Among US adults with insurance, 28 percent were underinsured in 2018–up from 23 percent in 2014. (Photo: Shutterstock)
Since the passage of the Affordable Care Act (ACA) uninsurance among Americans has dropped 8 percent—but a new problem, “underinsurance,” has risen at the same time, creating a significant group of insured Americans who struggle with health care costs.
The 2019 Biennial Health Insurance Survey, released on Feb. 7 by the Commonwealth Fund, finds that nearly 30 percent of Americans were underinsured and may have trouble affording their health care.
The problem of being underinsured
The study found that among US adults with insurance, 28 percent were underinsured in 2018, up from 23 percent in 2014. “Underinsured” is defined as those who have high health insurance deductibles and out-of-pocket medical expenses relative to their income, and are more likely to struggle paying health care bills or to skip treatment because of costs.
The report noted that becoming underinsured has been a problem for both those on the individual market and people covered through employer-based plans. “The greatest deterioration in the quality and comprehensiveness of coverage has occurred among people in employer plans,” the report's authors note. “Twenty-eight percent of U.S. adults who have health insurance through their employer were underinsured in 2018, up from 20 percent just four years earlier. At the same time, people who bought plans on their own through the individual market or the marketplaces were the most likely to be underinsured, with 42 percent reporting a lack of adequate coverage in 2018.”
According to David Blumenthal, M.D. Commonwealth Fund president, the survey underlines a growing problem with employer-based insurance. “More than 15 million people get their health insurance through their employers,” he said. “While the ACA expanded and improved coverage options for people without a job-based health plan, the law largely left the employer market alone. The results of this survey indicate that it may be time for policymakers to pay some serious attention to the relatively quick erosion of employer coverage and its impact on workers.”
Underinsured wait on care, have medical debt
The Commonwealth Fund study outlined why underinsurance is such a problem: it can delay care, which can result in higher costs down the road. And when care is delivered, the underinsured struggle to pay their bills.
The study found 41 percent of underinsured adults said they delayed needed care because of cost, compared to 23 percent of people with adequate insurance coverage. And almost half (47 percent) of underinsured adults reported problems with medical bills and debt—nearly twice the rate as those who are not underinsured (25 percent).
Fewer Americans lack insurance; preventive care improves
The study noted that the ACA has accomplished one of its primary goals: more Americans have become insured and stayed insured. “Despite changes by the Trump administration and Congress that were expected to weaken the ACA, this survey finds no change in the adult uninsured rate between 2016 and the second half of 2018,” the report said. “By late fall of 2018, 12.4 percent of adults were uninsured, down from a high of 20 percent in the Commonwealth Fund's 2010 survey, conducted the year the ACA became law.”
The study noted another benefit: the ACA's requirement that health plans provide screenings and preventive care without cost sharing. Free screenings and preventive care can improve consumers' health, the study notes, even if some have trouble affording follow-up care. “Having continuous coverage—even coverage that does not provide adequate cost protection—makes a significant difference in people's access to care,” the report said. “The majority of adults insured all year report a regular source of care, get timely preventive care, and receive recommended cancer screenings.”
Possible solutions
The report's authors pointed to a number of steps that could be taken to expand coverage and provide cost relief to American health care consumers. These include expanding Medicaid in all states, without restrictions such as work requirements; placing limits on short-term insurance plans; restore funding to navigator and outreach programs; establishing re-insurance programs in states seeking to reduce premiums; and providing subsidies for family coverage along with individual plans.
The study suggests that in addition to improving ACA coverage, lawmakers should also take steps to directly address rising health care costs. “Doing so will be critical for keeping down employer premiums and deductibles,” the report concluded.
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