SURVEY BRIEF AUGUST 2020 U.S. Health What did health insurance coverage look like for U.S. adults in the first half of 2020 as the country slid into the worst public health and economic crisis in generations? In this brief, Insurance we present findings from the Commonwealth Fund’s latest Biennial Health Insurance Survey, which assesses the extent and quality of coverage for U.S. working-age adults. We’ve conducted this survey since 2001. It uses three measures to gauge the adequacy of Coverage in 2020: insurance coverage: • whether or not people have insurance A Looming Crisis • if they have insurance, whether they experienced a gap in coverage in the prior year in Affordability • whether high out-of-pocket costs and deductibles are causing them to be underinsured, despite having continuous coverage throughout the year. The survey began on January 14, 2020 — just before the outbreak of the coronavirus Findings from the pandemic in the United States. We interviewed a nationally representative sample of 4,272 adults ages 19 to 64 about their health insurance coverage through June 5. (See “How Commonwealth Fund Biennial We Conducted This Study” for more detail.) Despite the severity of the pandemic and the abrupt disruption in economic activity beginning in March, the survey did not find Health Insurance Survey, 2020 statistically significant changes in coverage from the last time it was conducted in 2018. But it does show a persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues. SURVEY HIGHLIGHTS In the first half of 2020, 43.4 percent of U.S. adults ages 19 to 64 were inadequately Sara R. Collins insured. This is statistically unchanged from the last time we fielded the survey in 2018. Vice President The Commonwealth Fund The adult uninsured rate was 12.5 percent. In addition, 9.5 percent of adults were insured but had a gap in coverage in the past year and 21.3 percent were Munira Z. Gunja underinsured. These findings are also statistically unchanged from 2018. Senior Researcher The Commonwealth Fund Gabriella N. Aboulafia Program Assistant The Commonwealth Fund U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 2 There was no statistically significant change in coverage inadequacy between the months leading up to the pandemic and WHO IS UNDERINSURED? the months that followed, but this may change as the pandemic In this analysis, we use a measure of underinsurance that accounts for continues. an insured adult’s reported out-of-pocket costs over the course of a Half of adults who spent any time uninsured or who were year, not including insurance premiums, as well as their plan deductible. underinsured reported problems paying medical bills or said These actual expenditures and the potential risk of expenditures, as they were paying off medical debt over time. A quarter of those represented by the deductible, are then compared with household who were continuously insured and did not meet the threshold income. Specifically, we consider people who are insured all year to be for underinsurance also reported problems paying bills. underinsured if: People who reported problems paying medical bills experienced • their out-of-pocket costs, excluding premiums, over lingering financial problems including damage to their credit the prior 12 months are equal to 10 percent or more of ratings and depleted savings. household income; or • their out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 5 percent or more of household income for individuals living under 200 percent of the federal poverty level ($25,520 for an individual or $52,400 for a family of four in 2020); or • their deductible constitutes 5 percent or more of household income. The out-of-pocket cost component of the measure is only triggered if a person uses their plan to obtain health care; it does not provide information about the plan design. This is why we include a deductible component since it is an indicator of the financial protection the plan offers and the risk of incurring costs before someone gets health care. The definition does not include people who are at risk of incurring high costs because of other aspects of their plan’s design, such as copayments or uncovered services. commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 3 More Than Two of Five Working-Age Adults Are Inadequately Insured More Than Two of Five Working-Age Adults Are Inadequately Insured Percent of adults ages 19–64 In the first half of 2020, 43.4 percent of adults were inadequately insured. Insured all year, not underinsured Insured all year, underinsured This group is made up of people Insured now, had a coverage gap Uninsured now who were uninsured at the time of 100% the survey (12.5%), were insured but had experienced a coverage gap in 90% the past year (9.5%), or were insured 80% continuously but had such high out-of- 57% pocket costs or deductibles relative to 56% 54% 55% 56% 56% 70% their income that they were effectively underinsured (21.3%).1 (See box above.) 60% Despite the pandemic, we find no 50% statistically significant change in 40% any of our measures of coverage 16% 16% 17% 22% 21% 21% adequacy from 2018. We also did not 30% find significant changes in coverage 8% 10% 20% 13% adequacy between the months leading 10% 10% 10% up to the pandemic and the months 10% 20% 19% 16% that followed, but this may change as 12% 12% 13% the pandemic continues. 0% The uninsured rate we found falls into 2010 2012 2014 2016 2018 2020 the range of estimates of recent federal surveys conducted in 2018 and 2019 Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who (11.7% and 13.7%, respectively.) (See were insured at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. “Estimates of U.S Uninsured Rates” for Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding detail.) It is important to note that our premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income Source: Sara R. Collins, Munira Z. Gunja, and Gabriella estimated uninsured rate has a margin (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, N.hadAboulafia, U.S. Health a coverage gap” Insurance refers to Coverage in 2020: adults who wereA insured Looming Crisis in Affordability — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults of sampling error of +/– 1.3 percent and who reported being uninsured at the time of the survey. therefore, the true estimate is likely Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). between 11.2 percent and 13.9 percent.2 commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 4 High Uninsured Rates Reported Among People of Color, Small-Business Workers, High Uninsured People Rates with Low Reported Among Incomes, PeopleAdults and Young of Color, Small-Business Workers, People with Low Incomes, and Young Adults More than one-third of Latino Percent of adults ages 19–64 who were Percent of adults adults, workers in small businesses uninsured anytime in the past year ages 19–64 (i.e., fewer than 20 employees), who were and adults with low incomes underinsured were either uninsured at the time 40 of the survey or spent some time 38 uninsured in the past year (Table 1). 34 This was two or more times higher than comparison groups. Young 30 adults also reported high rates 28 of being uninsured. People with 24 incomes below 133 percent of the federal poverty level (i.e., $16,971 for an individual and $34,846 for 17 a family of four in 2020) reported 16 14 uninsured rates that were three 12 10 times higher than adults with incomes at 400 percent of the poverty level or higher (i.e., $51,040 for an individual and $104,800 Latino Black White 19–34 50–64 <133% 400%+ <20 100+ <133% 400%+ for a family of four). They also FPL FPL FPL FPL had underinsured rates that were Race/Ethnicity Age Poverty status Employer size Poverty status two times as high as their higher- income counterparts. Notes; “Uninsured anytime in the past year” refers to adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. FPL = federal poverty level. Data: Commonwealth Fund Biennial Health Insurance Survey (2020). Notes: “Uninsured anytime in the past year” refers to adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10%Source: Sara of or more R. Collins, income; Munira Z. Gunja, and out-of-pocket Gabriella costs, N. Aboulafia, excluding U.S. Health premiums, Insurance equaled Coverage 5% or more ofinincome 2020: A Looming if Crisis in Affordability — Findings from low-income (<200% of poverty); or deductibles the Commonwealth equaled 5% or more ofFund Biennial income. FPLHealth Insurance = federal Survey, poverty 2020 (Commonwealth Fund, Aug. 2020). level. Data: Commonwealth Fund Biennial Health Insurance Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 5 One-Quarter of Adults in Employer Plans Are Underinsured One-Quarter of Adults in Employer Plans Are Underinsured Percent of adults ages 19–64 with private coverage who were insured all year and were underinsured Among people who were insured all year in private health plans, Total Employer-provided coverage Individual coverage^ people who were enrolled in plans 60 they bought on their own in the individual market — either directly from an insurer or the Affordable 50 Care Act (ACA) marketplaces — 45 44 were underinsured at the highest 42 40 rates. But one-quarter of adults 40 37 37 in employer plans also were underinsured. Because there were an estimated 122 million working- 30 27 28 28 age people in employer plans, compared to just 15 million in the 22 22 26 26 individual market, there were far 20 19 24 more underinsured people with 20 20 employer coverage than with 17 individual market insurance.3 10 The growth in the underinsured since 2010 has been driven by increasingly inadequate coverage in 0 employer health plans. 2010 2012 2014 2016 2018 2020 Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Respondents may have had another type of coverage at some point during the year but had coverage for the entire previous 12 months. ^ For 2014–2020, individual coverage includes adults who got coverage in the individual market and the marketplaces. ^ ForCommonwealth Data: 2014–2020, individual coverage Fund Biennial includes Health Insurance adults Surveys who2012, (2010, got coverage 2014, 2016,in2018, the 2020). individual market and the marketplaces. Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket Source: Sara costs, R. Collins, Munira excluding Z. Gunja, premiums, and Gabriella equaled N. Aboulafia, 5% U.S. or more Health of income Insurance if low-income Coverage in 2020: A Looming Crisis in Affordability — Findings5% (<200% of poverty); or deductibles equaled from or the moreCommonwealth Fund Biennial Health of income. Respondents may Insurance have hadSurvey, another2020 (Commonwealth type of coverageFund, Aug.point at some 2020). during the year, but had coverage for the entire previous 12 months. Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 6 Share ofPrivately Share of Privately Insured Insured Adults Adults with Deductibles with Deductibles of $1,000 of $1,000 or More Hasor More Has Doubled SinceDoubled Since 2010 2010 Percent of adults ages 19–64 with private coverage* and deductibles of $1,000 or more The Commonwealth Fund’s measure of underinsurance includes how much people spent out of pocket in the past year 60 and the size of their deductible, both calculated as a share of their income. Over the past decade, 45 46 deductibles have grown both in 45 43 prevalence and size. The share of 38 the adult population in private health plans with deductibles of 32 $1,000 or more doubled between 30 2010 and 2020. 22 15 0 2010 2012 2014 2016 2018 2020 * Base is those with private coverage who specified deductible. Private coverage includes those with coverage through an employer or coverage through the individual market. For 2014–2020, individual coverage includes adults who got coverage in the individual market and the marketplaces. Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). * Base is those with private coverage who specified deductible. Private coverage includes those with coverage through an employer or coverage through the individual market.Source: For 2014–2020, individual Sara R. Collins, Munira coverage includes Z. Gunja, and adults Gabriella who gotU.S. N. Aboulafia, coverage in the individual Health Insurance Coveragemarket in 2020: A Looming Crisis in Affordability — and the marketplaces. Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 7 Deductibles Have Deductibles Have Grown Grown Faster Faster ThanThan Income, Income, TakingTaking Up Shares Up Larger LargerofShares of Household Budgets, Leaving Household Moreand Budgets People Underinsured Leaving More People Underinsured In 2010, only 7 percent of people in Percent of adults ages 19–64 with private plans had deductibles that private coverage who had deductibles 2010 2012 2014 2016 2018 2020 amounted to 5 percent or more of that were 5% or more of income income. By 2016, that share was 15 percent. Because of the dominance Total 7% 11% 13% 15% 16% 15% of employer coverage in U.S. health insurance, this overall rate has closely tracked that of people Insurance source at time of survey* enrolled in employer plans. People who get coverage in Employer-provided coverage 6% 9% 11% 13% 15% 14% the individual market and ACA marketplaces face higher Individual and marketplace coverage^ 18% 29% 22% 24% 23% 27% deductibles, on average, relative to their incomes, than people in employer plans. Those with Firm size (base: full- or part-time incomes under 250 percent of workers with coverage through poverty ($31,900 for an individual their own employer)^^ and $65,500 for a family of four in 2020) are eligible for marketplace 2–99 employees 7% 15% 20% 13% 18% 16% plans with reduced cost-sharing, including lower deductibles. But 100 or more employees 5% 6% 9% 13% 14% 14% people with incomes over that threshold see higher deductibles, which ranged as high as $8,150 for silver-level plans in the 38 states * Respondents may have had another type of coverage at some point during the year. Private coverage includes those with coverage through an employer or throughwhere thethe federal individual government market. *^Respondents For 2014–2020, mayindividual have hadcoverage another includes type ofadults who got coverage coverage at some in the point individual during market the year. and the Private marketplaces. coverage includes ^^those Does not withinclude operated the marketplaces in the adults who are self-employed. coverage through an employerFund or through Biennialthe individual market. Data: Commonwealth Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). 2020 plan year.4 ^ For 2014–2020, individual coverage includes adults who got coverage in the individual market and the marketplaces. ^^ Does not include adults who are self-employed. Source: Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability — Data: Commonwealth Fund Biennial HealthFindings from Insurance the Commonwealth Surveys (2010, 2012, Fund 2014,Biennial Health 2016, 2018, Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 8 People with Inadequate Insurance Coverage Have More Problems Paying Medical Bills People with Inadequate Insurance Coverage Have More Problems Paying Medical Bills Percent of adults ages 19–64 who had medical bill or debt problems in the past year Inadequate insurance coverage leaves people exposed to high health care costs; Total these expenses can quickly turn into Insured all year, not underinsured medical debt. Half of adults who spent Insured all year, underinsured any time uninsured and those who were Uninsured anytime in the past year underinsured reported problems paying medical bills or said they were paying off 52 49 medical debt over time. But rates also were high among people with coverage all year who were not underinsured: one-quarter 38 reported medical bill problems or debt. 37 Even though their income combined with 34 35 their insurance deductible and out-of- pocket spending didn’t meet the threshold 27 27 24 25 for underinsurance, they still struggled 23 with medical bills. The majority of people 21 19 18 in this group had employer coverage (data 17 14 14 not shown). 12 8 The majority (67%) of adults who reported 6 medical bill or debt problems said the person in their household who incurred Had problems paying Contacted by collection Had to change Medical bills/debt Any bill problem or the medical bill was insured when the or unable to pay agency for unpaid way of life to pay bills being paid over time medical debt care was provided (Table 5). Among those medical bills medical bills paying off debt over time, more than half Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of (54%) income;had incurred out-of-pocket debt of $2,000 or more. costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Uninsured anytime in the past year” refers to adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. Among demographic groups, Blacks were Data: Commonwealth Fund Biennial Health Insurance Survey (2020). significantly more likely than whites to report problems with medical bills (45% vs. Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, Source: excluding premiums, equaled 10% or more of Sara R. Collins, income; Munira Z. Gunja, out-of-pocket andexcluding costs, Gabriella N.premiums, Aboulafia, U.S. Health 5% equaled Insurance Coverage or more in 2020: of income 35%), if A Looming Crisis as were lower-income in Affordability — people (133% Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). of poverty or lower) compared to people low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Uninsured anytime in the past year” refers to adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. with higher incomes (400% of poverty or Data: Commonwealth Fund Biennial Health Insurance Survey (2020). higher) (42% vs. 27%) (data not shown). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 9 Medical Debt Leaves People with Lingering Financial Problems Medical Debt Leaves People with Lingering Financial Problems Paying off accumulated medical Percent of adults ages 19–64 who had the following financial problems in the past two years debt over time can have a major because of medical bill problems/debt^ impact on people’s lives. Many adults with medical bill or debt problems reported serious financial problems. Among those who reported any medical bill or debt problem, 37 percent said they had used up all their savings to pay their bills, 40 percent had received a lower credit rating as a result of their medical debt, 31 percent 40 racked up debt on their credit 37 cards, and one-quarter were unable 31 to pay for basic necessities such as 26 food, heat, or rent. People who were 20 underinsured were particularly affected: nearly half (48%) said they 11 3 had used up all their savings to pay off their bills (Table 5). Used all of Received a Took on credit Unable to pay Delayed Took out a Had to declare savings lower credit card debt for basic education or mortgage bankruptcy rating necessities career plans against your (food, rent, home or took heat) out a loan ^ Base: Respondents who reported at least one of the following medical bill problems in the past 12 months: had problems paying medical bills, contacted by a collection agency for unpaid bills, had to change way of life in order to pay medical bills, or has outstanding medical debt. ^Data: Base: RespondentsFund Commonwealth whoBiennial reported at least Health one ofSurvey Insurance the following (2020). medical bill problems in the past 12 months: had problems paying medical bills, contacted by a collection agency for unpaid bills, had to change way of life in order to pay medical bills, or has outstanding medical debt. Source: Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability — Data: Commonwealth Fund Biennial Health Insurance Findings from Survey (2020). the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 10 Uninsured Uninsured or Underinsured or Underinsured Adults Adults Often Often Avoid Avoid or Delay or Delay Getting NeededGetting Needed Health Care and Health Care and Medications Medications Percent of adults ages 19–64 who had any of four access problems in the past year because of cost While insurance status is not the only determinant of whether a person has access Total to health care, it is the most important.5 Insured all year, not underinsured Research has concluded that the ACA’s coverage expansions led to significant Insured all year, underinsured improvements in access over the past 10 Uninsured anytime in the past year years.6 But financial barriers to care remain in 56 the U.S. because millions of people either lack insurance or have coverage with significant cost-sharing. More than one-third (35%) of 43 all adults reported at least one cost-related 41 problem getting needed health care in the 34 35 past year including not filling a prescription; 33 skipping a recommended test, treatment or 26 26 follow-up visit; not going to a doctor when 25 24 23 sick; or not getting needed specialist care. 21 21 20 19 Rates were highest among adults who spent 14 15 any time uninsured during the year (56%) and 10 12 those who were underinsured (43%). But even 9 adults who were insured all year and not underinsured had access issues: 23 percent Did not fill prescription Skipped recommended Had a medical problem, Did not get needed At least one of four reported at least one cost-related problem test, treatment, or did not visit doctor specialist care access problems getting health care. Most of this group had follow-up or clinic because of cost employer coverage (data not shown). Cost-related Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; problems out-of-pocket costs, getting needed care excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Uninsured anytime in the past year” refers to adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. were higher among people with incomes Data: Commonwealth Fund Biennial Health Insurance Survey (2020). below 133 percent of poverty compared to those with incomes of 400 percent of poverty Notes: “Underinsured” refers to adultsSource: Sara R.insured who were Collins, Munira all yearZ.but Gunja, and Gabriellaone experienced N. Aboulafia, U.S. Healthout-of-pocket of the following: Insurance Coverage orinmore in 2020: A Looming Crisis costs, (42% — Affordability vs. 25%), and also among Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income (Commonwealth Fund, Aug. 2020). workers in small businesses of less than 20 if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Uninsured anytime in the past year” refers to employees compared to those in companies adults who were either uninsured at the time of the survey or spent some time uninsured in the past year. with 100 or more employees (42% vs. 31%) Data: Commonwealth Fund Biennial Health Insurance Survey (2020). (data not shown). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 11 People with Higher Deductibles More Frequently Report Financial Problems Because People of Medical with Higher BillsMore Deductibles or Delaying Care Financial Frequently Report Because of Cost Problems Because of Medical Bills or Delaying Care Because of Cost The survey indicates that deductibles Percent of adults ages 19–64 with private coverage Percent of adults ages 19–64 with private coverage who were insured all year and said “yes” to the who were insured all year and said “yes” to the following alone are associated with financial following happening to them* happening to them in the past 12 months* problems and may impact people’s decisions about whether to get needed health care. People in private health plans who were insured all year with Deductible <$1,000 Deductible <$1,000 deductibles of $1,000 or more were Deductible $1,000 or more Deductible $1,000 or more significantly more likely than those with lower or no deductibles to report 42 problems paying medical bills or said 41 38 they were paying off medical debt over time. Of this group, only half (53%) met 29 the definition of underinsured (data not 26 shown). People with higher deductibles 21 18 also were carrying higher debt loads: 62 percent of people with deductibles 11 of $1,000 or more who said they were paying off medical debt had incurred Any bill problem or Took on credit card debt At least one of four access Did not fill a prescription for debt of $2,000 or more compared to 46 medical debt** because of medical bills*** problems because of cost^ medications for health percent of those with lower deductibles problems^^ who owed payments for bills (Table 5). * Base is those with private coverage who specified their deductibles. Private coverage includes those with coverage through an employer or through the individual market or marketplaces. ** Includes any of the following in the past 12 months: 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 Higher bills; deductibles can lead people to * Base medical is those bills/debt with being private paid coverage over time. who *** Includes specified anyone who took their deductibles. on credit Privateofcoverage card debt because includes medical bills/debt in thethose with past two coverage years. through Base is limited anwho said they had a medical bill to those problem or debt. ^ Includes any of the following because employer or through the individual market or marketplaces. of cost: did not fill a prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit decide doctor against getting needed care even or clinic; did not see a specialist when needed. ^^ Base is limited to those with health problems. Health problems include hypertension or high blood pressure; heart failure or heart attack; diabetes; asthma, emphysema, ** Includes any or oflung thedisease; followinghigh in cholesterol; the pastor12depression, months:anxiety, or other mental had problems healthorproblem. paying unable to pay medical bills; contacted by collection if they have health problems. People agency Data: for unpaid Commonwealth medical Fund bills; had Biennial Health to change Insurance way of life to pay bills; medical bills/debt being paid over time. Survey (2020). with at least one health problem who *** Includes anyone who took on credit card debt because of medical bills/debt in the past two years. Base is limited to those who said were enrolled in higher-deductible they had a medical bill problem orSource: debt. Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability — plans were more likely to report that Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020 (Commonwealth Fund, Aug. 2020). ^ Includes any of the following because of cost: did not fill a prescription; skipped recommended medical test, treatment, or follow-up; they had not filled a prescription or had had a medical problem but did not visit doctor or clinic; did not see a specialist when needed. skipped a dose of medication for their ^^ Base is limited to those with health problems. Health problems include hypertension or high blood pressure; heart failure or heart health problem than people with lower attack; diabetes; asthma, emphysema, or lung disease; high cholesterol; or depression, anxiety, or other mental health problem. or no deductibles. Data: Commonwealth Fund Biennial Health Insurance Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 12 Adults Adults WhoWho LookLook for for but Dobut NotDo BuyNot Buy Plans Plans in the in theMarket Individual Individual Market or or Marketplaces Marketplaces Cite Cite Affordability Affordability Percent of adults ages 19–64 with individual The ACA dramatically reformed the individual insurance market by banning coverage or who tried to buy it in past three years* insurers from denying coverage, charging higher premiums, or excluding preexisting conditions for people with What is the MAIN reason you did not buy a plan? health problems. In addition, it provided Percent of adults ages 19–64 who did not buy health subsidies to offset the cost of premiums insurance on their own in the past three years for people with incomes under 400 percent of poverty and deductibles 71 and other cost-sharing for those under Bought a health 250 percent of poverty. Given the loss insurance plan Did not buy a of employer coverage and declining 58% health incomes among millions of people insurance plan 6 because of the COVID-19 pandemic, 4 3 16 42% the marketplaces, along with Medicaid, The plan You found You gained The Some other could become more important than ever was too out you were health deductibles reason^ in insuring Americans. expensive not eligible insurance and/or to buy a plan through copayments Despite the ACA reforms, survey data has another were too high consistently indicated that affordability source remains a widespread challenge for many people enrolled in the individual market and the marketplaces or for those who want to enroll.7 This year, we asked people who had purchased or tried * Includes adults who either bought individual coverage within the past three years or tried to buy individual coverage within the past three years. ^ Respondents who reported “some other reason” to buy said that they found the enrollment process too difficult, they found out they missed the deadline, and they could not find a plan that covered what they needed, among other a plan in the individual market reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2020). or the marketplaces in the past three * Includes adults who either bought individual coverage within the past three years or tried to buy individual coverage within the past years about their experience. Nearly 60 three years. Source: Sara R. Collins, Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. Health Insurance Coverage in 2020: A Looming Crisispercent of those in Affordability — who tried to buy a plan ^ Respondents who reported “some other Findings from the reason” Commonwealth said Fundthe that they found Biennial Health Insurance enrollment Survey, process too 2020 they difficult, (Commonwealth Fund,missed found out they Aug. 2020). ultimately enrolled. When we asked why the deadline, and they could not find a plan that covered what they needed, among other reasons. people did not buy a plan, 71 percent Data: Commonwealth Fund Biennial Health Insurance Survey (2020). cited cost as the main reason. commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 13 CONCLUSION AND POLICY IMPLICATIONS The United States entered the pandemic with 30 million uninsured • increasing outreach and enrollment efforts to inform people of people and more than 40 million underinsured. These numbers their coverage options, particularly those who lose employer are certain to climb this year. The Congressional Budget Office coverage projects that the U.S. economy will contract by more than 5 percent • banning non-ACA-compliant plans like short-term policies that in 2020 and 25 million fewer people will be working in the third leave people exposed to catastrophic health care costs quarter of 2020 compared to the end of 2019.8 The Urban Institute estimates that this employment disruption will leave 3.5 million • developing an autoenrollment mechanism that will enable more people uninsured by the end of the year.9 And millions more people to enroll and stay enrolled in comprehensive coverage. will suffer income loss through furloughs, wage cuts, and declining There are other paths to universal coverage and improved business revenue. Unless there is a significant drop in premiums and affordability, like a single payer or “Medicare for All” approach.10 deductibles in private coverage, many households will face health The reforms outlined here don’t preclude such a path but could care costs that take up a growing share of shrinking budgets. be a practical first step toward a more regulated insurance system Coverage insecurity will leave people with mounting medical debt, that includes more public financing. But ongoing policy inaction on as well as significant financial barriers to getting the health care they insurance coverage combined with the raging pandemic is certain need to survive the pandemic and lead healthy and productive lives. to tip the nation’s health care affordability problems into crisis for Several policy options at the federal and state levels could move the U.S. households. nation toward universal, comprehensive coverage and provide relief to U.S. families. These include: • expanding Medicaid in the 12 states that have yet to do so or providing a federal fallback option for people eligible in those states • enhancing and extending the ACA marketplace subsidies both for premiums and cost-sharing • allowing more people with unaffordable employer plans to purchase subsidized coverage through the marketplaces, possibly through a public plan commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 14 HOW WE CONDUCTED THIS STUDY The resulting weighted sample is representative of the approximately 193.5 million U.S. adults ages 19 to 64. The survey has an overall maximum margin The Commonwealth Fund Biennial Health Insurance Survey, 2020, was of sampling error of +/– 2.0 percentage points at the 95 percent confidence conducted by SSRS from January 14 through June 5, 2020. The survey level. As estimates get further from 50 percent, the margin of sampling error consisted of telephone interviews in English and Spanish and was conducted decreases. The RDD landline portion of the survey achieved a 7.7 percent among a random, nationally representative sample of 4,272 adults ages 19 response rate and the RDD cellular phone component achieved a 6.5 percent to 64 living in the continental United States. A combination of landline and response rate. cellular phone random-digit dial (RDD) samples was used to reach people. In We also report estimates from the 2010, 2012, 2014, 2016, and 2018 Commonwealth Fund Biennial Health Insurance Surveys. The surveys all, 400 interviews were conducted with respondents on landline telephones through 2016 were conducted by Princeton Survey Research Associates and 3,872 interviews were conducted on cellular phones. International using the same stratified sampling strategy that was used in The sample was designed to generalize to the U.S. adult population and 2018 and 2020 by SSRS. to allow separate analyses of responses from low-income households. In 2010, the survey was conducted from July 14 to November 30, 2010, Statistical results are weighted to correct for the stratified sample design, the among 3,033 adults ages 19 to 64; in 2012, the survey was conducted from overlapping landline and cellular phone sample frames, and disproportionate April 26 to August 19, 2012, among 3,393 adults ages 19 to 64; in 2014, the survey was conducted from July 22 to December 14, 2014, among 4,251 nonresponse that might bias results. The data are weighted to the U.S. adult adults ages 19 to 64; in 2016, the survey was conducted from July 12 to population by age, sex, race/ethnicity, education, household size, geographic November 20, 2016, among 4,186 adults ages 19 to 64; and in 2018, the region, population density, and household telephone use, using the U.S. survey was conducted from June 27 to November 11, among 4,225 adults Census Bureau’s 2019 Current Population Survey. ages 19 to 64. ESTIMATES OF U.S. UNINSURED RATES Current uninsured rate Survey [confidence interval] Population Time frame Sample frame 12.5% U.S. adults Commonwealth Fund Biennial Health Insurance Survey11 January–June 2020 Dual-frame, RDD telephone survey [11.2%, 13.9%] ages 19–64 13.7% U.S. adults Multistage area probability design; National Health Interview Survey (NHIS) (Jan.–June 2019)12 January–June 2019 [12.9%, 14.6%] ages 18–64 personal household interviews13 11.7% U.S. adults Probability-selected sample; Current Population Survey (CPS) (2019)14 January–December 2018 [11.4%, 12.0%] ages 19–64 personal and telephone interviews15 commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 15 REVISION TO THE 2018 UNDERINSURED ESTIMATE In the 2018 Biennial Survey, two nonresponse categories in a question used to gather income information (those earning more than $35,000) were recoded during questionnaire development without a corresponding adjustment to the created variable that underlies the underinsured measure. This error had an impact on our 2018 estimate and was discovered this year in our analysis of trend data on this measure. We are therefore revising the 2018 estimate as part of the release of this year’s survey. The consequences of this error in 2018 are below. The revised 2018 estimates are not statistically different from the reported estimates. Underinsured estimates, rates, full population of 19-to-64-year- old adults • The 2018 estimate was 22.6% [21.0, 24.2] • The corrected 2018 estimate is 21.3% [19.8, 22.9] • The 2020 estimate is 21.3% [19.7, 23.0] Underinsured estimates, millions, full population of 19-to-64- year-old adults • The 2018 estimate was 43.8 million [40.5, 47.1] • The corrected 2018 estimate is 41.4 million [38.2, 44.5] • The 2020 estimate is 41.1 million [37.8, 44.5] Underinsured estimates, rates, 19-to-64-year-old adults insured all year with private insurance • The 2018 estimate was 29.7 percent [27.3, 32.2] • The corrected 2018 estimate is 27.5 percent [25.2, 30.0] • The 2020 estimate is 27.6 percent [25.2, 30.1] commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 16 Table 1. Insurance Status by Demographics, 2020 (base: adults ages 19–64) Insured all year Uninsured Uninsured anytime in the last year Insured anytime NOTES all year Insured all year, Insured all year, in the Insured now, Uninsured Total last year (19–64) not underinsured underinsured had a gap now CI = confidence interval. The survey has an overall Point Point Point Point Point Point maximum margin of sampling CI CI CI CI CI CI estimate estimate estimate estimate estimate estimate error of +/– 2.0 percentage points at the 95 percent 145.6, 104.8, 37.8, 39.4, 16.2, 21.7, confidence level (CI). As Total (millions) 193.5 150.8 109.6 41.1 42.7 18.5 24.3 155.9 114.4 44.5 46.0 20.7 26.8 estimates get further from 76.3%, 54.7%, 19.7%, 20.5%, 8.4%, 11.2%, 50 percent, the margin of Percent distribution 100.0% 77.9% 56.7% 21.3% 22.1% 9.5% 12.5% sampling error decreases. 79.5% 58.6% 23.0% 23.8% 10.8% 13.9% “Insured all year” refers to Unweighted n 4,272 3,289 2,384 905 983 425 558 adults who were insured for the full year up to and Gender on the survey field date; Male 49 77 59 18 23 10 14 “Underinsured” defined Female 50 79 55 25 21 9 11 as insured all year but Age experienced one of the following: out-of-pocket 19–34 34 72 50 22 28 14 14 expenses, excluding 35–49 31 76 57 19 24 9 15 premiums, equaled 10% or 50–64 32 86 62 24 14 6 9 more of income; out-of- Race/Ethnicity pocket expenses, excluding premiums, equaled 5% Non-Hispanic White 59 84 61 23 17 8 9 or more of income if low Black 13 76 58 18 24 12 12 income (<200% of poverty); Latino 18 60 43 17 40 12 28 or deductibles equaled 5% Asian/Pacific Islander 4 81 59 22 19 11 8 or more of income; “Insured now, had a gap” refers to Other/Mixed 4 77 48 30 23 14 9 adults who were insured at Poverty status the time of the survey but Below 133% poverty 27 66 36 30 34 14 19 were uninsured at any point 133%–249% poverty 18 71 48 23 29 13 17 during the year before the 250%–399% poverty 18 82 60 21 19 8 10 survey field date; “Uninsured now” refers to adults who 400% poverty or more 31 90 74 16 10 5 4 reported being uninsured at Below 200% poverty 41 67 40 27 33 14 19 the time of the survey. 200% poverty or more 53 86 67 19 14 7 7 * At least one of the Fair/Poor health status, following health problems: 50 78 55 23 22 10 12 or any health problem* hypertension or high blood Adult work status pressure; heart failure or heart attack; diabetes; Not working 33 73 50 23 27 12 15 asthma, emphysema, or lung Full-time 54 82 62 19 18 8 10 disease; or high cholesterol. Part-time 13 74 50 24 26 9 17 ** Base: Full- and part-time Employer size** employed adults ages 19–64. 1–19 employees 23 62 42 20 38 12 26 20–49 employees 9 77 55 22 23 6 17 DATA 50–99 employees 8 79 54 25 21 9 13 Commonwealth Fund 100 or more employees 59 88 68 20 12 7 5 Biennial Health Insurance Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 17 Table 2. Insurance Status, 2010–2020 (base: adults ages 19–64) 2010 2012 2014 2016 2018 2020 Point Point Point Point Point Point CI CI CI CI CI CI estimate estimate estimate estimate estimate estimate Total (millions) 183.6 183.9 182.8 187.4 193.9 193.5 Unweighted n 3,033 3,393 4,251 4,186 4,225 4,272 NOTES CI = confidence interval. 69.7, 68.0, 69.7, 76.6, 76.1, 76.3, Insured all year 71.7 70.3 71.7 78.4 77.7 77.9 The survey has an overall 73.6 72.5 73.6 80.2 79.2 79.5 maximum margin of sampling error of +/– 2.0 percentage Insured all year, 53.6, 51.7, 52.8, 54.2, 54.4, 54.7, 55.8 54.2 55.0 56.5 56.3 56.7 points at the 95 percent not underinsured 57.9 56.7 57.2 58.7 58.2 58.6 confidence level (CI). As estimates get further from Insured all year, 14.4, 14.4, 15.1, 20.1, 19.8, 19.7, 50 percent, the margin of 15.9 16.1 16.7 21.9 21.3 21.3 underinsured 17.6 18.0 18.4 23.9 22.9 23.0 sampling error decreases. “Insured all year” refers to Uninsured 26.4, 27.5, 26.4, 19.8, 20.8, 20.5, adults who were insured 28.3 29.7 28.3 21.6 22.3 22.1 for the full year up to and anytime 30.3 32.0 30.3 23.4 24.0 23.8 on the survey field date; “Underinsured” defined Insured now, 7.0, 8.9, 11.3, 8.3, 8.9, 8.4, as insured all year but 8.1 10.4 12.6 9.5 10.0 9.5 had a gap 9.4 12.0 14.1 10.9 11.2 10.8 experienced one of the following: out-of-pocket 18.5, 17.5, 14.2, 10.7, 11.2, 11.3, expenses, excluding Uninsured now 20.2 19.3 15.7 12.0 12.4 12.5 22.0 21.3 17.2 13.5 13.6 13.9 premiums, equaled 10% or more of income; out-of- pocket expenses, excluding premiums, equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income; “Insured now, had a gap” refers to adults who were insured at the time of the survey but were uninsured at any point during the year before the survey field date; “Uninsured now” refers to adults who reported being uninsured at the time of the survey. DATA Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 18 Table 3. Underinsured Indicators, 2010–2020 (base: adults insured all year, ages 19–64) 2010 2012 2014 2016 2018 2020 Percent distribution 100% 100% 100% 100% 100% 100% Unweighted n 2,206 2,417 3,032 3,268 3,254 3,289 Out-of-pocket medical expenses equal 10% or more 15% 15% 13% 17% 14% 16% of family annual income Out-of-pocket medical expenses equal 5% or more 12% 10% 12% 13% 11% 11% of income if low income* Cumulative percent using two indicators above 19% 18% 18% 21% 19% 20% Deductible equals 5% or more of income 6% 8% 11% 12% 13% 12% Cumulative percent using all three indicators 22% 23% 23% 28% 27% 27% NOTES * “Low income” defined as <200% of the federal poverty level. DATA Commonwealth Fund Biennial Health Insurance Surveys (2010, 2012, 2014, 2016, 2018, 2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 19 Table 4. Deductibles and Benefits Covered, by Insurance Adequacy and Income, 2020 (base: adults ages 19–64 who were privately insured* and reported their deductible level for their insurance plan) Total privately insured adults, Total privately insured adults Total privately Total privately insured all year insured insured adults, adults Below 200% 200% poverty insured all year Not Underinsured^ poverty or more underinsured Percent distribution 100% 18% 76% 100% 72% 28% Unweighted n 2,246 412 1,702 2,027 1,454 573 Annual deductible per person No deductible 24 37 20 23 28 10 $1–$99 4 6 4 4 5 2 $100–$499 12 16 10 12 14 7 NOTES $500–$999 15 12 16 15 17 9 * Private coverage includes $1,000–$2,999 28 19 31 28 27 32 adults enrolled in employer insurance or coverage $3,000–$4,999 9 5 10 10 6 18 through the individual market. $5,000 or more 8 5 9 8 2 23 ^ “Underinsured” defined as insured all year but experienced one of the Insurance covers all or part of following: out-of-pocket the following health care needs:^^ expenses, excluding premiums, equaled 10% or Dental care 82 73 85 83 85 79 more of income; out-of- pocket expenses, excluding premiums, equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. ^^ Includes all respondents with private coverage, including those who did not report their income or deductible level for their insurance plan. DATA Commonwealth Fund Biennial Health Insurance Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 20 Table 5. Medical Bill Problems, by Insurance Continuity, Insurance Adequacy, and Deductible Level, 2020 (base: adults ages 19–64) Deductible levels among adults with Insurance continuity private coverage who were insured all year not underinsured* who were insured private insurance Insured all year, Insured all year, during the year $1,000–$2,999 $3,000 or more $1,000 or more All adults with No deductible underinsured Total 19–64 Uninsured all year** $1–$999 <$1,000 Insured all year Percent distribution 100% 78% 57% 21% 22% 100% 23% 31% 28% 18% 54% 46% Unweighted n 4,272 3,289 2,384 905 983 2,027 449 617 592 369 1,116 1,007 Medical bill problems in past year Had problems paying or unable to pay medical bills 24 20 14 34 38 19 11 14 25 28 13 25 Contacted by collection agency for unpaid medical bills 14 11 8 19 25 10 7 9 13 14 8 13 NOTES Had to change way of life to pay bills 12 9 6 18 21 9 5 8 13 12 6 12 * “Underinsured” defined Any of above three bill problems 29 25 19 40 46 23 14 19 30 31 17 30 as insured all year but Medical bills/debt being paid off over time 23 22 17 35 27 24 14 21 31 34 17 32 experienced one of the Any bill problem or medical debt 37 33 27 49 52 33 21 29 40 42 26 41 following: out-of-pocket expenses, excluding Base: Any medical debt premiums, equaled 10% or Unweighted n 1,011 746 408 338 265 516 65 140 180 131 211 326 more of income; out-of- pocket expenses, excluding How much are the medical bills that are being paid off over time? premiums, equaled 5% Less than $2,000 43 43 53 30 43 42 — 50 43 25 51 37 or more of income if low $2,000 to less than $4,000 21 22 18 28 18 24 — 22 25 31 19 26 income (<200% of poverty); $4,000 to less than $8,000 17 17 15 21 18 19 — 14 17 27 15 20 or deductibles equaled 5% or $8,000 to less than $10,000 4 4 3 6 2 3 — 3 2 6 3 4 more of income. $10,000 or more 12 11 8 14 14 10 — 9 12 9 9 11 ** Limited to adults who are Was this for care received in past year or earlier? aware of their deductible amount. Adults who were Past year 46 47 46 48 45 49 — 41 53 48 45 52 not aware of their deductible Earlier year 45 44 47 40 47 42 — 51 36 41 47 36 amount were then asked if Both 8 9 7 11 7 9 — 6 11 11 6 11 their deductible was less than $1,000 or $1,000 or more. 96 Base: Any bill problem or medical debt additional adults were able to Unweighted n 1,630 1,117 642 475 513 688 97 192 236 163 302 419 estimate if their deductible Percent reporting that the following happened in the past two was less than $1,000 or $1,000 years because of medical bills: or more. Received a lower credit rating 40 38 33 46 44 35 — 32 38 38 31 37 ^ More than one person with Used up all of savings 37 35 26 48 41 35 — 30 40 36 31 38 medical bill problems and one Took on credit card debt 31 32 30 35 28 36 — 28 43 40 29 42 person uninsured and the Unable to pay for basic necessities (food, heat, or rent) 26 22 18 28 33 18 — 19 18 16 18 17 other insured. Delayed education or career plans 20 17 15 20 26 19 — 15 21 25 15 22 — Sample size too small to Took out a mortgage against your home or took out a loan 11 10 7 15 12 12 — 8 14 12 11 13 show results. Had to declare bankruptcy 3 2 3 2 4 2 — 4 1 2 4 1 Insurance status of person/s at time care was provided DATA Insured at time care was provided 67 82 81 84 34 88 — 84 93 90 83 92 Commonwealth Fund Uninsured at time care was provided 28 14 16 12 57 9 — 11 5 8 14 6 Biennial Health Insurance Other insurance combination^ 2 1 0 1 4 1 — 1 0 1 1 1 Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 21 Table 6. Access Problems, by Insurance Continuity, Insurance Adequacy, and Deductible Level, 2020 (base: adults ages 19–64) Deductible levels among adults with Insurance continuity private coverage who were insured all year not underinsured* who were insured private insurance Insured all year, Insured all year, during the year $3,000 or more $1,000 or more $1,000–$2,999 All adults with No deductible underinsured NOTES Total 19–64 Uninsured all year** $1–$999 <$1,000 * “Underinsured” defined Insured all year as insured all year but experienced one of the following: out-of-pocket expenses, excluding Percent distribution 100% 78% 57% 21% 22% 100% 23% 31% 28% 18% 54% 46% premiums, equaled 10% or Unweighted n 4,272 3,289 2,384 905 983 2,027 449 617 592 369 1,116 1,007 more of income; out-of- pocket expenses, excluding premiums, equaled 5% Access problems in past year or more of income if low Went without needed care in past year because of costs: income (<200% of poverty); or deductibles equaled 5% or Did not fill prescription 21 17 14 25 34 17 13 13 20 26 13 22 more of income. Skipped recommended test, treatment or follow-up 19 15 10 26 33 16 9 11 21 26 10 22 ** Limited to adults who are Had a medical problem, did not visit doctor or clinic 21 15 12 24 41 16 8 11 22 27 9 23 aware of their deductible amount. Adults who were Did not get needed specialist care 15 12 9 20 26 12 7 10 13 23 8 17 not aware of their deductible At least one of four access problems because of cost 35 29 23 43 56 30 21 22 37 43 21 38 amount were then asked if their deductible was less than $1,000 or $1,000 or more. 96 Preventive care additional adults were able to Regular source of care 89 93 93 93 73 92 91 93 93 93 92 92 estimate if their deductible was less than $1,000 or Blood pressure checked in past two years ¥ 90 94 93 96 78 94 90 94 96 96 92 96 $1,000 or more. Received mammogram in past two years (females age 40+) 69 75 75 73 39 78 79 79 77 75 79 76 ¥ In past year if respondent Received pap test in past three years (females ages 21–64) 72 74 75 74 63 76 68 74 83 79 71 82 has hypertension or high Received colon cancer screening in past five years (age 50+) 60 65 64 67 36 64 67 65 62 64 65 64 blood pressure. Cholesterol checked in past five years ¥¥ 72 78 78 76 50 81 77 79 85 82 78 83 ¥¥ In past year if respondent has hypertension or high Seasonal flu shot in past 12 months 46 50 50 49 30 51 50 50 55 49 51 52 blood pressure, heart disease, or high cholesterol. Access problems for people with health problems ^ Base: Respondents Unweighted n 2,468 1,952 1,351 601 516 1,073 214 327 335 197 560 559 with at least one of the following health problems: Skipped doses or not filled a prescription for medications for the hypertension or high blood 20 15 9 29 39 15 14 9 18 22 11 18 health problem(s)^ . . . because of the cost of the medicines? pressure; heart failure or heart attack; diabetes; asthma, emphysema, or lung disease; high cholesterol; or depression, anxiety, or other mental health problem. DATA Commonwealth Fund Biennial Health Insurance Survey (2020). commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 22 NOTES 1. We revised our 2018 estimate of underinsured adults, after identifying a Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019); coding error in the measure for that year. The revision changes the 2018 Sara R. Collins et al., Americans’ Views on Health Insurance at the End of a estimate from 22.6 percent to 21.3 percent, which is not a statistically Turbulent Year (Commonwealth Fund, Mar. 2018); and Sara R. Collins et al., significant difference. (See “Revision to the 2018 Underinsured Estimate” for How the Affordable Care Act Has Improved Americans’ Ability to Buy Health detail.) The 2020 estimate is unchanged at 21.3 percent, but with the margin Insurance on Their Own: Findings from the Commonwealth Fund Biennial of sampling error, could range from 19.7 to 23 percent. Health Insurance Survey, 2016 (Commonwealth Fund, Feb. 2017). 2. The Biennial Survey has a maximum margin of sampling error of +/– 2 percent 8. Congressional Budget Office, “Interim Economic Projections for 2020 and at the 95 percent confidence interval. As estimates get further from 50 2021,” May 2020. percent in either direction, the margin of sampling error decreases. This is why the estimated uninsured rate has a smaller margin of sampling error. 9. Jessica Banthin et al., Changes in Health Insurance Coverage Due to the COVID-19 Recession (Urban Institute, July 2020). 3. Analysis of the 2019 Current Population Survey by Sherry Glied and Ougni Chakraborty of New York University for the Commonwealth Fund. 10.Linda J. Blumberg et al., Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer (Commonwealth Fund and Urban 4. Commonwealth Fund analysis of the 2020 QHP landscape data, HealthCare. Institute, Oct. 2019). gov, Apr. 2020. 11.Commonwealth Fund Biennial Health Insurance Survey, 2020. 5. Institute of Medicine, Hidden Costs, Value Lost: Uninsurance in America (National Academies Press, 2003). Noncoverage-related barriers to care 12.Robin A. Cohen et al., Health Insurance Coverage: Early Release of Estimates include structural racism in the health care system, lack of provider capacity from the National Health Interview Survey, January–June 2019 (National such as in rural areas, and, most recently because of the pandemic, fear. Center for Health Statistics, May 2020). 6. Sherry A. Glied, Sara R. Collins, and Saunders Lin, “Did the Affordable Care 13.National Center for Health Statistics, “About the National Health Interview Act Lower Americans’ Financial Barriers to Health Care?,” Health Affairs Survey,” updated Jan. 16, 2019. 39, no. 3 (Mar. 2020): 379–86; Ezekiel J. Emanuel and Abbe R. Gluck, The 14.Edward R. Berchick, Jessica C. Barnett, and Rachel D. Upton, Health Insurance Trillion Dollar Revolution (Public Affairs, 2020); and David Blumenthal, Sara Coverage in the United States: 2018 (U.S. Census Bureau, Nov. 2019). R. Collins, and Elizabeth J. Fowler, “The Affordable Care Act at 10 Years — Its Coverage and Access Provisions,” New England Journal of Medicine, 15.U.S. Census Bureau, Design and Methodology: Current Population Survey — published online Feb. 26, 2020. America’s Source for Labor Force Data, Technical Paper 77 (Census Bureau, Oct. 2019). 7. Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do They Lack Coverage? Findings from the Commonwealth Fund commonwealthfund.org Survey Brief, August 2020 U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability 23 ABOUT THE AUTHORS Gabriella N. Aboulafia is a program assistant in the Health Care Sara R. Collins, Ph.D., is vice president for Health Care Coverage and Coverage and Access program at the Commonwealth Fund. Ms. Access at the Commonwealth Fund. An economist, Dr. Collins directs the Aboulafia is responsible for providing daily support for the program with Fund’s program on insurance coverage and access. She also directs the responsibilities ranging from administration and grants management Fund’s research initiative on Tracking Health System Performance. Since to tracking health reform policy developments and working on research joining the Fund in 2002, Dr. Collins has led several national surveys on projects. She graduated with distinction with a B.S. in public health from health insurance and authored numerous reports, issue briefs, and journal the University of North Carolina, Gillings School of Global Public Health in articles on health insurance coverage and policy. She has provided invited May 2019. testimony before several Congressional committees and subcommittees. Prior to joining the Fund, Dr. Collins was associate director/senior research ACKNOWLEDGMENTS associate at the New York Academy of Medicine. Earlier in her career, she The authors thank Robyn Rapoport, Rob Manley, and Jazmyne Sutton was an associate editor at U.S. News & World Report, a senior economist of SSRS, and David Blumenthal, Liz Fowler, Michelle Doty, Jesse at Health Economics Research, and a senior health policy analyst in the Baumgartner, Barry Scholl, Chris Hollander, Deborah Lorber, Jen New York City Office of the Public Advocate. Dr. Collins holds a Ph.D. in Wilson, and Paul Frame, all of the Commonwealth Fund. economics from George Washington University. Munira Z. Gunja, M.P.H., is senior researcher in the Health Care Editorial support was provided by Deborah Lorber. Coverage and Access program at the Commonwealth Fund. Ms. Gunja joined the Fund from the U.S. Department of Health and Human Services in the office of the Assistant Secretary for Planning and Evaluation For more information about this brief, please contact: (ASPE), Division of Health Care Access and Coverage, where she received Sara R. Collins, Ph.D. the Secretary’s Award for Distinguished Service. Before joining ASPE, Vice President, Health Care Coverage, Access, and Tracking she worked for the National Cancer Institute where she conducted The Commonwealth Fund data analysis for numerous studies featured in scientific journals. Ms. srccmwf.org Gunja graduated from Tulane University with a B.S. in public health and international development and an M.P.H. in epidemiology. commonwealthfund.org Survey Brief, August 2020 About the Commonwealth Fund 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, and people of color. 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.