Survey shows millions of people struggling to afford health care

Nearly decade-long trend of rising uninsured rates among young adults reversed; biennial health insurance survey finds 75 million people struggled with medical debt and 80 million were unable to afford the health care they need

Eighty-four million people―nearly half of all working-age U.S. adults―went without health insurance for a time last year or had out-of-pocket costs that were so high relative to their income they were considered underinsured, according to the Commonwealth Fund 2012 Biennial Health Insurance Survey. The survey also found that the proportion of young adults ages 19-25 who were uninsured during the year fell from 48 percent to 41 percent between 2010 and 2012, reversing a nearly decade-long trend of rising uninsured rates in that age group. This reversal is likely due to a provision in the 2010 Affordable Care Act allowing young adults to stay on their parents' health insurance until age 26, the authors say. The report, Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act, finds that the percentage of Americans who were uninsured, underinsured, or had gaps in their health coverage grew steadily between 2003 and 2010, with the number of underinsured nearly doubling from 16 million in 2003 to 29 million in 2010. However, between 2010 and 2012, the numbers of underinsured adults leveled off, growing to 30 million. The authors say that this is partly a result of slower health care cost growth and lower overall health spending by consumers, combined with declining household incomes. But provisions in the health reform law-such as requiring insurers to cover recommended preventive care without any cost to patients-also are beginning to make health care more affordable for many consumers.

"The early provisions of the Affordable Care Act are helping young adults gain coverage and improving the affordability of health care during difficult economic times for American families," said Sara Collins, Ph.D., a Commonwealth Fund vice president and the study's lead author. "It will be critical to continue to monitor the effects of the law as the major provisions go into effect in 2014 and beyond to ensure it achieves its goal of near-universal, comprehensive health insurance."

Millions Are Struggling to Afford Health Care and Falling into Medical Debt

According to the survey, people are increasingly skipping needed health care because they can't afford it. In 2012, 80 million people reported that, during the past year, they did not go to the doctor when they were sick or did not fill a prescription due to cost. Reports of skipping needed care rose substantially from 2003, when 63 million people did not get care because of cost.

Medical debt also continues to burden U.S. households. According to the report, in 2012, 41 percent of working-age adults, or 75 million people, had problems paying their medical bills or were paying off medical bills over time, up from 58 million in 2005. Nearly one of five (18%) adults were contacted by a collections agency over unpaid bills, and 16 percent had to change their way of life because of medical bills. The report finds that medical debt has substantial consequences: 42 percent of survey respondents who reported having trouble with medical bills, or an estimated 32 million people, had a lower credit rating because of unpaid bills and 6 percent, or an estimated 4 million, had to declare bankruptcy because of their bills.

Impact of the Affordable Care Act

The health reform law has already helped millions of young adults gain insurance coverage and protected people from insurance company practices like cancelling policies retroactively when a subscriber becomes sick, or putting a limit on how much they will pay out in a given year or lifetime. But the bulk of the law's effects will not be felt until 2014, when the health insurance reforms are fully implemented and the new state insurance marketplaces are up and running. Using the survey findings to determine how the Affordable Care Act will impact Americans currently uninsured or underinsured, the report finds that:

• Eighty-seven percent of the 55 million people who were uninsured for some time during the year in 2012 have incomes that would make them eligible for subsidized health insurance through the insurance marketplaces or expanded Medicaid under the law, though coverage is limited to those legally present in the U.S.

• Up to eighty-five percent of the 30 million underinsured adults might be eligible for either Medicaid or subsidized health insurance plans with reduced out-of-pocket costs under the law.

The authors say it is critical that the federal government and the states continue to implement the Affordable Care Act, cautioning that if states don't expand Medicaid as the law originally intended, millions of low-income families will be at risk for being uninsured even after the law takes full effect in 2014.

"The costs of health care and health coverage in the United States have been on an unsustainable trajectory, straining family and government budgets," said Commonwealth Fund president David Blumenthal, M.D. "It is important that lawmakers and regulators across the country take the steps necessary to ensure that all Americans can benefit fully from the law's improvements to the quality, efficiency, and affordability of our health care system."

Additional Report Findings:

• In 2012, about three-fourths of working-age adults with low incomes (less than $14,856 a year for an individual or $30,657 for a family of four)-an estimated 40 million people-were uninsured or underinsured.

• Fifty-nine percent of adults with moderate incomes (between $14,856 and $27,925 for an individual or between $30,657 and $57,625 for a family of four)-or 21 million people -were uninsured or underinsured.

• Adults who were uninsured were less likely to receive recommended preventive care in 2012. For example, only 48 percent of women who were uninsured during the year received a mammogram within the recommended period, compared to 77 percent of those who were well insured all year.