How Well Does Insurance Coverage Protect Consumers from Health Care Costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 216 Sara R. Collins, Ph.D. Vice President, Health Care Coverage and Access The Commonwealth Fund National Coalition on Health Care: Affordable Health Care Summit November 2, 217
EXHIBIT 1 Who is Underinsured? The underinsured measure is based on: a continuously insured adult s reported out-of-pocket costs over the course of a year, not including premiums, and the health plan deductible. Someone is considered underinsured if: Out-of-pocket costs, excluding premiums, over the prior 12 months are 1 percent or more of household income; or Out-of-pocket costs, excluding premiums, are 5 percent or more of household income if income is under 2 percent of poverty ($23,76 for an individual and $48,6 for a family of four); or Deductible is 5 percent or more of household income.
EXHIBIT 2 Summary of Major Findings The share of adults who were insured all year but were underinsured rose sharply in 216. Underinsured rates among people in employer plans, especially those in larger firms, ticked up significantly in 216. People covered in the individual market, including the ACA marketplaces, had the highest underinsured rates among privately insured adults. Deductibles have become an increasingly large factor in these rising rates more people than ever before have plans with deductibles and more have deductibles that are high relative to income. People who were underinsured report problems paying medical bills and getting timely health care at rates nearly as high as those who were uninsured.
EXHIBIT 3 More Than One-Quarter of Insured Adults Were Underinsured in 216 Percent adults ages 19 64 insured all year who were underinsured* 28 22 23 23 2 12 13 1 23 25 21 212 214 216 * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; outof-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. Data: Commonwealth Fund Biennial Health Insurance Surveys (23, 25, 21, 212, 214, and 216).
EXHIBIT 4 Underinsured Rates by Source of Coverage Percent adults ages 19 64 insured all year who were underinsured* 23 25 21 212 214 216 Total 12% 13% 22% 23% 23% 28% Insurance source at time of survey** Employer-provided coverage 1% 12% 17% 2% 2% 24% Individual coverage^ 17% 19% 37% % 37% 44% Marketplace^^ 44% Medicaid 22% 16% 32% 31% 22% 26% Medicare (under age 65, disabled) 39% 24% % 32% 42% 47% Firm size (base: full- or part-time workers with coverage through their own employer)^^^ 2-99 employees 14% 16% 26% 26% 22% 1 or more employees 11% 16% 16% 14% 22% * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; outof-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. ** Adults with coverage through another source are not shown here. Respondents may have had another type of coverage at some point during the year, but had coverage for the entire previous 12 months. ^ For 214 and 216, includes those who get their individual coverage through the marketplace and outside of the marketplace. ^^ Adults enrolled in marketplace coverage are not shown for 214 because no one in the sample would have had marketplace coverage for the full year. ^^^ Does not include adults who are self-employed. Data not available. Data: Commonwealth Fund Biennial Health Insurance Surveys (23, 25, 21, 212, 214, and 216).
EXHIBIT 5 Deductibles in Private Plans Have Grown over the Past Decade Percent adults ages 19 64 with private coverage* 75 23 25 21 212 214 216 6 52 51 15 4 38 34 29 25 22 * Base is those who specified deductible. Data: Commonwealth Fund Biennial Health Insurance Surveys (23, 25, 21, 212, 214, and 216). 44 39 37 35 No deductible $1 $999 $1, $2,999 $3, or more 7 9 18 Amount of deductible 23 27 1 2 4 9 11 13
EXHIBIT 6 High Deductibles Relative to Income by Coverage Source Percent adults ages 19 64 insured all year who had deductibles that were 5% or more of income 23 25 21 212 214 216 Total 3% 3% 6% 8% 11% 12% Insurance source at time of survey* Employer-provided coverage 2% 2% 6% 8% 11% 13% Individual coverage^ 7% 12% 17% % 24% 23% Marketplace^^ 22% Firm size (base: full- or part-time workers with coverage through their own employer)^^^ 2-99 employees 4% 6% 15% 2% 13% 1 or more employees 1% 5% 6% 8% 13% * Respondents may have had another type of coverage at some point during the year, but had coverage for the entire previous 12 months. ^ For 214 and 216, includes those who get their individual coverage through the marketplace and outside of the marketplace. ^^ Adults enrolled in marketplace coverage are not shown for 214 because they did not have marketplace coverage for the full year. ^^^Does not include adults who are self-employed. Data not available. Data: Commonwealth Fund Biennial Health Insurance Surveys (23, 25, 21, 212, 214, and 216).
EXHIBIT 7 Underinsured Rates Highest Among Low-Income Adults and Those with Health Problems Percent adults ages 19 64 insured all year who were underinsured* 75 75 6 15 49 44 44 42 38 33 <2% FPL 2% FPL or more 2 14 16 16 5 9 23 25 21 212 214 216 6 15 17 2 9 9 Fair/poor health status or any chronic condition** 28 27 2 17 No health problem 23 25 21 212 214 216 17 34 23 Notes: FPL refers to federal poverty level. Income levels are for a family of four in 216. * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; outof-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. ** Respondent has at least one of the following health conditions: hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; or high cholesterol. Data: Commonwealth Fund Biennial Health Insurance Surveys (23, 25, 21, 212, 214, and 216).
EXHIBIT 8 More Than Half of Underinsured Adults Reported Medical Bill Problems, Close to Rate of Uninsured Percent adults ages 19 64 75 Insured all year, not underinsured* Insured all year, underinsured* Uninsured during the year 6 52 54 15 13 32 4 Had problems paying or unable to pay medical bills 17 24 24 2 8 8 Contacted by collection agency for unpaid medical bills Had to change way of life to pay bills 18 38 29 Medical bills being paid off over time 25 At least one medical bill problem or debt * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; outof-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. Data: Commonwealth Fund Biennial Health Insurance Survey (216).
EXHIBIT 9 Adults with High Deductibles Reported Problems Paying Medical Bills at Twice the Rate of Adults Without Deductibles Percent adults ages 19 64 with private coverage who were insured all year 75 6 No deductible Deductible $3, or more 4 15 12 24 Had problems paying or unable to pay medical bills 1 5 7 Contacted by collection agency for unpaid medical bills 18 Had to change way of life to pay bills 13 27 Medical bills being paid off over time 21 At least one medical bill problem or debt Data: Commonwealth Fund Biennial Health Insurance Survey (216).
EXHIBIT 1 Adults with Medical Bill Problems Had Lingering Financial Problems Percent adults ages 19 64 who reported the following happened in the past two years because of medical bill problems^ 75 Insured all year, not underinsured* Insured all year, underinsured* Uninsured during the year 6 15 47 34 25 Used all of savings 29 4 49 Received a lower credit rating 38 22 21 Took on credit card debt 5 1 Took out a mortgage against your home or took out a loan 6 8 1 8 Had to declare bankruptcy ^ Base: Respondents who reported at least one of the following medical bill problems in the past 12 months: had problems paying medical bills, contacted by a collection agency for unpaid bills, had to change way of life in order to pay medical bills, or has outstanding medical debt. * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. Data: Commonwealth Fund Biennial Health Insurance Survey (216).
EXHIBIT 11 More Than Two of Five Underinsured Adults Reported Problems Getting Needed Care Because of Cost Percent adults ages 19 64 75 6 15 Insured all year, not underinsured* Insured all year, underinsured* Uninsured during the year 36 27 28 31 31 24 11 11 11 7 Had a medical problem, but did not go to a doctor or clinic Did not fill a prescription Skipped a medical test, treatment, or follow-up recommended by a doctor 17 26 Did not see a specialist when you or your doctor thought you needed to see one 22 52 At least one cost-related access problem * Underinsured defined as insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 1% or more of income; outof-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<2% of poverty); or deductibles equaled 5% or more of income. Data: Commonwealth Fund Biennial Health Insurance Survey (216).
EXHIBIT 12 Adults with High Deductibles Reported Problems Getting Needed Care Because of Cost Percent adults ages 19 64 with private coverage who were insured all year 75 6 No deductible Deductible $3, or more 47 15 1 Had a medical problem, but did not go to a doctor or clinic 14 23 Did not fill a prescription 8 32 Skipped a medical test, treatment, or follow-up recommended by a doctor 5 2 Did not see a specialist when you or your doctor thought you needed to see one 22 At least one costrelated access problem Data: Commonwealth Fund Biennial Health Insurance Survey (216).
EXHIBIT 13 Looking forward: The ACA and implications of the Administration s recent actions for underinsurance Health plans sold through associations of small businesses could offer cheap but skimpy coverage that could leave employees exposed to high costs and potentially fraud. Short term health plans also could offer cheap but skimpy coverage that could leave individuals exposed to high health care costs. Ending payments for cost-sharing reductions (CSRs) has resulted in pricing disruptions and consumer confusion for 218, but eligible enrollees still have access to these plans that lower their deductibles and cost-sharing. Proposed marketplace changes for 219 include giving states much more flexibility to decide what services health plans cover in the marketplaces.
EXHIBIT 14 Looking forward: A red flag for employer coverage More than half of adults who are underinsured have coverage through an employer. In 216, underinsured rates among people in employer plans ticked up significantly, especially among those in larger firms. Policy options include raising the minimum coverage standard for employer plans, setting a standard for deductible exclusions. A fundamental reimagining of private benefit design combined with health system delivery reform is needed to improve access to care and financial protection for workers, while lowering premium growth for employers.
Acknowledgments Munira Z. Gunja Senior Researcher, Health Care Coverage & Access Michelle M. Doty Vice President, Survey Research & Evaluation Herman K. Bhupal Program Assistant, Health Care Coverage & Access