 $7,060 9% 8% o Twenty percent used no health sponsors, which include a broad range of public and private organizations. For more information, visit $10,000 to Under $25,000 $15,740 18% 7% care in 2023. www.ebri.org. $25,000 to Under $50,000 $34,722 16% 3% o Twenty percent used less than $50,000 to Under $150,000 $80,646 23% 2% $500 in health care. ### $150,000 or more $304,277 22% 0.50% o Ten percent used between $500 ® and $887 in health care (with Source: EBRI estimates using 2023 Merative™ MarketScan Commercial Database. Endnotes $887 representing median spending on health care). 1 https://paragoninstitute.org/paragon-prognosis/the-rise-of-phantom-obamacare-enrollees-biden-covid-credits-drive-massive- increase-in-individual-market-enrollees-with-no-medical-claims/ © 2026, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2