Almost a quarter of Americans underinsured, survey finds

Photo: Luis Alvarez/Getty Images

Among those who were insured all year in 2023, almost a quarter (23%) were underinsured, meaning they had coverage for a full year that didn't provide them with affordable access to healthcare, according to a new survey from the Commonwealth Fund.

Polling a national sample of adults aged 18 to 64, the survey found that among underinsured adults, 66% had coverage through an employer, 16% were enrolled in Medicaid or Medicare, and 14% had a plan purchased in the marketplaces or the individual market.

Nearly three in five (57%) underinsured adults said they avoided getting needed healthcare because of its cost, while 44% said they had medical or dental debt they were paying off over time. 

These care delays, the survey found, have health consequences: Two in five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.

WHAT'S THE IMPACT

For the purposes of the survey, people were considered "underinsured" if their coverage doesn't enable affordable access to healthcare. That means a number of things could be true: Perhaps out-of-pocket costs over the prior 12 months, excluding premiums, were equal to 10% or more of household income; perhaps the individual or family deductible constituted 5% or more of household income; or perhaps out-of-pocket costs over the prior 12 months, excluding premiums, were equal to 5% or more of household income for individuals living under 200% of the federal poverty level ($29,160 for an individual or $60,000 for a family of four in 2023).

Among the insured working-age adults in the U.S. who had high out-of-pocket costs or deductibles relative to their income in 2024 that they were effectively underinsured, the vast majority were in employer plans. About 14% had plans purchased in the individual market or the marketplaces, and 16% were enrolled in Medicaid or Medicare.

Being uninsured or underinsured are barriers to getting timely healthcare, the survey found. Fifty-seven percent of working-age adults who were underinsured and 70% of those who lacked continuous coverage said they did not get needed care because of the cost. This included not going to the doctor when sick, skipping a recommended follow-up visit or test, not seeing a specialist when recommended, or not filling a prescription.

Forty-two percent of adults who didn't get care because of cost said it was for an ongoing health condition, 29% said it was for a new health problem, and 28% said it was for both.

One in five respondents said they had delayed getting mental health care because of cost, with higher rates of delayed care reported by those with inadequate coverage.

Three in 10 reported they were paying off medical debt, with underinsured adults reporting this at the highest rate. Of survey respondents with employer coverage, those with low and moderate income reported paying off medical debt at higher rates than those with higher income. People in employer plans and the individual market and marketplaces reported significantly higher rates of medical debt than people who had Medicaid.

Medical debt can have lasting financial consequences. Two of five adults reporting debt said they had used up all or part of their savings to pay it off, and 28% said they received a lower credit rating because of it.

THE LARGER TREND

The Commonwealth Fund floated a few suggestions to policymakers, including permanently extending the enhanced marketplace premium tax credits set to expire in 2025, creating a longer period of continuous Medicaid eligibility and creating an auto enrollment mechanism for comprehensive health coverage.

To improve insurance design and protect consumers from medical debt, authors suggested lowering deductibles and out-of-pocket costs in marketplace plans; adjusting premiums and cost sharing based on employee income; and lower healthcare cost growth.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.