• Small-business workers are facing higher costs for family health coverage than those at larger firms.
• Affordability and healthcare costs are key concerns for American workers and voters in the midterms.
• Small firms struggle with health benefit options due to less bargaining power and higher costs.

Health insurance costs are going up, and it's especially rough for workers at small businesses.

A new annual survey of employers and their health benefits from KFF found that small-business workers pay more for family coverage than workers at firms of every other size. At the same time, many of these workers have fewer plan choices than at larger firms, meaning they're often stuck with whatever option their employer selected.

From 2025 to 2026, annual worker contributions for family coverage at firms with 10 to 199 workers increased from $8,889 to $9,687, a 9% increase. While the largest firms saw a sharper increase, workers' contributions at employers with 5,000 or more employees were nearly $3,000 less. For all firms, contributions rose about 9% to $7,471.

Of covered workers at small firms, nearly one in three has a plan requiring an employee contribution of over $12,000 annually, more than double the rate at large firms.

According to the survey, 66% of small firms offer health benefits, compared with 98% of firms with 200 or more workers. That's up from 59% in 2025 but remains below the 72% level of five years ago.

Workers at small firms pay an average 37% of the family premium, compared with 25% at larger firms.

While premiums for health insurance plans that cover only a worker and not their family are similar for small and large businesses, the average deductible at small firms is nearly $1,000 higher than at large firms. More than half of small-firm workers face a deductible of at least $2,000, compared to just a third of large-firm workers.

Though the report doesn't get into the discrepancy for family plans in depth, small businesses often have less bargaining power with insurers. Because small businesses operate on smaller margins, they often don't have the money to subsidize spouses and children at the same level as larger businesses. Risk is also more concentrated among smaller businesses, meaning that future premiums and claims may be heightened by a single employee with costly medical needs.

Additionally, because small firms are much less likely to self-fund, they're often more dependent on insurers and therefore pass along rate increases to their workers. Average annual premiums rose 5% in 2026, with employers citing projected cost increases, while the survey separately found that GLP-1 coverage can affect prescription-drug spending. Workers at small employers are more likely to have weaker coverage for specialty drugs.

Affordability is top of mind for Americans gearing up to vote in the midterms. Healthcare costs remain a top financial concern. Millions of Americans have lost health coverage as ACA marketplace subsidies expired and Medicaid enrollment protections ended.

Small businesses have been hit hard over the past few years by inflation, higher interest rates, and tariffs. Small businesses have been embracing AI as a cost-saving measure, though many face unexpected costs due to token overuse or subscription price increases.

Dozens of workers have told Business Insider that preparing for retirement has been a significant source of stress as they navigate a tight job market. However, among employers that offer health benefits, 23% of firms with 200-999 workers offer retiree health benefits, versus 35% of firms with 5,000 or more workers.

There are some silver linings for workers. Premiums for single workers are slightly lower at smaller firms than at larger ones overall. Employees at small firms on single health insurance plans were much more likely to have their entire premium paid by their employer, though they're also much more likely to pay more than half of the family premium. Among small firms offering coverage, nearly all offer family coverage.