Study finds patients paying for insurance still pile on medical debt, or skip care to avoid it

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While the rate of people without health insurance remains at a historic low, lack of insurance and being underinsured remains problematic for millions, according to the latest research from The Commonwealth Fund.

“The State of U.S. Health Insurance 2024: Findings from the Commonwealth Fund Biennial Health Insurance Survey,” details a major challenge for the United States: People have insurance, yet may not seek out health care due to costs and fear of medical debt, said Sara R. Collins, PhD, senior scholar and vice president for health care coverage and access and tracking health system performance. She presented the findings in an online meeting with Commonwealth Fund President Joseph R. Betancourt, MD, MPH, and Bethanne Fox, vice president for outreach and strategy. Health Care Coverage and Access Researcher Avni Gupta, PhD, is co-author of the study.

Joseph R. Betancourt, MD, MPH
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Sara Collins, PhD
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“We find ourselves in a unique moment in 2024,” Betancourt said. “Thanks to the Affordable Care Act, recent expansions in premium subsidies for marketplace plans, more Americans have coverage than ever before. The uninsured rate is at a historic low. People with pre-existing conditions can access coverage without discrimination and preventive care is available at no cost. These are very real and important achievements.

“However, having health insurance doesn't always mean access to affordable, timely care,” he said.

Insured, but underinsured

The expansions in premium subsidies for ACA Marketplace health insurance led to annual premium savings of $387 to $2,914 for people.

Approximately 23% of working age adults have insurance plans that leave them underinsured. The study based that on at least one of three criteria:

• In the last year, out-of-pocket costs were at least 10% of household income (excluding premiums).
• In the last year, out-of-pocket costs were at least 5% of household income for people under 200% of the federal poverty level, or $29,160 for an individual or $60,000 for a family of four.
• The deductible was 5% or more of household income.

Among the 23% of people who were underinsured, 66% of them had health insurance coverage through an employer plan. Another 14% had coverage through the ACA Marketplace, 11% were on Medicaid, 6% were on Medicare and 4% had another form of insurance.

Problems health, insurance or both

Patients with insurance that does not fully cover costs encounter at least one of four problems:

• Did not fill a prescription – 25% of respondents, including those with chronic conditions asthma, emphysema, lung disease, diabetes, heart failure or heart attack, depression or other mental health conditions, hypertension and high cholesterol.
• Skipped a recommended test, treatment or follow-up – 33%. Among them, 41% said it worsened their medical condition.
• Had a medical problem but did not visit a doctor or clinic – 34%
• Did not get needed specialist care – 29%

“Those who do get care often leave the hospital or a doctor's office with bills they can't pay,” Collins said.

In the survey, 29% of working-age adults said they were repaying medical debt over time, and among them, 48% had debt of at least $2,000. Carrying medical debt led to anxiety for at least 79% of respondents. They also used up part or all of their savings to cover health care costs (41%), cut back on food, heat or rent (38%), or delayed care or getting prescription drugs (36%).

As for the nature of debt, 49% involved hospital care, but 36% involved doctor’s office visits, 36% was for dental care, 35% was for emergency care, 10% was for ambulance services and 2% was for long-term care.

“While the stories we hear about medical debt in the media frequently highlight unexpected health care events like emergency room visits that leave people with lots of medical bills, our survey findings suggest that the source of much of medical debt is simply care for chronic health problems, about half of adults with debt said stem from treatment they receive for an ongoing condition,” Collins said. “We also find that hospital care is the most frequently cited source of debt.”

A big problem in primary care

Regarding those who skipped a doctor or clinic visit due to fear of debt, the survey did not indicate direct effects on primary care. However, it’s often a blend of situations when patients delay health care, Betancourt said, citing his experience as a primary care physician. He touched on the point during his opening remarks and in response to a question from Medical Economics.

“The way I view it, we pay now, or we pay later, and the cost later is a lot more than investing in affordability,” he said. Some conditions, such as managing diabetes, may develop over a longer time, while some are more acute, like heart failure.

The study highlights situations where patients might need critical exams, either for prevention or treatment, but copays and deductibles put those out of reach, Betancourt said. That leads to problems not just with money, but with morale.

“Again, I would argue they have very significant implications for long-term well-being and costs,” Betancourt said. “So clearly, it's tough to nail down, as Sarah said, the particulars, but it's the portfolio of challenges I think that is most concerning and most troubling.

“And as I mentioned in my opening comments, it's not just troubling for the patient, it's troubling for caregivers as well,” he said. “It's no surprise why we see incredible demoralization of health care providers, fatigue and the like. You know that is largely powered by the fact that as a caregiver, I know what my patient needs. I want to get it to them. Their inability to get it, inability to afford it, red tape that makes it difficult for them to get it is deeply distressing for both parties, and certainly impacting the primary care community, leading, in many ways, to the primary care crisis that we see today.”