NEW YORK, Oct. 26 (UPI) — Affording healthcare is a struggle for half of working-age Americans, and almost one-third are overwhelmed by medical debt, according to a new survey of more than 6,100 adults by The Commonwealth Fund released Thursday.
The New York-based private foundation, which is focused on affordable and quality healthcare for all, noted that medical debt is a growing problem that makes insured and uninsured Americans sicker and poorer. And affordability challenges affect people on employer plans, Medicaid, Medicare and marketplace coverage.
“I was not shocked at all by what we found,” Dr. Joseph Betancourt, president of The Commonwealth Fund, told reporters at a briefing on the findings. He added that “patients’ experiences range from confusion to frustration to legitimate threats to their health and well-being.”
For the survey, telephone and online interviews were conducted in English and Spanish with a nationally representative sample of 7,873 adults age 19 and older between April 18 and July 31, 2023. Then, the analysis focused on 6,121 respondents of working age, between 19 and 64 years old.
The survey focused in part on the cost of health insurance.
“While having insurance is always better than not having it, the findings challenge the assumption that health insurance coverage in the U.S. buys affordable access to care,” the survey report said.
It noted that “large shares of insured working-age adults surveyed said it was very difficult or somewhat difficult to afford their healthcare.”
That included 43% of those with employer coverage, 57% with marketplace or individual-market plans, 45% with Medicaid and 51% with Medicare.
Delayed healthcare
“Many insured adults said they or a family member had delayed or skipped needed healthcare or prescription drugs because they couldn’t afford it in the past 12 months,” the reported said.
That included 29% of those with employer coverage, 37% covered by marketplace or individual-market plans, 39% enrolled in Medicaid and 42% with Medicare.
“Cost-driven delays in getting care or in missed care made people sicker,” the report said. “Fifty-four percent of people with employer coverage who reported delaying or forgoing care because of costs said a health problem of theirs or a family member got worse because of it, as did 61% in marketplace or individual-market plans, 60% with Medicaid and 63% with Medicare.
“Insurance coverage didn’t prevent people from incurring medical debt. Thirty percent of adults with employer coverage were paying off debt from medical or dental care, as were 33% of those in marketplace or individual-market plans, 21% with Medicaid and 33% with Medicare.”
Many Americans are saddled with medical debt because “we still have gaps in our insurance system, leaving millions without coverage for short or extended periods of time,” the report’s lead author, Sara Collins, senior vice president for health care coverage and access and tracking health system performance at The Commonwealth Fund, told UPI via email.
Significant hardships
For people with health insurance, copays and deductibles or narrow provider networks pose significant hardship. On a tight household budget, it may be difficult to cover the bills, leading to medical debt that has to be paid off over time.
“While media stories often focus on people who experience emergencies that leave them with lots of bills they can’t pay, we find that half of people reporting medical debt said it resulted from treating an ongoing condition” such as cancer or diabetes, Collins said.
The report “is a staggering indictment of U.S. healthcare and the financial burdens that it imposes on Americans,” Jonathan Oberlander, a professor and chair of social medicine and health policy and management at the University of North Carolina at Chapel Hill, told UPI via email.
“No part of American health insurance is safe: Persons with Medicare, Medicaid, individually purchased and employer-offered coverage, as well as the uninsured, are vulnerable to the high costs of medical care.”
As the report points out, “even with insurance, more than 1 in 5 Americans must pay off debt from medical or dental care,” Dr. Joshua Liao, an internal medicine physician and associate chair for health systems at the University of Washington School of Medicine in Seattle, told UPI via email.
He noted that “while the issues encompassed by the survey unfortunately aren’t new, its findings are still timely and noteworthy.”
High deductibles
A large part of the problem lies in high deductibles on state healthcare marketplaces. The average cost on a silver plan is $4,000 to $5,000 nationally, Leighton Ku, a George Washington University health policy professor and board member of the DC Health Benefit Exchange Authority, told UPI in a telephone interview.
“That’s at the heart of why so many people who are insured have affordability problems.” Ku said.
Not being aware of the cost of healthcare services may lead to unpleasant surprises.
“Unlike grocery shopping, in which I always see the price of an apple before I put it in my cart, patients rarely know the price of a visit, test, procedure or a new prescription drug ordered by their healthcare provider in advance,” Ellen Meara, a professor of health economics and policy at the Harvard T.H. Chan School of Public Health, told UPI via email.
“They may learn only when they get a bill, often much later, requiring them to pay whatever insurance will not pay.”
One of the best ways to reduce medical debt is to expand insurance access.
So far, 10 states have elected not to expand Medicaid eligibility under the Affordable Care Act, despite consistent evidence that this would reduce medical debt and improve access to care, William Schpero, assistant professor in the division of health policy and economics of population health sciences at Weill Cornell Medicine in New York, told UPI via email.
“Congress can also take steps to improve the affordability of private insurance by extending — and further increasing — enhanced premium subsidies for plans purchased on state insurance marketplaces that are currently set to expire in 2025,” Schpero said.

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