Six in ten employees with employer-sponsored health insurance have paid for healthcare or medication entirely in cash at some point, skipping the claims process altogether. That figure comes from Payability, Measured, a new national study by healthcare payment company Paytient Technologies and Greenwald Research, which surveyed 2,024 full-time, employer-insured workers in mid-2026. Paytient, which sells payroll-based payment tools for out-of-pocket healthcare costs, commissioned the study.
The reasons employees gave were practical rather than principled. Among those who had paid cash, 45% said a provider was out of network, 37% cited a lower cash price, 30% said it was simply faster, and 27% hadn’t yet met their deductible. Each of those decisions represents a benefit the employer is paying for that went unused at that moment, and the transaction left no trace in claims data.
Only 29% of employees believe their employer fully understands what paying out of pocket actually feels like, and just 28% said their benefits feel designed with someone like them in mind. Health benefit costs are projected to rise 8.2% per employee in 2027, the steepest increase in 24 years, according to Marsh’s 2026 National Survey of Employer-Sponsored Health Plans. Most employers heading into that renewal cycle are working from an incomplete picture of how their plan is actually being used.
The study finds that payment timing, not payment size, is what most employees are actually navigating. Given a hypothetical choice between a $1,000 healthcare bill due the next day and a $2,000 bill with six months to pay, 67% said the smaller amount due immediately would be harder to manage.
The preference for installment payments over lump sums was consistent across income levels: 70% of workers earning under $50,000 preferred spreading costs over time, compared with 72% in the $50,000 to $99,000 range and 67% of those earning more than $100,000.
“This isn’t a low-income affordability story,” said Lisa Weber, chief research officer and head of healthcare insights at Greenwald Research, in a statement. “It’s a structural preference that cuts across the entire workforce.”
The implication runs directly into how employers typically respond to rising plan costs. Marsh found that 59% of employers plan cost-cutting changes to health benefits in 2027, with higher deductibles as the primary lever.
The Paytient data, however, shows that raising the financial threshold employees must clear before coverage kicks in doesn’t just shift costs. Instead, it reshapes when and whether employees seek care at all. Among workers who said a $500 healthcare expense would be difficult to manage, 68% had delayed or skipped needed care in the past year. Among those for whom difficulty started at $1,000, that figure was 43%. Among workers who said they wouldn’t struggle with any of those amounts, it dropped to 13%.
Deferred care does not disappear. It returns later as a higher-acuity, higher-cost claim, absorbed by the same plan the employer just made harder to use. That cost shows up before the claim does. The study found that 34% of employees had worked while feeling unwell, 24% reported distraction at work, 21% said their productivity suffered, and 15% had missed work entirely because of concerns about paying for healthcare. More than half said a major healthcare expense affected their financial wellbeing for more than a month.
The study also documented a predictable pressure point that advisors can use in renewal conversations: the deductible reset. Eighty-four percent of employees know their deductible resets January 1, and 72% said that reset actively affects their care decisions. Every new plan year opens with a surge of cost-driven avoidance, and employers who have recently raised deductibles to manage the sharpest health cost increase in a generation are compounding that effect.
The Paytient study argues for pairing a higher-deductible plan with a structured, payroll-based payment mechanism that lets employees spread out-of-pocket costs over time. Sixty-eight percent of employees said they would prefer to pay a major healthcare expense through smaller paycheck deductions rather than a lump sum. That is a higher share than the 62% who prefer tax withholding structured the same way.
The payroll infrastructure already exists. Extending it to out-of-pocket costs does not change the plan’s financial structure, but it changes how employees engage with it.
Employees who can pay for care at the moment it’s needed seek it sooner. Earlier intervention reduces severity, which in turn reduces total plan spend. For plan sponsors heading into 2027 facing the growing population of insured workers who cannot afford to use the coverage they carry, that chain of logic is worth walking through before deductible decisions get locked into the next plan year.
Joe Gabler, chief operating officer of Paytient, framed it in terms of plan architecture. “Using payroll to smooth out-of-pocket costs is the plan design opportunity hiding in plain sight, and it can help employers save substantially on plan costs,” he said.
The study is the second in Paytient’s four-part Payability Papers series. Open enrollment is underway for most large employers right now, and the deductible decisions being finalized this month will shape utilization patterns through the entire 2027 plan year. Gabler’s framing puts that in the hands of plan advisors. Payroll already collects premiums and withholds taxes, and the growing share of insured workers unable to afford the care their plans nominally cover suggests the architecture is already there. It just has not been extended to the moment care is actually needed.
