Commonwealth Fund: Underinsurance Is Undermining Americans’ Health

On Nov. 21, leaders at The Commonwealth Fund, the New York City-based public-interest foundation, released their latest report on the health insurance coverage of consumers, a biennial report called “The State of U.S. Health Insurance in 2024: Findings from the Commonwealth Fund Biennial Health Insurance Survey.” The report reveals major challenges around health insurance coverage for Americans, including the key issue of underinsurance.

The Commonwealth Fund’s press release, posted to the organization’s website on Thursday morning, began thus: “The Affordable Care Act (ACA) and recent reductions in marketplace premiums have brought U.S. uninsured rates to record lows, with most working-age Americans covered throughout the year. However, a new Commonwealth Fund survey shows that coverage gaps remain, and health plans — including those offered by employers, which cover most people — do not always guarantee affordable or timely access to care. The report suggests ways policymakers can expand coverage and lower costs for consumers.”

On behalf of The Commonwealth Fund, SSRS, a survey company, interviewed 8,200 adults aged 19 to 64, and Commonwealth Fund experts analyzed 6,400 survey responses. Based on their analysis, Commonwealth Fund leaders wee able to determine that 23 percent of survey respondents with insurance coverage were underinsured—which they defined as “enrolled in health plans with high out-of-pocket costs that make it difficult to afford care. Among those underinsured,” the Commonwealth Fund noted, “two-thirds (66 percent) had coverage through an employer, 14 percent had individual or marketplace plans, and 11 percent were enrolled in Medicaid. More than half (57 percent) reported forgoing care because of cost and 44 percent said they carry medical debt.”

There were numerous key findings, among them the following

Ø  Two-thirds of underinsured adults—66 percent—are covered through an employer-based health plan.

Ø  More than half of adults who were uninsured or underinsured reported skipping recommended treatments or not filling prescriptions due to cost.

Ø  Up to one-third of people with a chronic condition, such as heart failure and diabetes, chose not to fill prescriptions for their health conditions due to cost.

Ø  Over one-third of working-age adults who were uninsured or underinsured are paying off medical or dental debt, forcing many to delay or avoid necessary care, forgo essential needs, and experience stress.

Ø  Nearly half (48 percent) of all adults with medical debt owe $2,000 or more; one of five (21percent) carry a staggering $5,000 or more in debt.

Ø  About half (51 percent) of adults with debt said it stemmed from treatment they received for an ongoing health condition; hospital care was cited as the most frequent source of debt (49 percent).

Ø  Delaying or skipping care is harming people’s health. Two of five adults (41 percent) who skipped or delayed needed care because of the cost said their health problem has worsened as a result. This was especially true for people who were experiencing poor health and had lower incomes (45 percent).

Joseph R. Betancourt, M.D., M.P.H., president of The Commonwealth Fund, made a statement at the outset of a press briefing held online on Wednesday, Nov. 19, prior to the official release of the survey results. “Our biennial health insurance survey provides a broad look at Americans’ experiences with health insurance, including the quality of their coverage,” Dr. Betancourt said. “What it reveals is a critical weakness in the U.S. health insurance system: even with coverage, too many Americans are still struggling to afford the care they need. We find ourselves in a unique moment in 2024. Thanks to the Affordable Care Act, and 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 preexisting conditions can access coverage without discrimination, and preventative 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.”

Indeed, Betancourt said, “Our findings underscore how the high cost of coverage across the majority of insurance plans is impacting people every day. And with so many insured Americans facing such high out-of-pocket costs and deductibles, they’re being forced to take on medical debt and even skip needed care altogether. I’ll say this isn’t just a healthcare issue, it’s an economic one; when people are forced to spend a significant portion of their income on healthcare without adequate protection, they’ve often pushed into debt and forced to choose between their health and financial security. Personally, as a primary care doctor, I see first-hand how these critical coverage gaps aren’t just national data points; they are impacting individual lives. I regularly care for patients who struggle to afford essential medications, battle denied claims for the care they need; I see older patients who had to deal with this over the years, and because they didn’t have adequate coverage before Medicare, are now sicker, and cost our healthcare system more because of it. Looking ahead, especially as we face a new Congress and administration, we hope these findings help advance clear policy solutions to address these challenges and the lived experiences of millions of Americans.”

The report was authored by Sara R. Collins, Ph.D., senior scholar and vice president for healthcare coverage and access, and Avni Gupta, Ph.D., researcher for healthcare coverage and access, both at The Commonwealth Fund.

The press release notes that “Policy options that could bring better coverage to more people include:

Ø  Permanently extend enhanced marketplace premium tax credits, introduced during the COVID pandemic, which are set to expire in 2025. Without these credits, annual premium costs for consumers in marketplace plans will spike by an average $705 and an estimated 4 million could lose coverage.

Ø  Remove medical debt from credit reports and enforce stronger requirements on hospitals to prevent patients from accumulating debt.

Ø  Lower deductibles and out-of-pocket costs in marketplace plans.

Ø  Adjust premiums and cost sharing in employer plans based on workers’ incomes to make coverage more affordable and comprehensive for lower-wage employees.

Ø  Establish a federal fallback option to cover the estimated 1.5 million uninsured people in the 10 states that haven’t expanded their Medicaid programs.

Ø  Allow states to maintain continuous Medicaid eligibility for adults for 12 months — as has been done for children in Medicaid and the Children’s Health Insurance Program. This would help prevent lapses in coverage because of eligibility changes, administrative errors, and other factors that can leave people uninsured and unable to get care.”

The full report can be accessed here.

As explained on the organization’s website, “The Commonwealth Fund was established in 1918 with the broad charge to enhance the common good. Its founder, Anna M. Harkness, is among the first women to start a private foundation. Today, the mission of the Commonwealth Fund is to promote a high-performing, equitable health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including people of color, people with low income, and those who are uninsured. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.”