INSURING the FUTURE Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty APRIL 2013 The Commonwealth Fund, among the first private foundations started by a woman philanthropist— Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. 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. INSURING the FUTURE Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty APRIL 2013 ABSTRACT The major insurance coverage provisions of the Affordable Care Act go into effect in January 2014, providing new insurance options for people without health insurance and insurance market protections for consumers. The Commonwealth Fund Biennial Health Insurance Survey of 2012 finds that the reform law has significantly increased health insurance coverage of young adults. But the findings also underscore why it is critical that implementation continue on schedule. Nearly half (46%) of adults ages 19 to 64, or an estimated 84 million people, did not have insurance for the full year or were underinsured and unprotected from high out-of-pocket costs. Two of five (41%) adults, or 75 million people, reported they had problems paying their medical bills or were paying off medical debt. And more than two of five (43%), or 80 million people, reported cost-related problems getting needed health care. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new Fund publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. no. 1681. Contents List of Exhibits and Tables...............................................................................................................vi About the Authors........................................................................................................................viii Acknowledgments........................................................................................................................viii Executive Summary.........................................................................................................................ix Introduction......................................................................................................................................1 Survey Findings.................................................................................................................................1 The Affordable Care Act Will Expand and Improve the Affordability of Health Insurance and Health Care...................................................................................14 Looking Forward............................................................................................................................21 Survey Methodology......................................................................................................................22 Notes...............................................................................................................................................23 Tables..............................................................................................................................................25 List of Exhibits and Tables Exhibit ES-1 The Percentage of Young Adults Uninsured Declined over 2010–2012, While Rates Rose in Other Age Groups Exhibit ES-2 In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Exhibit ES-3 No Improvement in Coverage for Adults Overall from 2010 to 2012 Exhibit ES-4 Adults with Low Incomes Are Uninsured and Underinsured at the Highest Rates, 2012 Exhibit ES-5 Under Full Implementation, the Affordable Care Act Has the Potential to Provide New Coverage and Protections to Working-Age Adults Exhibit 1 The Percentage of Young Adults Uninsured Declined over 2010–2012, While Rates Rose in Other Age Groups Exhibit 2 In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Exhibit 3 No Improvement in Coverage for Adults Overall from 2010 to 2012 Exhibit 4 Since 2003, the Proportion of Adults with High Deductibles Has More Than Tripled Exhibit 5 Adults with Low Incomes Are Uninsured and Underinsured at the Highest Rates, 2012 Exhibit 6 One of Three Adults in the Individual Insurance Market Spent 10 Percent or More of Income on Premiums in 2012 Exhibit 7 Millions of Adults Continue to Report Problems Paying Medical Bills or Medical Debt Exhibit 8 Problems with Medical Bills or Accrued Medical Debt Highest Among Adults with Low and Moderate Incomes, 2012 Exhibit 9 Adults with Low Incomes Less Likely to Be Able to Pay for Basic Necessities Because of Medical Bill or Debt Problems Exhibit 10 Number of Adults Reporting Cost-Related Problems Getting Needed Care Increased, 2003–2012 Exhibit 11 Cost-Related Problems Getting Needed Care Are Highest Among Adults with Low and Moderate Incomes, 2012 vi Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Exhibit 12 Adults Uninsured During the Year or Underinsured Are More Likely to Skip Doses or Not Fill Prescriptions for Chronic Conditions, 2012 Exhibit 13 Uninsured Adults Are Less Likely to Have a Regular Source of Care, 2012 Exhibit 14 Uninsured Adults and Adults with Gaps in Coverage Have Lower Rates of Cancer Screening Tests, 2012 Exhibit 15 Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act Exhibit 16 Under Full Implementation, the Affordable Care Act Has the Potential to Provide New Coverage and Protections to Working-Age Adults Exhibit 17 Annual Premium Amount and Tax Credits for a Family of Four Under the Affordable Care Act, 2014 Table 1 Continuity and Adequacy of Insurance in 2012 Table 2 Insurance Costs, Benefits, and Problems by Insurance Continuity, Insurance Adequacy, and Income Table 3 Medical Bill Problems, by Insurance Continuity, Insurance Adequacy, and Income Table 4 Access Problems, by Insurance Continuity, Insurance Adequacy, and Income www.commonwealthfund.orgvii About the Authors Sara R. Collins, Ph.D., is vice president for Affordable Health Insurance at The Commonwealth Fund. An economist, Dr. Collins joined the Fund in 2002 and has led the Fund’s national program on health insurance since 2005. Since joining the Fund, she has led several national surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage and policy. She has pro- vided invited testimony before several Congressional committees and subcommittees. Prior to joining the Fund, Dr. Collins was associate director/senior research associate at the New York Academy of Medicine, Division of Health and Science Policy. Earlier in her career, she was an associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Office of the Public Advocate. She holds an A.B. in economics from Washington University and a Ph.D. in economics from George Washington University. She can be e-mailed at src@cmwf.org. Ruth Robertson, M.Sc., was senior research associate for the Affordable Health Insurance program at The Commonwealth Fund until February 2013. She focused on national and international survey development and data analysis. She also tracked, researched, and wrote about emerging policy issues related to U.S. health reform, the comprehensiveness and affordability of health insurance coverage, and access to care. Previously, she was a senior health policy researcher at the King’s Fund in London. Ms. Robertson holds a B.A. in economics from the University of Nottingham and an M.Sc. in social policy and planning from the London School of Economics and Political Science. Tracy Garber, M.P.H., is senior policy associate for The Commonwealth Fund’s Affordable Health Insurance pro- gram, for which she provides grant support, analyzes Fund survey data, and tracks and analyzes health reform implementation. Prior to joining the Fund, she was the development assistant and volunteer coordinator for the Hamilton-Madison House in lower Manhattan, a settlement house. Ms. Garber received her bachelor’s degree in women’s studies and English from the University of Delaware in 2008, and her M.P.H. from the CUNY School of Public Health at Hunter College in 2012. Michelle McEvoy Doty, Ph.D., is vice president of survey research and evaluation for The Commonwealth Fund. She has authored numerous publications on cross-national comparisons of health system performance, access to quality health care among vulnerable populations, and the extent to which lack of health insurance contributes to inequities in quality of care. She received her M.P.H. and Ph.D. in public health from the University of California, Los Angeles. Acknowledgments The authors thank David Blumenthal, Cathy Schoen and Barry Scholl for helpful comments, Deborah Lorber, Chris Hollander, Paul Frame, and Suzanne Augustyn for editorial support and design, and Cara Dermody, Shreya Patel, and Petra Rasmussen for research assistance. viii Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 EXECUTIVE SUMMARY The Share of Young Adults Without Insurance Declined Between 2010 and 2012 In early 2014, Americans will experience a funda- The percentage of young adults, ages 19 to 25, who mental transformation in their health insurance sys- were uninsured for any time during the prior year tem. The major health coverage provisions of the fell from 48 percent in 2010 to 41 percent in 2012, Affordable Care Act go into effect in January of that from 13.6 million to 11.7 million—a decline of 1.9 year, providing new options for people who do not million (Exhibit ES-1). Indeed, nearly 8 of 10 have insurance and sweeping new protections for (79%) young adults reported that they were insured those who buy health plans on their own. The at the time of the survey in 2012, up from 69 per- Congressional Budget Office projects that the com- cent in 2010, or a gain in health insurance coverage bination of new subsidies for health insurance and for an estimated 3.4 million young adults. This consumer protections will enable 14 million unin- marks an abrupt reversal in a decade-long upward sured people to gain coverage in 2014, and 27 mil- climb in the number of uninsured young adults, lion by 2021. one that is most likely the result of the Affordable Using data from the Commonwealth Fund Care Act’s requirement that children under age 26 Biennial Health Insurance Survey of 2012, this be permitted to stay in or join a parent’s health report examines the current state of insurance cover- plan. Meanwhile, uninsured rates for other age age in the United States and its financial and health groups increased or stayed the same. implications for working-age adults. Exhibit ES-1. The Percentage of Young Adults Uninsured Declined over 2010–2012, While Rates Rose in Other Age Groups Percent of adults ages 19–64 75 Insured now, time uninsured in past year Uninsured now 50 46 48 41 41 17 34 30 22 30 29 26 28 28 17 20 28 10 25 9 8 9 9 8 10 9 17 20 15 15 31 5 7 24 24 4 5 21 22 24 17 18 20 19 18 21 11 10 13 13 0 2003 2005 2010 2012 2003 2005 2010 2012 2003 2005 2010 2012 2003 2005 2010 2012 Total Ages 19–25 Ages 26–49 Ages 50–64 Note: Totals may not equal sum of bars because of rounding. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). www.commonwealthfund.orgix Nearly Half of Adults Either Spent a Time Lower-Income Adults Are Uninsured and Without Coverage or Were Underinsured in 2012 Underinsured at Higher Rates In 2012, nearly half (46%) of U.S. adults ages 19 to Americans with low or moderate incomes continue 64, an estimated 84 million people, did not have to be less protected from health care costs than insurance for the full year or had coverage that pro- higher-income Americans, because they either are vided inadequate protection from health care costs uninsured or have coverage with high cost-sharing (Exhibit ES-2). Thirty percent, or 55 million peo- requirements, whether copayments or coinsurance, ple, were uninsured at the time of the survey or relative to their income. Three-quarters of working- were insured but had spent some time uninsured in age adults with incomes under 133 percent of the the past year. An additional 16 percent, or 30 mil- federal poverty level ($14,856 for an individual or lion people, were insured but had such high out-of- $30,657 for a family of four)—an estimated 40 mil- pocket medical costs relative to their income that lion people—either experienced a time without they could be considered underinsured. health insurance or were underinsured in 2012 The number of adults who had gaps in their (Exhibit ES-4). Among adults earning between 133 coverage or were underinsured climbed steadily over percent and 249 percent of poverty ($27,925 for an the past decade, rising from 61 million in 2003 to individual or $57,625 for a family of four), 59 per- 81 million in 2010, or from 36 percent of working- cent, or an estimated 21 million people, had a time age adults to 44 percent (Exhibit ES-3). Between without coverage or were underinsured. People with 2010 and 2012, however, there was little change incomes under 250 percent of poverty comprised 72 seen. This stasis likely reflects both the gains in cov- percent of the total number of Americans who were erage among young adults and the countervailing uninsured or poorly insured in 2012. deterioration in coverage for adults in older age groups. Exhibit ES-2. In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Uninsured during the year* 30% Insured all year, 55 million not underinsured^ 54% Insured all year, underinsured^ 100 million 16% 30 million 84 6 1 4 mi ll i o 1 9– n a d ult s a g es Note: Numbers may not sum to indicated total because of rounding. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). x Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Exhibit ES-3. No Improvement in Coverage for Adults Overall from 2010 to 2012 Adults ages 19–64, in the past 12 months: 2003 2005 2010 2012 26% 28% 28% 30% Uninsured during the year* 45 million 48 million 52 million 55 million 9% 9% 16% 16% Insured all year, underinsured^ 16 million 16 million 29 million 30 million Uninsured during the year* or 36% 37% 44% 46% underinsured^ 61 million 64 million 81 million 84 million Any bill problem or medical 34% 40% 41% ^^ debt** 58 million 73 million 75 million Any cost-related access 37% 37% 41% 43% problem*** 63 million 64 million 75 million 80 million * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ** Includes: had problems paying or unable to pay medical bills; contacted by collection agency for unpaid medical bills; had to change way of life to pay bills; medical bills being paid off over time. *** Includes any of the following because of cost: had a medical problem, did not visit doctor or clinic; did not fill a prescription; skipped recommended test, treatment, or follow-up; did not get needed specialist care. ^^ A comparable bill problems question series was not asked in 2003. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). Exhibit ES-4. Adults with Low Incomes Are Uninsured and Underinsured at the Highest Rates, 2012 Percent of adults ages 19–64 Insured all year, underinsured^ 100 Insured now, time uninsured in past year Uninsured now 75 75 23 59 50 46 22 17 35 16 15 16 25 10 52% 17 Uninsured during 35 37% the year* 8 10 19 22 19% 30% 11 3 7% 0 5 Total <133% 133%–249% 250%–399% 400%+ FPL FPL FPL FPL <$30,657 $57,625 $92,200 $92,200+ Notes: Totals may not equal sum of bars because of rounding. FPL refers to federal poverty level. Income levels are for a family of four in 2012. ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.orgxi Millions Are Struggling to Pay Medical Bills were uninsured at the time of the survey in 2012 Gaps in health insurance, inadequate coverage, and were significantly less likely to have a regular source large medical bills leave millions of U.S. adults bur- of care or to be up-to-date on recommended choles- dened with debt. In 2012, more than two of five terol, blood pressure, and colon cancer screenings, (41%) adults ages 19 to 64, or 75 million people, and mammograms. Given their much lower rates of reported problems paying their medical bills or said insurance coverage, adults with low incomes were they were paying off medical debt over time far less likely than those with higher incomes to (Exhibit ES-3). Of those who reported difficulties have a regular source of care or to get preventive paying medical bills or paying off medical debt, 42 care tests and cancer screenings. percent (32 million people) said they received a lower credit rating as result of unpaid medical bills. The Health Reform Law Will Expand and Improve Coverage and Make Health Care While the number of adults reporting medi- More Affordable cal bills or debt problems climbed in the past The Affordable Care Act has already helped millions decade, the number was statistically unchanged of young adults gain or maintain health insurance, between 2010 and 2012. This is likely because there banned carriers from placing limits on what they was some improvement in the coverage of young will pay and from cancelling policies retroactively adults, but either no improvement or a deterioration because of illness, and improved the reliability of in coverage for older age groups. health insurance purchased in the individual mar- ket. Indeed, those protections may be partly respon- Costs Prevent Many Americans from Getting Needed Health Care sible for the slowing rate of growth in underinsured In 2012, more than two of five (43%) adults, or an adults over the past two years. estimated 80 million people, reported cost-related But it is imperative for federal and state pol- problems getting needed health care (Exhibit ES-3). icymakers to complete the rollout of the law’s cen- This is up from 37 percent, or 63 million people, in tral coverage provisions. These include expanded eli- 2003. These problems, which included not going to gibility for Medicaid and for subsidized comprehen- the doctor when sick or not filling a prescription, sive insurance plans made available through the new were most pronounced among people with no insurance marketplaces. These changes will be rein- insurance or with inadequate coverage. More than forced with sweeping insurance market reforms, two-thirds of adults (67%) who were uninsured at including banning insurers from charging people any time and more than half (51%) who were higher premiums based on health or gender or lim- underinsured reported cost-related problems getting iting or denying benefits because of preexisting needed care. health conditions, among others. Of the estimated 55 million adults who had Adults Who Lack Health Insurance Are Less a gap in coverage in 2012, 87 percent had incomes Likely to Have a Regular Source of Care or that would make them eligible for subsidized health Receive Recommended Preventive Care insurance under the law. Twenty-eight million had Insurance coverage makes a substantial difference in incomes below 133 percent of the poverty level, Americans’ use of health care services. People who making them eligible for Medicaid, and 20 million xii Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 had incomes between 133 percent and 399 percent they are eligible for the new coverage options, of poverty, making them eligible for subsidized whether because they are not aware of their eligibility, health plans (Exhibit ES-5). In addition, of the 30 they are unable to find an affordable premium, or million adults who were underinsured in 2012, 85 they elect not to enroll. percent had incomes that could make them eligible Finally, the Supreme Court, while upholding for Medicaid or subsidized health plans, with reduced most of the law, transformed the key requirement out-of-pocket spending. More people insured and that states open their Medicaid programs to individ- better-quality coverage will likely lead to less medical uals with incomes up to 133 percent of poverty into cost–fueled debt and fewer cost-related access an option. To date, about half the states have indi- problems. cated they will participate in the Medicaid expan- Achieving the goal of near-universal coverage sion. Some states, including Arkansas, are negotiat- will take time, and there are important caveats to ing with the Department of Health and Human note. First, the law does not provide subsidized cover- Services to use the funds intended for the Medicaid age to people who are not in the U.S. legally. expansion to provide people newly eligible for the Jonathan Gruber, an economist at the Massachusetts program with equivalent benefits through private Institute of Technology, has estimated that of people insurance plans. While all states may eventually who will remain uninsured in 2016, about 5 million choose to participate in the expansion over the next will be undocumented immigrants. Second, both the decade, poor families in many states will continue to Congressional Budget Office and Gruber predict that be at risk of going without health insurance even after many Americans will not be insured, even though the Affordable Care Act goes into full effect in 2014. Exhibit ES-5. Under Full Implementation, the Affordable Care Act Has the Potential to Provide New Coverage and Protections to Working-Age Adults Subsidized private Private Coverage options in 2014 Medicaid insurance insurance 133%–249% 250%–399% Adults ages 19–64, <133% FPL FPL FPL 400%+ FPL in the past 12 months: Total <$30,657 $57,625 $92,200 $92,200+ 30% 52% 37% 19% 7% Uninsured during the year* 55 million 28 million 13 million 6 million 3 million 16% 23% 22% 16% 10% Insured all year, underinsured^ 30 million 12 million 8 million 5 million 4 million Any bill problem or medical 41% 51% 52% 40% 25% debt** 75 million 27 million 18 million 13 million 12 million Any cost-related access 43% 53% 53% 43% 28% problem*** 80 million 28 million 19 million 14 million 13 million Spent 10% or more of house- 15% 36% 23% 13% 4% hold income on premiums 14 million 5 million 4 million 3 million 2 million (among privately insured)**** Notes: FPL refers to federal poverty level. Total column includes those with undesignated income. Income levels are for a family of four in 2012. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ** Includes: had problems paying or unable to pay medical bills; contacted by collection agency for unpaid medical bills; had to change way of life to pay bills; medical bills being paid off over time. *** Includes any of the following because of cost: had a medical problem, did not visit doctor or clinic; did not fill a prescription; skipped recommended test, treatment, or follow-up; did not get needed specialist care. **** Base: Respondents who specified income level and premium for private insurance plan. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.orgxiii Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act INTRODUCTION coverage that will allow them to maintain their In early 2014, many Americans will experience a health while shielding their earnings and savings fundamental transformation in the nation’s health from the risk of high medical costs. insurance system. The major coverage provisions of the Affordable Care Act go into effect in January SURVEY FINDINGS 2014, providing new options for people without The Share of Uninsured Young Adults Declined health insurance and sweeping new protections for Between 2010 and 2012 consumers who buy health plans on their own. The Beginning in September 2010, the Affordable Care Congressional Budget Office projects that the com- Act required insurance companies and employers bination of new federal subsidies for insurance and offering health plans that include dependent cover- consumer protections will help bring new health age to allow children up to age 26 to remain in or coverage to 14 million people in 2014, and 27 mil- enroll in their parents’ policies. Insurers and lion by 2021. employers were required to make this change— Using data from the Commonwealth Fund which applies to all health plans, including self- Biennial Health Insurance Survey of 2012, this insured employer plans, and to all young adults, report examines the current state of health insurance regardless of dependent status, living situation, or coverage in the United States and the financial and marital status—by the time of the next open enroll- health implications for working-age adults. We also ment period. The survey finds that young adults explore the impact the Affordable Care Act’s initial made gains in coverage between 2010 and 2012. set of insurance-related provisions, which went into The survey asked all adults whether they effect in 2010, are having, as well as the potential had health insurance and, if they did, whether they effects of the major insurance reforms that will be had been without insurance for any time in the past rolled out next year. Conducted from April to 12 months. The survey findings show a substantial August 2012, the survey of 3,393 adults ages 19 to increase in the share of young adults who were 64 finds that many Americans, particularly young insured at the time of the survey. Nearly 8 of 10 adults, are already benefitting from the health (79%) young adults ages 19-25 reported that they reform law. were insured at the time of the survey in 2012, up At the same time, the survey finds that mil- from 69 percent in 2010, or a gain in health insur- lions of Americans are experiencing gaps in their ance coverage for an estimated 3.4 million young health coverage, high health care costs relative to adults. This estimate of coverage gain in this age income, and problems paying medical bills and get- group is similar to an earlier estimate based on fed- ting needed care. Once the law is fully imple- eral data for the period September 2010 to mented, many stand to gain comprehensive, stable December 2011.1 www.commonwealthfund.org1 The share of young adults ages 19 to 25 Gaps in health insurance coverage. The survey finds who were uninsured for any time during the prior that 30 percent of working-age adults, an estimated year fell from 48 percent in 2010 to 41 percent in 55 million people, were uninsured for some time in 2012 (Exhibit 1)—an estimated decline of 1.9 mil- 2012 (Exhibit 2, Table 1). Nearly one of five (19%) lion, from 13.6 million uninsured young adults in respondents said they currently did not have health 2010 to 11.7 million in 2012. In contrast, unin- insurance; an additional 10 percent had insurance sured rates for other age groups increased or stayed but experienced a time without it during the prior the same. year (Exhibit 3, Table 1). Nearly Half of U.S. Adults Were Uninsured at Underinsurance. The survey also examined whether One Time or Were Underinsured insured people had policies that adequately pro- While young adults made significant gains over the tected them from medical costs. Using a measure of past two years, coverage for working-age adults over- “underinsurance” developed by Cathy Schoen and all failed to improve. Continuing high unemploy- colleagues, the analysis calculated the proportion of ment—especially long-term unemployment—has household income spent on out-of-pocket health left millions of adults without affordable coverage care costs, excluding insurance premiums, and options. Even people with coverage are facing higher whether plan deductibles were high relative to deductibles, leaving them more exposed to health income.2 In 2012, 16 percent of adults ages 19 to care costs. 64, or an estimated 30 million people, had such high out-of-pocket costs and deductibles relative to Exhibit 1. The Percentage of Young Adults Uninsured Declined over 2010–2012, While Rates Rose in Other Age Groups Percent of adults ages 19–64 75 Insured now, time uninsured in past year Uninsured now 50 46 48 41 41 17 34 30 22 30 29 26 28 28 17 20 28 10 25 9 8 9 9 8 10 9 17 20 15 15 31 5 7 24 24 4 5 21 22 24 17 18 20 19 18 21 11 10 13 13 0 2003 2005 2010 2012 2003 2005 2010 2012 2003 2005 2010 2012 2003 2005 2010 2012 Total Ages 19–25 Ages 26–49 Ages 50–64 Note: Totals may not equal sum of bars because of rounding. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). 2 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 incomes that they could be considered underinsured high out-of-pocket costs relative to their incomes. (Exhibit 3). Among adults who were insured all year, 45 percent While the estimated number of underin- of those who had purchased coverage on the indi- sured adults did not change between 2010 and vidual market were underinsured, more than twice 2012, there were nearly twice as many underinsured the rate for those in employer-based health plans adults in 2012 as there were in 2003, when approxi- (20%) (data not shown). mately 16 million adults were underinsured. In 2012, the combination of coverage gaps Helping to fuel growth in the number of underin- and underinsurance meant that nearly half (46%) of sured adults in both employer-based and individual U.S. working-age adults, or an estimated 84 million market plans are rising health care costs combined people, were poorly protected from the costs of with widespread changes in benefit plan design that health care (Exhibit 2). continue to shift costs to enrollees. Among insured adults who reported information about plan deduct- Uninsured and Underinsured Counts Leveled Off Between 2010 and 2012 ibles, the proportion who had a deductible between The number of adults who were underinsured or $1 and $499 fell from 35 percent in 2003 to 20 had gaps in coverage climbed steadily during the percent in 2012 (Exhibit 4, Table 2). At the same past decade, from a total of 61 million, or 36 per- time, the share of insured adults with a deductible cent of working-age adults, in 2003, to 81 million, of $1,000 or greater more than tripled, climbing or 44 percent, in 2010 (Exhibit 3). The number of from 7 percent in 2003 to 25 percent in 2012. people with gaps climbed from an estimated 45 mil- People with coverage through the individual lion in 2003 to 52 million in 2010; the number of insurance market were particularly at risk of having Exhibit 2. In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Uninsured during the year* 30% Insured all year, 55 million not underinsured^ 54% Insured all year, underinsured^ 100 million 16% 30 million 84 –6 1 4 mi 19 ll i o n a d ult s a g e s Note: Numbers may not sum to indicated total because of rounding. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.org3 underinsured adults rose from 16 million in 2003 to its on benefits, and requiring insurers to cover rec- 29 million in 2010. ommended preventive services without cost-sharing. There was, however, little change between While the slowdown in health care costs and 2010 and 2012 in either of these measures of insur- new consumer protections may translate into slower ance coverage. With regard to coverage gaps, the growth in what families spend on health care, it is lack of movement may reflect an improvement in important to note that real median U.S. household coverage among young adults and the countervail- income declined by 1.5 percent from 2010 to ing decline in coverage among older adults. As for 2011.4 The combination of these two trends may underinsurance, the lack of change may stem from have contributed to out-of-pocket cost burdens rela- several factors. First, annual growth in U.S. health tive to income remaining largely unchanged over care costs has slowed over the past four years, falling the past two years. from 7.6 percent in 2007 to 3.9 percent between 2009 and 2011.3 Second, the Affordable Care Act’s Lower-Income Adults Are Uninsured and Underinsured at the Highest Rates initial set of insurance market reforms, which went People with low or moderate incomes continue to into effect in 2010, may have reduced out-of-pocket have by far the poorest protection against health costs, particularly for people who are insured care costs, either because they lack health insurance through individual market plans or school health or have high cost-sharing relative to their incomes. plans. Those reforms are designed to protect con- Three-quarters of working-age adults with incomes sumers against catastrophic costs and the costs of under 133 percent of the poverty level ($14,856 for preventive care, by banning insurance carriers from an individual or $30,657 for a family of four), an imposing limits on what plans will pay over a life- estimated 40 million people, either experienced a time, banning retroactive coverage cancellations time without insurance or were underinsured in when a person becomes ill, phasing out annual lim- Exhibit 3. No Improvement in Coverage for Adults Overall from 2010 to 2012 Adults ages 19–64 2003 2005 2010 2012 26% 28% 28% 30% Uninsured during the year* 45 million 48 million 52 million 55 million 17% 18% 20% 19% Uninsured now 30 million 32 million 37 million 36 million Insured now, time uninsured in 9% 9% 8% 10% past year 16 million 16 million 15 million 19 million 74% 72% 72% 70% Insured all year 127 million 125 million 132 million 129 million 9% 9% 16% 16% Insured all year, underinsured^ 16 million 16 million 29 million 30 million Insured all year, not 65% 63% 56% 54% underinsured^ 111 million 109 million 102 million 100 million Uninsured during the year* or 36% 37% 44% 46% underinsured^ 61 million 64 million 81 million 84 million * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Note: Sum of “Uninsured during the year” and “Underinsured” may not sum to noted totals because of rounding. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). 4 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Exhibit 4. Since 2003, the Proportion of Adults with High Deductibles Has More Than Tripled Percent of insured adults ages 19–64* 75 2003 2005 2010 2012 50 47 45 44 43 35 33 25 26 25 20 18 11 12 12 12 7 10 0 No deductible $1–$499 $500–$999 $1,000 or more * Base: Those who reported information about a deductible. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). 2012 (Exhibit 5). Among adults earning between of their budgets to health insurance premiums, par- 133 percent and 250 percent of poverty ($27,925 ticularly for coverage purchased in the individual for an individual or $57,625 for a family of four), insurance market. In 2012, 15 percent of privately 59 percent, or an estimated 21 million people, had a insured working-age adults, an estimated 14 million time without coverage or were underinsured. In all, people, reported spending 10 percent or more of people with incomes under 250 percent of poverty their income on premiums (Exhibit 6, Table 2). comprised 72 percent of the total number of Among adults who purchase coverage on their own Americans who were uninsured or poorly insured in and thus are on the hook for the full premium, 31 2012 (data not shown). percent spent 10 percent or more of their income on premium costs—more than twice the proportion Americans Are Spending a Large Share of Their of adults with employer benefits who spent that Income on Premiums much for their portion of the premium (13%). Like health care cost growth, the rate of increase in Americans with low and moderate incomes health insurance premiums has also slowed over the shoulder the heaviest burden of premiums, relative past four years. In 2012, average annual premiums to those with higher incomes. In 2012, more than for single coverage in employer-based plans climbed one-third (36%) of privately insured adults with by 3 percent, to $5,615, and by 4 percent, to incomes below 133 percent of poverty spent 10 per- $15,745 for family plans.5 This is down from 8 per- cent or more of their income on premiums (Exhibit cent and 9 percent increases for single and family 6). Even among adults with somewhat higher plans in the prior year.6 Nevertheless, growth in pre- incomes—between 133 percent and 249 percent of miums is outstripping growth in family incomes. poverty—nearly one-quarter (23%) spent 10 per- The Commonwealth Fund survey found cent or more of their income on premiums. that many Americans allocate a considerable portion www.commonwealthfund.org5 Exhibit 5. Adults with Low Incomes Are Uninsured and Underinsured at the Highest Rates, 2012 Percent of adults ages 19–64 Insured all year, underinsured^ 100 Insured now, time uninsured in past year Uninsured now 75 75 23 59 50 46 22 17 35 16 15 16 25 10 52% 17 Uninsured during 35 37% the year* 8 10 19 22 19% 30% 11 3 7% 0 5 Total <133% 133%–249% 250%–399% 400%+ FPL FPL FPL FPL <$30,657 $57,625 $92,200 $92,200+ Notes: Totals may not equal sum of bars because of rounding. FPL refers to federal poverty level. Income levels are for a family of four in 2012. ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Millions of Adults Are Struggling to Pay paying off accumulated medical debt reported they Medical Bills were carrying more than $4,000 in debt. Sixteen Exposure to health care costs, either by being unin- percent reported $8,000 or more in debt (Table 3). sured or underinsured, has made it difficult for fam- Many respondents were also dealing with ilies to pay their medical bills. The survey asked collection agencies about medical bills. About one respondents whether they had experienced problems of five (22%) adults, an estimated 41 million peo- with medical bills over the past year, including if ple, said they had been contacted by a collection they had difficulty paying bills or were unable to agency about medical bills. Of those, most—32 mil- pay them, had been contacted by a collection lion adults—said a collection agency had contacted agency concerning outstanding medical bills, or had them about bills they could not pay. An estimated 7 been forced to change their lives significantly to pay million adults reported a billing error had prompted their bills. The survey also asked respondents a collection agency to contact them. whether they were paying off medical debt over The number of adults reporting problems time. In 2012, two of five (41%) adults ages 19 to paying medical bills and debt climbed in the past 64, or an estimated 75 million people, reported any decade, rising from 58 million people, or about a one of these problems (Exhibit 7, Table 3). third (34%) of working-age adults in 2005—the Many of the people surveyed were carrying first year the questions were asked on the survey— substantial medical debt. One of four (26%), or 48 to 73 million, or 40 percent, in 2010 (Exhibit 7). million people, said they were paying off medical However, the number of people reporting such debt. More than one-quarter (29%) who were problems was unchanged, statistically speaking, 6 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Exhibit 6. One of Three Adults in the Individual Insurance Market Spent 10 Percent or More of Income on Premiums in 2012 Percent of adults ages 19–64 with private health insurance who spent 10% or more of income on premiums* 75 50 36 25 31 23 15 13 13 0 4 Total <133% 133%– 250%– 400%+ Employer Individual FPL 249% 399% FPL FPL FPL <$30,657 $57,625 $92,200 $92,200+ * Base: Respondents who reported their income level and premium costs for their private insurance plan. Notes: Income levels are for a family of four in 2012. FPL refers to federal poverty level. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Exhibit 7. Millions of Adults Continue to Report Problems Paying Medical Bills or Medical Debt Percent of adults ages 19–64 2005 2010 2012 In the past 12 months: 23% 29% 30% Had problems paying or unable to pay medical bills 39 million 53 million 55 million Contacted by a collection agency about medical 21% 23% 22% bills 36 million 42 million 41 million Contacted by collection agency for unpaid 13% 16% 18% medical bills 22 million 30 million 32 million Contacted by a collection agency because of 7% 5% 4% billing mistake 11 million 9 million 7 million 14% 17% 16% Had to change way of life to pay bills 24 million 31 million 29 million Any of three bill problems 28% 34% 34% (does not include billing mistake) 48 million 62 million 63 million 21% 24% 26% Medical bills being paid off over time 37 million 44 million 48 million 34% 40% 41% Any of three bill problems or medical debt 58 million 73 million 75 million * Subtotals may not sum to total: respondents who answered “don’t know” or refused are included in the distribution but not reported. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2005, 2010, and 2012). www.commonwealthfund.org7 between 2010 and 2012. This is likely the conse- reported problems paying medical bills or said they quence of improvement in young adults’ health were paying off medical debt over time. Yet many coverage, but no improvement in coverage for adults in households with higher incomes also strug- older age groups. gled to pay medical bills. For example, two of five Adults who were uninsured for any time adults with incomes between 250 percent of poverty during the year or who had health insurance but ($27,925 for individuals and $57,625 for a family were underinsured reported the highest rates of of four) and 399 percent of poverty ($44,680 for an medical bill problems. In 2012, three of five (61%) individual and $92,200 for a family of four) and adults who were uninsured during the year and 55 one-quarter of those in families with incomes of 400 percent who were underinsured reported medical percent of poverty or more, reported problems pay- bill problems or accrued medical debt, compared ing bills or said they were paying off debt. with one-quarter (26%) of those who were insured Medical bill burdens have significant conse- all year with adequate coverage (Exhibit 8, Table 3). quences for household budgets and potential long- Adults in households with low and moderate term financial implications for many adults. Among incomes are the hardest hit by medical bill prob- those who reported difficulties with medical bill lems, compared with those in higher-income house- payments or said they were paying off medical debt, holds. Half (51%) of adults in families with nearly seven of 10 (68%)—an estimated 51 million incomes under 133 percent of federal poverty level people—suffered other financial consequences as a and half (52%) of those with incomes between 133 result (Exhibit 9, Table 3). For example, 42 percent, percent and 249 percent of poverty or an estimated 32 million people, said they Exhibit 8. Problems with Medical Bills or Accrued Medical Debt Highest Among Adults with Low and Moderate Incomes, 2012 Percent of adults ages 19–64 with medical bill problems or accrued medical debt** 75 61 50 55 51 52 41 40 25 25 26 0 Total <133% 133%– 250%– 400%+ Insured Insured Uninsured FPL 249% 399% FPL all year, all year, during FPL FPL not under- under- the insured^ insured^ year* <$30,657 $57,625 $92,200 $92,200+ Notes: FPL refers to federal poverty level. Income levels are for a family of four in 2012. ** 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 expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). 8 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 received a lower credit rating as result of unpaid left a prescription unfilled; skipped a medical test, medical bills; 37 percent, or an estimated 28 million treatment, or follow-up visit recommended by a people, said they used all their savings because of doctor; did not go to a doctor or clinic when sick; medical bills; and 27 percent, or 20 million people, or did not see a specialist, even though a doctor or took on credit card debt. One-quarter of adults the respondent thought doing so was necessary. reported they were unable to pay for basic necessi- The share of adults who reported experienc- ties such as food, heat, or rent because of medical ing at least one of these cost-related problems get- bills. And 6 percent, or 4 million, adults reported ting needed care has steadily increased over the past that they had to declare bankruptcy because of their nine years. More than two of five (43%) adults, an medical bills. estimated 80 million people, reported going without needed care because of costs in 2012, up from 37 Many Americans Do Not Get Needed Health percent, or 63 million people, in 2003 (Exhibit 10, Care Because of Costs Table 4). The number of people reporting problems Greater exposure to health costs, either because of a rose sharply across all measures over that period. loss of benefits or higher cost-sharing, has erected Adults who were uninsured for any time significant barriers to timely health care for millions during the year or those underinsured reported cost- of adults. In the Commonwealth Fund survey, related access problems at the highest rates. The respondents were asked whether they did not seek majority of adults who spent any time during the needed medical care in the past 12 months because year uninsured reported they had not received of the cost, specifically, whether they: Exhibit 9. Adults with Low Incomes Less Likely to Be Able to Pay for Basic Necessities Because of Medical Bill or Debt Problems Percent of adults ages 19–64 with medical bill problems or accrued medical debt* 133%– 250%– In the past two years because of <133% FPL 249% FPL 399% FPL 400%+ FPL medical bills: Total <$30,657 $57,625 $92,200 $92,200+ 42% Received a lower credit rating 49% 53% 33% 30% 32 million 37% Used all of savings 41% 49% 29% 25% 28 million 27% Took on credit card debt 15% 29% 39% 37% 20 million Unable to pay for basic necessities 25% 33% 32% 18% 7% (food, heat, or rent) 19 million 22% Delayed career or education plans 28% 24% 18% 17% 17 million Took out a mortgage against your 7% 6% 7% 9% 10% home or took out a loan 5 million 6% Had to declare bankruptcy 6% 7% 4% 3% 4 million 68% Any of the above 70% 75% 67% 62% 51 million * Base: 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. Notes: FPL refers to federal poverty level. Income levels are for a family of four in 2012. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.org9 needed care because of cost. Nearly seven of 10 or more reported cost-related problems getting (67%) adults who were uninsured for a time during needed care. the year reported at least one cost-related problem Many adults with chronic health problems getting needed care (Exhibit 11, Table 4). And half report not filling prescriptions or skipping doses of (51%) of adults who had had health insurance but prescription drugs for their health conditions were underinsured said they had not received because of the cost. More than one-third (36%) of needed care because of cost. A significant share of adults, an estimated 66 million people, reported respondents who had adequate health insurance also having one of the following chronic conditions: reported problems: over a quarter (28%) of adults hypertension or high blood pressure, diabetes, who had health insurance all year and were not asthma, emphysema, lung disease, or heart disease underinsured reported forgoing needed care because (data not shown). Over a quarter (28%) of chroni- of cost. cally ill adults who took regular medications for These problems were most acute among their conditions reported skipping doses or not fill- adults with low and moderate incomes. Because of ing a prescription because they could not afford to cost concerns, more than half (53%) of adults in pay for it (Exhibit 12, Table 4). families with incomes under 133 percent of federal Among people with chronic health prob- poverty level and more than half (53%) of those lems, rates of cost-related problems getting needed with incomes between 133 and 249 percent of pov- care were highest among those without insurance erty had not gotten needed care. Yet many in house- coverage or who were poorly insured. Sixty percent holds with higher incomes reported similar prob- of those who were uninsured at the time of the sur- lems. More than two of five (43%) adults with vey and 52 percent of those insured but with a gap incomes between 250 percent and 399 percent of in the past year reported skipping doses or not fill- poverty and more than one-quarter (28%) of those ing prescriptions (Exhibit 12). One-third of adults in families with incomes of 400 percent of poverty who were underinsured had skipped a dose or not filled a prescription for their condition, compared Exhibit 10. Number of Adults Reporting Cost-Related Problems Getting Needed Care Increased, 2003–2012 Percent of adults ages 19–64 2003 2005 2010 2012 In the past 12 months: 22% 24% 26% 29% Had a medical problem, did not visit doctor or clinic 38 million 41 million 49 million 53 million 23% 25% 26% 27% Did not fill a prescription 39 million 43 million 48 million 50 million 19% 20% 25% 27% Skipped recommended test, treatment, or follow-up 32 million 34 million 47 million 49 million 13% 17% 18% 20% Did not get needed specialist care 22 million 30 million 34 million 37 million 37% 37% 41% 43% Any of the above access problems 63 million 64 million 75 million 80 million Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012). 10 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Exhibit 11. Cost-Related Problems Getting Needed Care Are Highest Among Adults with Low and Moderate Incomes, 2012 Percent of adults ages 19–64 who had any of four access problems** in past year because of cost 75 67 50 53 53 51 43 43 25 28 28 0 Total <133% 133%– 250%– 400%+ Insured Insured Uninsured FPL 249% 399% FPL all year, all year, during FPL FPL not under- under- the <$30,657 $57,625 $92,200 $92,200+ insured^ insured^ year* Notes: FPL refers to federal poverty level. Income levels are for a family of four in 2012. ** Did not fill a prescription; did not see a specialist when needed; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic. ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Exhibit 12. Adults Uninsured During the Year or Underinsured Are More Likely to Skip Doses or Not Fill Prescriptions for Chronic Conditions, 2012 Percent of adults ages 19–64 with at least one chronic condition* who skipped doses or did not fill prescription for chronic condition because of cost 75 60 50 52 25 33 28 14 0 Total Insured all Insured all year, Insured now, Uninsured now year, not underinsured^ time uninsured underinsured^ in past year * Adults with hypertension or high blood pressure; diabetes; asthma, emphysema, or lung disease; or heart disease, who take prescription medications on a regular basis. ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.org11 with 14 percent of adults with chronic health prob- Nearly all (94%) adults who were insured all year, lems and adequate insurance. including those who were considered underinsured, reported having a regular source of care (Exhibit 13, Uninsured Adults Are Less Likely to Table 4). In contrast, just under two-thirds (64%) Have a Regular Source of Care or Get Preventive Screenings of those who were uninsured at the time of the sur- The survey asked respondents about their use of vey reported a regular source of care. health care services, including whether they had a regular source of care, or if they had received pre- Preventive care. Preventive screening tests such as ventive screening tests in a recommended time colonoscopies have been shown to save thousands of frame. Adults who were uninsured were at a higher lives each year.8 Yet many adults in the United States risk of not having a regular source of care, or not do not receive recommended screenings. Indeed, receiving preventive care. screening rates for breast cancer, cervical cancer, and colorectal cancer have all been found to fall short of Regular source of care. People who have a regular the national targets set by the federal Healthy People source of care are more likely to receive preventive 2020 initiative.9 care and adhere to a physician’s treatment regimen, The survey asked adults whether they had allowing health problems to be identified and received a set of preventive care screenings in the treated early before costly hospital stays become nec- recommended time frame.10 In 2012, nearly nine of essary.7 The survey asked adults whether there was a 10 adults (89%) were up-to-date with blood pres- regular doctor, medical group, health center, or sure checks, but only seven of 10 had their choles- clinic where they went for care when they needed it. terol checked in the past five years, and about half Exhibit 13. Uninsured Adults Are Less Likely to Have a Regular Source of Care, 2012 Percent of adults ages 19–64 Total Insured all year, not underinsured^ Insured all year, underinsured^ Insured now, time uninsured in past year 100 Uninsured now 94 96 75 88 88 89 93 93 90 79 75 70 73 50 64 64 46 44 45 25 40 32 26 0 Regular source Seasonal flu shot Cholesterol checked Blood pressure of care checked ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Notes: Seasonal flu shot in past 12 months; cholesterol checked in past five years (in past year if has hypertension, heart disease, or high cholesterol); blood pressure checked in past two years (in past year if has hypertension or high blood pressure). Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). 12 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 (52%) of those 50 and older had a colon cancer survey but had had a gap in their coverage were screening in the past five years (Exhibits 13 and 14). screened, as were just 45 percent of respondents Among women, three-quarters had received a Pap without coverage at the time of the survey. test and 69 percent had received a mammogram in Given the much lower rates of insurance the recommended time frames. Finally, very few coverage among adults with low incomes, as a group adults received seasonal flu shots: just 40 percent they were far less likely than adults with higher had a flu shot in the past 12 months. incomes to receive preventive care services. Just over Rates of getting preventive tests were sub- half (54%) of adults with incomes under 133 per- stantially lower among people without health insur- cent of poverty had their cholesterol checked in the ance. Only one-third of adults who were uninsured past five years, compared with 87 percent of those during the year had a colon cancer screening, com- with incomes of 400 percent of poverty or higher pared with 58 percent of those who were insured all (Table 4). Only half (49%) of women with low year and were not underinsured. Fewer than half incomes had a mammogram in the recommended (48%) of women who were uninsured any time had time frames, compared with 87 percent of women a mammogram, versus 77 percent of women who with higher incomes. And fewer than two of five were insured all year and not underinsured. And (39%) adults ages 50 to 64 with incomes under 133 while nearly 80 percent of adults who were insured percent of poverty received a colon cancer screening all year and not underinsured had their cholesterol in the past five years, versus 62 percent of those checked in the recommended time frame, only 64 with incomes of 400 percent of poverty or more. percent of those who were insured at the time of the Exhibit 14. Uninsured Adults and Adults with Gaps in Coverage Have Lower Rates of Cancer Screening Tests, 2012 Percent of adults Total 100 Insured all year, not underinsured^ Insured all year, underinsured^ Uninsured during the year* 75 81 77 75 73 70 50 64 69 58 52 53 48 25 33 0 Received Pap test Received colon cancer Received mammogram screening ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deduct- ibles equaled 5% or more of income. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” Notes: Pap test in past three years for females ages 21–64; colon cancer screening in past five years for adults ages 50–64; and mammogram in past two years for females ages 40–64. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). www.commonwealthfund.org13 THE AFFORDABLE CARE ACT WILL EXPAND costs), silver (70% of costs), gold (80% of costs), AND IMPROVE THE AFFORDABILITY OF and platinum (90% of costs). For people with low HEALTH INSURANCE AND HEALTH CARE incomes, the average costs covered by the silver plan The enactment of the Affordable Care Act three are increased to 94 percent (for those with incomes years ago placed the United States on a path to up to 149% of the federal poverty level), 87 percent near-universal health insurance coverage. Millions of (150% to 199% of poverty), and 73 percent (200% young adults have gained or maintained insurance to 249% of poverty). There are also caps placed on through their parents’ plans. In addition, the law’s out-of-pocket spending, with lower limits for people initial set of insurance regulations banning carriers with incomes under 400 percent of poverty. from placing limits on what they will pay and from These new subsidized insurance options are cancelling health policies retroactively when some- complemented by a set of sweeping insurance market one becomes ill have already improved the reliability reforms, including: banning insurers from charging of health insurance for millions of Americans who people higher premiums based on health or gender; buy coverage on their own. Indeed, those protec- limiting what older people may be charged relative tions may be partly responsible for the slowing the to younger people; prohibiting carriers from limit- rate of growth in the numbers of underinsured ing or denying benefits because of preexisting health adults in the survey over the past two years. conditions; and requiring broad pooling of risk in But the survey’s findings demonstrate the state insurance markets to reduce the ability of carri- importance of the complete rollout of the law’s cen- ers to charge older or sicker enrollees higher rates. tral coverage provisions, which will go into effect January 2014. These provisions include an expan- How the Affordable Care Act Will Address sion in Medicaid eligibility for people in families Problems Identified in the Survey with household incomes up to 133 percent of the The combination of new affordable coverage federal poverty level, or $30,657 for a family of four options and insurance market reforms in the (Exhibit 15). Comprehensive insurance plans will be Affordable Care Act has the potential to reverse available through new health insurance marketplaces growth in the number of people who have gaps in in every state with tax credits available to people their health insurance, are underinsured, spend large with incomes up to 400 percent of poverty, or about shares of their income on premiums, struggle to pay $92,200 for a family of four, to help pay for medical bills, delay getting needed care because of premiums. Carriers selling plans in the new market- cost, and do not have a regular source of health care. places, as well as in the individual and small-group We examined the potential of the health markets, are required to provide an “essential health reform law to solve the problems reported by adults benefit” package that covers 10 categories of care, in the Commonwealth Fund survey. We assume that including basic services such as hospitalization and all states participate in the Medicaid expansion and emergency care, as well as mental health and mater- all adults who are eligible to enroll under the law do nity care. Insurers must offer these benefits at four so. It is important to keep in mind that some adults tiers of cost coverage: bronze plans (covering on whose incomes would make them eligible for the average 60% of a person’s annual medical law’s new coverage options will not be eligible because of their immigration status. 14 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Potential to Reduce the Number of Uninsured New subsidized private health plans with consumer Individuals protections. Up to 20 million adults who were unin- Of the estimated 55 million adults who had a gap sured for a time in 2012 and with incomes between in coverage in 2012, all those who are in the U.S. 133 percent and 399 percent of poverty will become legally would have access to new insurance options eligible for premium tax credits to help them pur- with consumer protections. Nearly 90 percent have chase private health plans through the health insur- incomes under 400 percent of poverty, or $92,200 ance marketplaces. for a family of four, making them eligible for subsi- dized coverage (Exhibit 16). New private health plans with consumer protections. Among adults with incomes of 400 percent of pov- New coverage under Medicaid. Up to 28 million erty or higher, up to 3 million who were uninsured adults who were uninsured for a time in 2012 and for a time in 2012 will be able to purchase private had incomes under 133 percent of poverty will plans with comprehensive benefits through the become eligible for Medicaid, with little or no pre- health insurance marketplaces or the individual mium or cost-sharing expenses. market. They will benefit from the law’s new con- sumer protections, including those banning insur- Exhibit 15. Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act Adults ages 19–64 Premium Federal Uninsured contribution Out-of-pocket Actuarial value: poverty Income Insured all year, during the as a share of limits^^ Silver plan level underinsured^ year* income S: <$14,856 2% (or <133% 28 M 12 M F: <$30,657 Medicaid) 94% S: $16,755 S: $2,083 133%–149% 3.0%–4.0% F: $34,575 F: $4,167 S: $22,340 150%–199% 13 M 8M 4.0%–6.3% 87% F: $46,100 S: $27,925 6.3%–8.05% 200%–249% 73% F: $57,625 S: $3,125 S: $33,510 F: $6,250 250%–299% 8.05%–9.5% 70% F: $69,150 6M 5M S: $44,680 S: $4,167 300%–399% 9.5% 70% F: $92,200 F: $8,333 S: $44,680+ S: $6,250 400%+ 3.5 M 4M — — F: $92,200+ F: $12,500 Four levels of cost-sharing: 1st tier (Bronze) actuarial value: 60% Catastrophic policy with essential benefits 2nd tier (Silver) actuarial value: 70% package available to young adults and people 3rd tier (Gold) actuarial value: 80% whose premiums are 8%+ of income 4th tier (Platinum) actuarial value: 90% Notes: Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ^^ For 2013. Source: Federal poverty levels are for 2012; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111- 148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx. www.commonwealthfund.org15 ance companies from denying or limiting least 60 percent of their health care costs may be eli- coverage because of preexisting health conditions gible to enroll in a subsidized health plan. or charging higher premiums based on health or gender. New coverage under Medicaid. Up to 12 million adults who were underinsured in 2012 and had Potential to Reduce the Number of People incomes under 133 percent of the poverty level will Who are Underinsured be eligible for Medicaid, with little or no cost-shar- Of the estimated 30 million people in the survey ing expenses. who had health insurance but were underinsured, an estimated 85 percent have incomes that could New subsidized private health plans with consumer make them eligible for Medicaid or subsidized protections. Up to 13 million adults in the survey health plans, with reduced out-of-pocket spending, who were underinsured in 2012 and had incomes through the insurance marketplaces. People who are between 133 percent and 399 percent of the poverty ineligible for subsidies because their income is too level might be eligible for premium tax credits to high will benefit from the law’s new essential health purchase private health plans through the market- benefit standard and insurance market protections places. In addition, adults earning up to 249 percent against limiting coverage for people with preexisting of poverty would have a greater share of their costs conditions. In addition, people who are offered covered by their health plans: up to 94 percent for employer-based insurance that does not cover at those earning up to 149 percent of poverty, Exhibit 16. Under Full Implementation, the Affordable Care Act Has the Potential to Provide New Coverage and Protections to Working-Age Adults Subsidized private Private Coverage options in 2014 Medicaid insurance insurance 133%–249% 250%–399% Adults ages 19–64, <133% FPL FPL FPL 400%+ FPL in the past 12 months: Total <$30,657 $57,625 $92,200 $92,200+ 30% 52% 37% 19% 7% Uninsured during the year* 55 million 28 million 13 million 6 million 3 million 16% 23% 22% 16% 10% Insured all year, underinsured^ 30 million 12 million 8 million 5 million 4 million Any bill problem or medical 41% 51% 52% 40% 25% debt** 75 million 27 million 18 million 13 million 12 million Any cost-related access 43% 53% 53% 43% 28% problem*** 80 million 28 million 19 million 14 million 13 million Spent 10% or more of house- 15% 36% 23% 13% 4% hold income on premiums 14 million 5 million 4 million 3 million 2 million (among privately insured)**** Notes: FPL refers to federal poverty level. Total column includes those with undesignated income. Income levels are for a family of four in 2012. * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ** Includes: had problems paying or unable to pay medical bills; contacted by collection agency for unpaid medical bills; had to change way of life to pay bills; medical bills being paid off over time. *** Includes any of the following because of cost: had a medical problem, did not visit doctor or clinic; did not fill a prescription; skipped recommended test, treatment, or follow-up; did not get needed specialist care. **** Base: Respondents who specified income level and premium for private insurance plan. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). 16 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Minimum Premium Affordability Standards for Employer Coverage Under the Affordable Care Act Under the Affordable Care Act, employers with 50 or more workers are required to offer health insur- ance benefits that meet minimum affordability and coverage standards, or they must pay a penalty if an employee becomes eligible for a premium tax credit in the new insurance marketplaces. The U.S. Treasury Department in its proposed rule has interpreted this provision of the law as requiring firms to offer coverage to the employee and dependent children, but not to the employee’s spouse.11 A spouse who is not offered employer coverage would be eligible for tax credits through the insurance market- place if he or she is has income below 400 percent of poverty. An offer of employer coverage is not considered to be affordable if the employee’s premium contribu- tion constitutes 9.5 percent or more of his or her income (or it covers less than 60 percent, on average, of medical costs). An employee who is offered an unaffordable plan would thus be eligible for a tax credit for a plan offered in the insurance marketplace if he or she were income-eligible, and the employer would then pay a penalty. In its final rule on premium tax credits, however, the Treasury Department defined affordability based on the employee’s cost of self-only coverage, rather than family coverage.12 In other words, an employee may have a family plan that costs him more than 9.5 percent of his income, but if a self-only policy offered by his company is less than 9.5 percent of his income, then his coverage would be deemed affordable, and neither he nor any dependents (children or spouse) would be eligible for a tax credit on the exchange. This interpretation of the law likely means there will be larger numbers of uninsured children and spouses than if Treasury had used premium contributions for a family plan as the basis for determining whether an offer of employer coverage is affordable. 87 percent for those earning up to 199 percent of Protection from High Premiums poverty, and 73 percent for those earning up to 249 Under the Affordable Care Act, taxpayers with percent of poverty. Out-of-pocket limits for a single incomes between 100 percent and 400 percent of policy will be set at $2,083 to 199 percent of pov- poverty ($23,050 to $92,200 for a family of four) erty, $3,175 to 299 percent of poverty, and $4,167 who do not have an affordable offer of health insur- up to 399 percent of poverty (Exhibit 15). ance through their jobs and are not eligible for Medicaid will be eligible for insurance premium tax New private health plans with consumer protections. credits to help cover the costs of plans sold through Up to 4 million adults with incomes equivalent to the new insurance marketplaces (see box). People 400 percent of the poverty level or higher who were eligible for the tax credits would contribute no more underinsured in 2012 might be able purchase pri- than 2 percent to 9.5 percent of their income vate plans with comprehensive benefits through the toward their premium. The amount of the credit health insurance marketplaces or the individual will be equal to the difference between the required market. These people will benefit from the reform premium contribution and the premium of the law’s new consumer protections. Out-of-pocket lim- benchmark health plan—the second-lowest-cost “sil- its are set at $6,250 for a single policy. ver plan” offered through the marketplace.13 An www.commonwealthfund.org17 individual may choose a plan that is not the bench- the premium contribution is a fixed percentage of mark plan, but the amount of the tax credit will be family income. determined based on the premium for the bench- mark plan, not the plan they enroll in, which could New coverage under Medicaid. In the survey, among be less or more than the benchmark. The tax credit adults with private health insurance and incomes cannot exceed the amount of the full premium. less than 133 percent of poverty, more than one- For example, a 40-year-old policyholder in a third (36%) spent 10 percent or more of their family of four has an income of $35,137—150 per- income on premiums (Exhibit 16). Most of these cent of the federal poverty level in 2014 (Exhibit adults will be eligible for Medicaid in 2014 and will 17). The required premium contribution for the pay little or nothing for premiums. policy would be 4 percent of income, or $1,405. The Kaiser Family Foundation estimates that this New subsidized private health plans with consumer family’s premium for a benchmark plan in a protections. Among adults with incomes between medium-cost area of the country would be $12,130. 133 percent and 249 percent of poverty with a pri- The family’s tax credit would thus be equal to the vate health plan, 23 percent spent 10 percent or benchmark premium less their required contribu- more of their income on insurance premiums. tion, or $10,725. A slightly older policyholder Under health reform, adults with incomes in this would be charged a higher premium in the market- range will be potentially eligible for tax credits to place, but the tax credit would also be higher, since purchase coverage through the new marketplaces; Exhibit 17. Annual Premium Amount and Tax Credits for a Family of Four Under the Affordable Care Act, 2014 Annual premium amount paid by policy holder and premium tax credit $15,000 Premium tax credit Required premium payment by policy holder Full premium = $12,130 $12,500 $10,000 5,454 7,416 Contribution $7,500 9,179 capped at 11,065 10,725 9.5% of Contribution 12,130 income capped at $5,000 8.05% of Contribution capped at income Contribution 6.3% of 6,676 $2,500 Contribution capped at capped at income 4,714 3.3% of 4.0% of 2,952 1,065 income 1,405 income $0 138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 500% FPL $32,326 $35,137 $46,850 $58,562 $70,275 $117,125 Notes: For an family of four, policy holder age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70. Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level. Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator, http://healthreform.kff.org/Subsidycalculator.aspx. 18 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 these credits will cap what they contribute to their New subsidized private health plans with consumer premiums, ranging from 3 percent to 8 percent of protections. Among adults with incomes between income. Individuals enrolled in employer-based 133 percent and 249 percent of poverty, 52 percent, plans who have premium contributions for a single or an estimated 18 million, reported problems with policy in excess of 9.5 percent of income will be eli- medical bills and debt. Among families with slightly gible for tax credits through the marketplaces. higher incomes, between 250 percent and 399 per- cent of poverty, 40 percent, or 13 million, reported New private health plans with consumer protections. problems paying medical bills. Most people in this An estimated 2 million privately insured adults income range who lack an offer of affordable earning 400 percent of poverty or more spent at employer health insurance will be eligible for pre- least 10 percent of their income on premiums. New mium tax credits to reduce their insurance costs. insurance market regulations that ban carriers from Cost-sharing credits and out-of-pocket limits will charging higher premiums on the basis of health sta- lower out-of-pocket costs, further reducing their tus or gender will help this group gain comprehen- exposure to expensive medical bills. sive coverage through the health insurance market- places or individual market. In addition. health New private health plans with consumer protections. plans will not be able to charge older adults premi- One-quarter of families earning 400 percent or ums that are more than three times those charged to more of the poverty level, or 12 million, reported younger adults. problems with medical bills and debt in 2012. New consumer protections will help those with incomes Protection from Medical Bill Problems and Debt in this range who must buy coverage on their own People with the highest rates of medical bill prob- gain comprehensive coverage through the state lems and debt—the uninsured, underinsured, and insurance marketplaces or the individual market, people with low or moderate income—will be pro- with limits on out-of-pocket spending. tected through expanded health insurance subsidies and market reforms that ban insurers from denying Reducing Cost Barriers to Getting Needed Care coverage or charging higher premiums on the basis Under the Affordable Care Act, low- and moderate- of health. income families will have reduced cost-sharing and limits on out-of pocket spending, which will help New coverage under Medicaid. Among the surveyed reduce cost-related barriers to obtaining needed care. adults with income under 133 percent of the pov- erty level, half (51%), or an estimated 27 million, New coverage under Medicaid. In the survey, among reported medical bill problems or debt (Exhibit 16). adults with income under 133 percent of poverty, Most adults with incomes in this range will be eligi- 53 percent, or an estimated 28 million, reported ble for Medicaid. They will pay little for premiums cost-related problems getting needed health care or out-of-pocket costs, which will protect them (Exhibit 16). Most families in this income range will from high medical bills. be eligible for Medicaid and face little or no cost-sharing. www.commonwealthfund.org19 New subsidized private health plans with consumer 20 million, will be those who are eligible for new protections. Among adults with incomes between coverage options but not enrolled—whether because 133 percent and 249 percent of poverty, 53 percent, they are unaware of their eligibility, they are not or an estimated 19 million, reported having at least able to find an affordable premium, or they elect one cost-related problem getting needed health care. not to enroll. More than two of five (43%) adults, or 14 million, Third, the Supreme Court’s decision in June in the next-higher income range (250% to 399% of 2012 transformed the reform law’s requirement that poverty) reported not getting needed care because of states expand their Medicaid programs into a volun- costs. Most adults in these income ranges who are tary option. In states that do not participate in the not offered affordable health insurance through expansion, people earning between 100 percent and their jobs will be eligible for plans featuring an 133 percent of the federal poverty level are eligible essential benefit package and limits on out-of-pocket for subsidized private coverage though the new mar- spending. ketplaces, though at higher premiums and cost-shar- ing than under Medicaid. When the law was writ- New private health plans with consumer protections. ten, it was assumed that most families with incomes Twenty-eight percent of respondents living at 400 under the poverty level would be eligible for the percent of poverty or more, or an estimated 13 Medicaid expansion. Therefore, no similar provision million adults, reported a cost-related problem get- was made for the poorest families. So, for states that ting needed care. People with such incomes who do not participate in the expansion, there would be must buy coverage on their own will be able to pur- no subsidized coverage for these families other than chase health insurance through the marketplaces what currently exists. To date, about half the states or individual market. Their coverage will have have indicated they will participate in the expan- an essential benefit package and limits on out-of- sion. Some states, like Arkansas, are negotiating pocket spending. with federal officials to use Medicaid expansion funds to provide residents who become newly eligi- Who Will Remain Uninsured? ble for Medicaid with equivalent benefits through There are some important limitations to consider private insurance plans. when assessing the potential effects of the Affordable Currently, all states participate in Medicaid Care Act. First, the law does not provide subsidized and the Children’s Health Insurance Program, with coverage to people who are not in the country states shouldering a higher share of the expense than legally. Jonathan Gruber, an economist at the they would under the Medicaid expansion. Thus, it Massachusetts Institute of Technology, has estimated seems likely that all states will eventually participate that of a projected 25 million people who will in the expansion over the next decade. However, remain uninsured in 2016, about 5 million will be in the near term, poor families are clearly at risk undocumented immigrants. Second, both the of continuing to go without health insurance in Congressional Budget Office and Gruber predict many states. that the balance of uninsured people, about 20 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 LOOKING FORWARD there are health plans available with sufficient pro- The Congressional Budget Office estimates that the vider network capacity to meet the new demand for health reform law will provide new insurance cover- health services. The reform law has provided the age to 27 million individuals by 2021—people who tools needed to achieve near-universal coverage over otherwise would have been uninsured. However, the next decade. It is up to us to ensure they are uncertainty surrounding states’ decisions to expand used effectively. Medicaid, undocumented immigrants’ ineligibility for subsidized insurance, and the potential that many eligible people will not enroll in the new cov- erage options together could leave 29 million people without coverage. It is imperative, therefore, that the federal government and the states work together to fully implement the law’s provisions, including informing the public about the new insurance options and helping people to apply and enroll. Federal and state officials must also ensure that when the state mar- ketplaces begin open enrollment in October 2013, www.commonwealthfund.org21 SURVEY METHODOLOGY The Commonwealth Fund Biennial Health Insurance Survey was conducted by Princeton Survey Research Associates International from April 26 to August 19, 2012. The survey consisted of 25-minute telephone interviews in either English or Spanish and was conducted among a random, nationally representative sam- ple of 4,432 adults age 19 and older living in the continental United States. Because relying on landline- only samples leads to undercoverage of American households, a combination of landline and cellular phone random-digit dial (RDD) samples was used to reach people, regardless of the type of telephones they use.14 In all, 2,217 interviews were conducted with respondents on landline telephones and 2,215 interviews were conducted on cellular phones, including 1,166 with respondents who live in households with no landline telephone access. The sample was designed to generalize to the U.S. adult population and to allow separate analyses of responses of low-income households. This report limits the analysis to respondents ages 19 to 64 (n=3,393). Statistical results are weighted to correct for the stratified sample design, the overlapping land- line and cellular phone sample frames, and disproportionate nonresponse that might bias results. The data are weighted to the U.S. adult population by age, sex, race/ethnicity, education, household size, geographic region, population density, and household telephone use, using the U.S. Census Bureau’s 2011 Annual Social and Economic Supplement. The resulting weighted sample is representative of the approximately 183.9 million U.S. adults ages 19 to 64. Respondents’ insurance status in the past 12 months is classified as either insured all year, insured when surveyed but uninsured during the past 12 months, or currently uninsured. These categories enabled exploration of insurance instability and its role in access to care and financial security. The study also classi- fied adults by income as a percent of the federal poverty level. Eight percent of adults ages 19 to 64 did not provide sufficient income data for classification. The survey has an overall margin of sampling error of +/– 2.3 percentage points at the 95 percent confidence level. The landline portion of the survey achieved a 22 percent response rate and the cellular phone component achieved a 19 percent response rate. We also report estimates from the 2003, 2005, and 2010 Commonwealth Fund Biennial Health Insurance Surveys. These surveys were conducted by Princeton Survey Research Associates International using the same stratified sampling strategy as was used in 2012 except the 2003 and 2005 surveys did not include a cellular phone random-digit dial sample.15 In 2003, the survey was conducted from September 3, 2003, through January 4, 2004, and included 3,293 adults ages 19 to 64; in 2005, the survey was con- ducted from August 18, 2005, to January 5, 2006, among 3,353 adults ages 19 to 64; in 2010, the survey was conducted from July 14 to November 30, 2010, among 3,033 adults ages 19 to 64. 22 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 NOTES 1 The Commonwealth Fund Survey of Young Adults found that between November 2010 and November 2011, an estimated 6.6 million young adults ages 19 to 25 stayed on or joined their parents’ health plans. These individuals likely would not have been able to do so prior to the passage of the Affordable Care Act. See S. R. Collins, R. Robertson, T. Garber, and M. M. Doty, Young, Uninsured, and in Debt: Why Young Adults Lack Health Insurance and How the Affordable Care Act Is Helping—Findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2011 (New York: The Commonwealth Fund, June 2012). An analysis of the National Health Interview Survey by HHS found that 3.1 million previously uninsured young adults gained coverage by December 2011. See B. D. Sommers, T. Buchmueller, S. L. Decker et al, “The Affordable Care Act Has Led to Significant Gains in Health Insurance and Access to Care for Young Adults,” Health Affairs, Jan. 2013 32(1):165–74. 2 People are defined as underinsured if they had health insurance all year but spent 10 percent or more of their income on out-of-pocket health costs, excluding premiums; spent 5 percent or more of their income on out-of- pocket costs if their incomes were under 200 percent of poverty ($46,100 for a family of four); or had deductibles that amounted to 5 percent or more of their income. The measure of underinsurance is conservative: other than the deductible component, it reflects out-of-pocket costs that were actually incurred over the past year rather than the extent to which a person’s health plan leaves them potentially exposed to high out-of-pocket costs. See C. Schoen, M. M. Doty, R. H. Robertson, and S. R. Collins, “Affordable Care Act Reforms Could Reduce the Number of Underinsured U.S. Adults by 70 Percent,” Health Affairs, Sept. 2011 30(9):1762–71. 3 M. Hartman, A. B. Martin, J. Benson et al., “National Health Spending in 2011: Overall Growth Remains Low, But Some Payers and Services Show Signs of Acceleration,” Health Affairs, Jan. 2013 32(1):87–99. 4 C. DeNavas-Walt, B. D. Proctor, and J. C. Smith, Income, Poverty, and Health Insurance Coverage in the United States: 2011 (Washington, D.C.: U.S. Census Bureau, Sept. 2012). 5 G. Claxton, M. Rae, N. Panchal et al., “Health Benefits in 2012: Moderate Premium Increases for Employer- Sponsored Plans; Young Adults Gained Coverage Under ACA,” Health Affairs, Oct. 2012 31(10):2324–33. 6 2011 Kaiser/HRET Employer Health Benefits Survey (EHBS). 7 M. K. Abrams, R. Nuzum, S. Mika, and G. Lawlor, Realizing Health Reform’s Potential: How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers (New York: The Commonwealth Fund, Jan. 2011); A. B. Bindman, K. Grumbach, D. Osmond et al., “Primary Care and Receipt of Preventive Services,” Journal of General Internal Medicine, May 1996 11(5):269–76; and L. A. Blewett, P. J. Johnson, B. Lee et al., “When a Usual Source of Care and Usual Provider Matter: Adult Prevention and Screening Services,” Journal of General Internal Medicine, Sept. 2008 23(9):1354–60. 8 Departments of the Treasury, Labor, and Health and Human Services, “Interim Final Rules for Group Health Plans and Health Insurance Issuers,” July 19, 2010, p. 28, http://www.healthcare.gov/center/regulations/prevention/regs. html. 9 Centers for Disease Control and Prevention, “Cancer Screening–United States, 2010,” Morbidity and Mortality Weekly Report, Jan. 27, 2012 61(3):41–45. 10 Blood pressure checked in the past two years (in past year if he or she has hypertension or high blood pressure); cholesterol checked in the past five years (in the past year if he or she has hypertension, heart disease, or high cho- lesterol); for women, Pap test in the past three years for ages 21–64; for women, mammogram in the past two years, ages 40 to 64; colon cancer screening in the past five years, ages 50 to 64. 11 See T. Jost, “Implementing Health Reform: Shared Responsibility Tax Exemptions and Family Coverage Affordability,” Health Affairs Blog, Jan. 31, 2013, http://healthaffairs.org/blog/2013/01/31/implementing-health- reform-shared-responsibility-tax-exemptions-and-family-coverage-affordability/; Department of the Treasury, Shared Responsibility for Employers Regarding Health Coverage; Proposed Rule, Federal Register, Jan. 2, 2013 78(1):218–53. www.commonwealthfund.org23 12 Department of the Treasury, Health Insurance Premium Tax Credit, Final Regulations, Federal Register, Feb. 1, 2013 78(22):7264–65. 13 S. R. Collins, “Proposed Rule on Premium Tax Credits: Who’s Eligible and How Much Will They Help?” The Commonwealth Fund Blog, Aug. 31, 2011. 14 According to the latest estimates from the 2012 National Health Interview Survey, more than a third (35.8%) of U.S. households have cellular telephones only. See S. J. Blumberg and J. V. Luke, Wireless Substitution: Early Release of Estimates from the National Health Interview Survey, January–June 2012, National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/nhis.htm. 15 In 2005, only 7.2 percent of households in the U.S. did not have landline telephones. See S. J. Blumberg and J. V. Luke, “Reevaluating the Need for Concern Regarding Noncoverage Bias in Landline Surveys,” American Journal of Public Health, Oct. 2009 9(10):1806–10. Employing a landline-only sample in 2001 and 2005 did not result in under- coverage of American households. 24 Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Table 1. Continuity and Adequacy of Insurance in 2012 (Base: adults 19–64) Total Insured Insured now, time Uninsured Uninsured during Insured all year, Insured all year, (19–64) all year uninsured in past year now the year* underinsured^ not underinsured^ Total (millions) 183.9 129.3 19.0 35.5 54.6 29.6 99.7 Percent distribution 100% 70% 10% 19% 30% 16% 54% Unweighted n 3393 2417 326 650 976 577 1840 Age 19–25 16 59 20 21 41 18 41 19–29 24 58 18 23 42 17 42 30–49 40 68 9 23 32 14 54 50–64 36 80 7 13 20 18 63 Race/Ethnicity White 63 78 9 14 22 17 60 Black 13 61 18 20 39 16 46 Hispanic 16 49 11 40 51 13 36 Asian/Pacific Islander (n=109) 3 80 12 8 20 19 61 Other/Mixed (n=149) 4 57 14 29 43 16 41 Income Less than $20,000 28 50 17 33 50 23 28 $20,000–$39,999 19 55 15 30 45 21 34 $40,000–$59,999 14 80 9 11 20 19 61 $60,000 or more 30 92 3 4 8 11 81 Poverty status Below 133% poverty 29 48 17 35 52 23 25 133%–249% poverty 19 63 15 22 37 22 41 250%–399% poverty 18 81 8 11 19 16 65 400% poverty or more 25 93 3 5 7 10 83 Below 200% poverty 40 51 17 32 49 23 28 200% poverty or more 51 85 6 9 15 14 71 Fair/Poor health status, or any 51 68 11 20 32 18 50 chronic condition or disability Adult work status Full-time 53 79 8 12 21 15 64 Part-time 13 59 15 26 41 16 43 www.commonwealthfund.org25 Not currently employed 34 61 12 27 39 17 43 Family work status At least one full-time worker 68 78 8 14 22 16 62 Only part-time worker(s) 10 51 18 31 49 17 34 No worker in family 22 56 14 30 44 18 38 Employer size** Self-employed/1 employee 6 63 14 23 37 25 38 2–19 employees 19 64 11 25 36 16 48 20–49 employees 9 63 8 29 37 17 46 50–99 employees 9 79 9 12 21 22 56 100–499 employees 16 81 8 10 19 15 66 500 or more employees 40 83 9 8 17 13 70 * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out of pocket expenses equaled 10% or more of income; out of pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ** Base: Full- and part-time employed adults ages 19–64. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). 26 Table 2. Insurance Costs, Benefits, and Problems by Insurance Continuity, Insurance Adequacy, and Income Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 (Base: insured adults 19–64) Insurance continuity Insured all year Federal poverty level Total insured Insured now, 133%– 250%– 400% adults Insured time uninsured Not Below 133% 249% 399% poverty 19–64 all year in past year Underinsured^ underinsured^ poverty poverty poverty or more Total (millions) 148.4 129.3 19.0 29.6 99.7 34.4 27.6 29.4 44.7 Percent distribution 100% 87% 13% 20% 67% 23% 19% 20% 30% Unweighted n 2743 2417 326 577 1840 673 498 508 848 Annual share of premium costs None 13 14 8 11 15 15 13 12 12 $1–$499 5 5 6 4 5 4 6 5 5 $500–$1,499 15 15 13 14 15 9 17 16 18 $1,500–$2,999 15 15 15 14 16 7 16 22 18 $3,000–$4,499 11 12 4 14 12 3 10 15 15 $4,500–$5,999 5 5 4 4 5 1 5 5 7 $6,000+ 9 9 5 12 8 1 5 12 14 Government insurance 17 13 39 19 12 48 22 5 1 Undesignated 11 12 6 8 13 11 6 8 10 Premium is 5% or more of household income* 35 33 53 56 26 46 48 41 22 Premium is 10% or more of household income* 15 13 28 32 7 36 23 13 4 Annual deductible per person** No deductible 38 36 53 27 39 64 39 30 25 $1–$499 18 19 11 15 20 14 18 21 19 $500–$999 11 11 9 11 11 5 10 17 13 $1,000 or more 22 23 17 40 18 7 22 24 34 Insurance covers all or part of the following health care needs: Prescription medicines 91 93 80 88 95 87 88 94 95 Mental health care 68 71 48 68 72 56 65 71 78 Maternity care 65 68 45 64 69 49 59 75 76 Birth control/contraception 47 49 39 48 49 47 44 50 52 Dental care 74 76 59 65 79 64 66 79 83 Vision care 70 72 53 64 75 65 66 74 73 Child’s dental and vision*** 71 72 69 62 75 66 60 74 77 Problems with current main insurance plan: Expensive medical bills for services not covered 28 26 36 46 20 27 35 32 23 by insurance Doctor charged more than insurance would pay 28 28 31 38 25 24 29 27 30 and had to pay the difference Doctor’s office would not accept insurance 20 18 35 24 16 28 22 15 17 Insurance denied payment for medical care 19 19 24 31 15 17 25 19 19 ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. * Base: Respondents who reported their income level and premium costs for their private insurance plan. ** Respondents who did not provide information on the size of their deductible are included in the distribution but not shown in table. *** Base: Respondent has children age 25 or younger. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Table 3. Medical Bill Problems, by Insurance Continuity, Insurance Adequacy, and Income (Base: adults 19–64) Insurance continuity Insured all year Federal poverty level Insured now, time Uninsured Below 133%– 250%– 400% Total Insured uninsured in Uninsured during Not 133% 249% 399% poverty 19–64 all year past year now the year* Underinsured^ underinsured^ poverty poverty poverty or more Total (millions) 183.9 129.3 19.0 35.5 54.6 29.6 99.7 53.1 35.6 33.1 46.8 Percent distribution 100% 70% 10% 19% 30% 16% 54% 29% 19% 18% 25% Unweighted n 3393 2417 326 650 976 577 1840 1015 641 574 887 Medical bill problems in past year Had problems paying or unable to pay medical bills 30 21 52 50 51 40 16 42 41 24 14 Contacted by collection agency for unpaid 18 11 36 33 34 20 8 30 25 13 5 medical bills Had to change way of life to pay bills 16 11 30 25 27 25 7 21 25 15 6 Any of three medical bill problems 34 24 60 57 58 43 18 47 47 29 16 Medical bills/debt being paid off over time 26 24 41 27 32 41 19 26 34 30 21 Any of three medical bill problems or medical debt 41 33 62 60 61 55 26 51 52 40 25 Base: Adults with any medical debt Unweighted n 875 573 128 174 302 232 341 272 214 179 171 How much are the medical bills that are being paid off over time? Less than $2,000 48 49 46 47 47 42 54 41 54 54 41 $2,000 to less than $4,000 21 22 22 16 19 23 21 21 18 18 25 $4,000 to less than $8,000 13 14 11 13 12 18 11 14 10 14 17 $8,000 to less than $10,000 4 5 2 5 3 4 5 5 2 2 8 $10,000 or more 11 8 18 15 17 12 6 13 13 12 9 Was this for care received in past year or earlier? Past year 50 55 40 41 41 53 57 34 46 60 60 Earlier year 43 38 54 51 52 40 37 53 49 37 35 Both 6 6 6 7 6 6 6 12 4 3 4 Base: Adults with any bill problem or medical debt Unweighted n 1409 820 203 386 589 325 495 532 331 247 218 Percent reporting that the following happened in the past two years because of medical bills: www.commonwealthfund.org27 Unable to pay for basic necessities (food, heat, 25 20 28 34 32 30 14 33 32 18 7 or rent) Used up all of savings 37 32 41 46 44 43 24 41 49 29 25 Took out a mortgage against your home or 7 7 7 8 8 10 5 6 7 9 10 took out a loan Took on credit card debt 27 32 26 17 20 32 32 15 29 39 37 Had to declare bankruptcy 6 7 2 5 4 9 5 6 7 4 3 Delayed education or career plans 22 17 23 32 29 22 14 28 24 18 17 Received a lower credit rating 42 34 59 49 53 44 28 49 53 33 30 Insurance status of person/s at time care was provided Insured at time care was provided 60 82 45 23 31 81 83 36 61 75 89 Uninsured at time care was provided 36 15 49 70 62 15 15 59 33 21 11 Other insurance combination 1 1 0 2 1 3 0 2 0 2 0 * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out of pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Table 4. Access Problems, by Insurance Continuity, Insurance Adequacy, and Income 28 (Base: adults 19–64) Insurance continuity Insured all year Federal poverty level Insuring the Future—Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2012 Insured now, time Uninsured Below 133%– 250%– 400% Total Insured uninsured Uninsured during Not 133% 249% 399% poverty 19–64 all year in past year now the year* Underinsured^ underinsured^ poverty poverty poverty or more Total (millions) 183.9 129.3 19.0 35.5 54.6 29.6 99.7 53.1 35.6 33.1 46.8 Percent distribution 100% 70% 10% 19% 30% 16% 54% 29% 19% 18% 25% Unweighted n 3393 2417 326 650 976 577 1840 1015 641 574 887 Access problems in past year Went without needed care in past year because of costs: Did not fill prescription 27 21 43 42 43 34 17 36 34 26 17 Skipped recommended test, treatment, or follow-up 27 18 44 48 47 30 15 34 36 24 16 Had a medical problem, did not visit doctor or clinic 29 18 52 58 56 31 14 37 44 25 14 Did not get needed specialist care 20 13 37 40 39 23 9 29 27 15 11 At least one of four access problems because of cost 43 34 68 67 67 51 28 53 53 43 28 Delayed or did not get preventive care screening 18 9 30 43 38 18 7 24 27 13 9 because of cost Preventive care Regular source of care 88 94 88 64 73 96 94 80 87 93 94 Blood pressure checked in past two years¥ 89 93 90 75 80 93 93 82 89 93 97 Received mammogram in past two years 69 75 — 39 48 70 77 49 64 70 87 (females ages 40–64) Received Pap test in past three years 75 79 74 57 64 73 81 69 68 74 87 (females ages 21–64) Received colon cancer screening in past five years 52 57 — 20 33 53 58 39 47 52 62 (ages 50–64) Cholesterol checked in past five years¥¥ 70 77 64 45 52 73 79 54 64 77 87 Seasonal flu shot in past 12 months 40 45 32 26 28 44 46 38 36 40 46 Access problems for people with health conditions Unweighted n 1375 1001 134 240 374 270 731 471 262 226 314 Stayed overnight in a hospital or visited the emergency room because of [this / any of these] 18 17 23 20 21 26 14 30 19 10 7 problem[s]** Unweighted n 1155 895 100 160 260 245 650 375 220 201 276 Skipped doses or not filled a prescription for medications for the health condition(s) because 28 19 52 60 57 33 14 37 44 28 7 of the cost of the medicines?*** * Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ¥ Checked in past year if respondent has hypertension or high blood pressure. ¥¥ Checked in past year if respondent has hypertension or high blood pressure, heart disease, or high cholesterol. ** Base: Respondents with at least one of the following health problems: hypertension or high blood pressure, heart disease, diabetes, asthma, emphysema, or lung disease. *** Base: Respondents who take prescription medications on a regular basis and have at least one of the following health problems: heart disease, hypertension or high blood pressure, diabetes, asthma, emphysema, or lung disease. — Sample size too small to show results. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012). Washington Office New York City Headquarters 1150 17th Street NW 1 East 75th Street Suite 600 New York, NY 10021 Washington, DC 20036 Tel: 212.606.3800 Tel: 202.292.6700 www.commonwealthfund.org