The number of Americans with health insurance has reached historic highs during the COVID-19 pandemic, but within that silver lining is a darker hue.
Many Americans have policies that offer only limited financial protection, to the point that many patients report forgoing necessary medical care or prescriptions to avoid facing punitive out-of-pocket expenses.
These are some of the findings of a new health report insurance survey led by the Commonwealth Fund, a private research foundation that promotes equitable, high-quality health care.
The survey follows other health insurance data, including some released by the US Census Bureau from its annual survey of the American community, showing that certain pandemic measures, particularly those passed by Congress, have brought more people to health insurance than ever before.
In 2021, nearly 299 million Americans had health insurancethe most on record, and the number of Americans without health insurance — just over 28 million in 2021 — had fallen by 1.4 million people from 2019, according to the American Community Survey.
During the pandemic, Congress blocked states from unenrolling anyone from Medicaid, the health plan for low-income Americans. It also increased grants to help pay for individual health plans purchased through Affordable Care Act markets.
Yet the increase in insurance has not necessarily provided sufficient financial protection and, by extension, necessary medical care.
The Affordable Care Act requires insurance plans to provide specified benefits, but it does not eliminate co-payments and deductibles that patients must pay.
“The big ‘but’ is that while it’s great that more people have insurance coverage, it’s also half the battle,” said Gideon Lukens, director of research and analytics data for health policy at the left-leaning research institute, the Center on Budget. and Political Priorities. “You still need to make sure people covered have access to it and don’t have to sacrifice their financial security to get it.”
Health policy analysts say Congress and states can take new steps to fatten health insurance rolls and protect patients’ financial security.
The Commonwealth Fund survey, which was conducted this year between March 28 and July 4, questioned 8,022 adults aged between 18 and 65. It revealed that 43% of adults of working age were insufficiently insured.
This means they were uninsured (9%), had a gap in their coverage from the previous year (11%) or were insured all year round but were “underinsured”, which the Commonwealth defines as having coverage that still did not provide affordable access. health care (23%).
As a result, Americans are less healthy than they could be, said Sara Collins, a Commonwealth senior fellow and vice president who co-wrote an analysis of the foundation’s findings.
“If you’re delaying doctor’s visits or not getting prescriptions filled because of cost, it means your overall health isn’t as good as it could have been,” she said. declared. “This not only impacts the lives of individuals, but also the productivity of employers and the general well-being of the economy. And financially, it has a huge impact on people in terms of medical debt.
Commonwealth considered a person to be underinsured if they experienced any of the following three circumstances:
- Excluding health insurance premiums, an individual in the last 12 months had to face direct health expenses amounting to at least 10% of household income.
- The previous year’s non-premium outlays were at least 5% of a household’s income for an individual whose income was below 200% of the federal poverty level (in 2022, that’s $27,180 for an individual or $55,500 $ for a family of four).
- The Medicare deductible requirement was 5% or more of household income.
The survey found that more than 4 in 10 people who got individual health plans for 2022, including those buying plans from Affordable Care Act marketplaces, were underinsured. But he also reported that nearly 30% of people with employer-sponsored health plans fell into the same category.
According to United States Census Bureau datamore than 164 million people obtained their health insurance through work in 2021.
The survey also revealed that people with low incomes were more likely to be underinsured. The same is true for those who considered themselves to be in fair or poor health or who identified themselves as having at least one chronic health condition, such as diabetes or hypertension.
People who were uninsured for at least part of the year or who were underinsured reported much higher rates of difficulty obtaining treatment due to cost. They either didn’t seek care when they had a medical problem, skipped a recommended treatment, test or follow-up visit, didn’t see a specialist when needed, or didn’t fill a prescription.
Overall, 61% of those considered underinsured and 71% of those who were uninsured for part of the year did not get needed medical care because of cost. Less than a third of those who had adequate insurance for the whole year did not.
High percentages of people with chronic conditions also said they had not filled their prescriptions in the previous year due to cost. This was the case for at least a quarter of people with diabetes, lung diseases such as emphysema and those who suffered from heart failure or heart attack.
Two-thirds of people who were underinsured or had gaps in coverage during the year also said they had trouble with medical bills, with many facing medical debt or making sacrifices in other parts of their lives to pay for medical bills. Many reported long-term consequences, including damage to their credit rating, having to dip into savings, or being unable to pay for other necessities, such as food, heat or rent.
Half of those surveyed said they would not be able to cover an unexpected medical bill of $1,000 within 30 days. Rates were even higher for blacks (69%) and for Latinos (63%).
Potential status fixes
Collins said one of the most effective ways to improve inadequate health insurance would be to last 12 recalcitrant states, most of them in the South, to expand Medicaid eligibility, as permitted by the Affordable Care Act, to all adults whose incomes reach 138% of the poverty level. This step alone could provide insurance coverage to 3.7 million additional people.
As other data has asserted, the Commonwealth report found that the uninsured were disproportionately young, Latino, low-income and living in the South.
The recently passed federal Inflation Reduction Act extended pandemic-era subsidies for in-market health insurance plans for another three yearswhich will help many people pay the premiums.
But enrollment in health coverage will likely decline when the COVID-19 public health emergency ends, most likely in 2023. That’s when the moratorium on opting out of Medicaid beneficiaries will also end. The change will force states to reassess each patient’s Medicaid eligibility, creating the risk that many millions of people, including those who should be eligible, will be squeezed out of the program due to bureaucratic snafus and red tape.
Collins said Congress could make other changes to market rules to reduce payouts for beneficiaries. The grants are now indexed to so-called Silver plans, which offer 70% actuarial coverage, meaning they typically cover up to 70% of an individual’s healthcare costs. Instead, the Commonwealth recommends linking subsidies to Gold plans, which cover 80% of health care costs.
Changing the benchmark to Gold plans would make those plans more affordable. It would also be costly for the federal government due to higher subsidy payments, which could make it a tough sell to lawmakers.
Nearly a dozen states have taken steps in the past two years to provide protections for residents facing medical debtand consumer advocates expect bills to be filed in other states next year.
More states could also provide assistance to low-income people, Collins said. As the federal government provides grants to help low-income Americans with healthcare costs, some states do too or providing assistance to help people pay premiums or reduce personal expenses. They include California, Colorado, Massachusetts, New Jersey, Washington, and Vermont.
Collins said more states could also follow Rhode Island’s lead of using insurance regulation to try to slow rising rates charged by medical providers, which could lower health insurance premiums.
Three states, Colorado, Nevada, and Washington, have created or plan to launch public health insurance plans that would provide lower-cost health insurance.
That will help, advocates say, but almost as important as having health insurance, health policy experts say, will be how much is left for beneficiaries.
“It’s one thing to have coverage, but the terms of that coverage must be adequate to meet the needs of enrollees,” said Justin Giovannelli, project director at the Center for Health Insurance Reforms. Georgetown University.