DATA BRIEF SEPTEMBER 2022 S Waren e-luone)e U.S. Health Insurance in 2022 Findings from the Commonwealth Fund Biennial Health Insurance Survey Sara R. Collins Lauren A. Haynes Relebohile Masitha The number and percentage of Americans lacking health insurance is falling to historic lows, thanks to policy changes aimed at helping people get and stay covered during the COVID-19 pandemic, as well as the recent decision by several states to expand Medicaid eligibility under the Affordable Care Act. Still, a large number of people in the United States remain uninsured or inadequately covered, a situation that will worsen when some temporary pandemic measures expire. In this data brief, we present findings from the Commonwealth Fund Biennial Health Insurance Survey to describe the state of Americans' health insurance coverage in 2022. We answer the following questions: e How many people experience gaps in their coverage, and how long are those gaps? e How many people have insurance but are underinsured? e Are health care costs affecting people's decision to get needed care? e Are these costs leaving people with medical bills they cannot pay? For the survey, SSRS interviewed a nationally representative sample of 8,022 adults age 19 and older between March 28 and July 4, 2022. This analysis focuses on 6,301 respondents under age 65. Note that because the 2022 edition of the Biennial Health Insurance Survey employed a new sampling method and was conducted mostly online rather than by telephone, as in the past, we are unable to present data on trends in responses over the years. To learn more about our survey, including the revised sampling method, see "How We Conducted This Survey." The é2 Commonwealth Fund The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey SURVEY HIGHLIGHTS Forty-three percent of working-age adults were inadequately insured in 2022. These individuals were uninsured (9%), had a gap in coverage over the past year (11%), or were insured all year but were underinsured, meaning that their coverage didn't provide them with affordable access to health care (23%). Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured. Forty-six percent of respondents said they had skipped or delayed care because of the cost, and 42 percent said they had problems paying medical bills or were paying off medical debt. Half (49%) said they would be unable to pay for an unexpected $1,000 medical bill within 30 days, including 68 percent of adults with low income, 69 percent of Black adults, and 63 percent of Latinx/Hispanic adults. Sixty-eight percent of Democrats, 55 percent of Independents, and 46 percent of Republicans said President Biden and Congress should make health care costs a top priority in the coming year. commonwealthfund.org WHO IS UNDERINSURED? For our analysis, people who are insured all year are considered to be underinsured if their coverage doesn't enable affordable access to health care. That means at least one of the following statements applies: e Out-of-pocket costs over the prior 12 months, excluding premiums, were equal to 10 percent or more of household income. e Out-of-pocket costs over the prior 12 months, excluding premiums, were equal to 5 percent or more of household income for individuals living under 200 percent of the federal poverty level ($27,180 for an individual or $55,500 for a family of four in 2022), e The deductible constituted 5 percent or more of household income. Because out-of-pocket costs occur only if a person uses their insurance to obtain health care, we also consider the deductible when determining whether someone is underinsured. The deductible is an indicator of the financial protection that a health plan offers as well as the risk of incurring costs before a person gets health care. We do not, however, consider the risk of incurring high costs owing to an insurance plan's other design features, such as out-of-pocket maximums, copayments, or uncovered services, since we do not ask about these features in the survey. Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey More than two of five working-age adults are inadequately insured. By mid-2022, 43 percent of adults ages 19 to 64 had inadequate insurance coverage, meaning they were uninsured at the time of the survey (9%), had coverage when surveyed but experienced a time without coverage in the past year (11%), or had continuous 23% coverage over the past year but were underinsured Insured all year, but (23%) (see the box, "Who Is Underinsured?") (Table 1). underinsured Percentage of adults ages 19-64, by insurance coverage Status within the past 12 months 57% Insured all year, not underinsured Our uninsured estimate is lower than the rate reported by the Centers for Disease Control and Prevention for this age group in the first quarter of 2022 (11.8%, with 11% a confidence interval of 10.3% to 13.3%) and recently Insured now, with by the U.S. Census Bureau for all of 2021 (11.6%, witha coverage gap confidence interval of 11.3% to 11.9%). (See "Estimates of U.S. Uninsured Rates" for detail.) U.S. uninsured rates have been declining as a result of historically high enrollment in Medicaid and in marketplace plans, driven primarily by pandemic-related policy changes! 9% Our survey estimate may indicate further gains through Uninsured now . ' the first half of 2022. But while smaller surveys like ours can provide leading indications of the overall direction of U.S. uninsured rates, federal surveys, given their large sample sizes, will always provide the most reliable point estimates. It's important to note that because our estimated uninsured rate has a margin of error of +/- .9 percent, the true estimate falls between 8 percent and 9.9 percent Notes: "Insured all year, but 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 household income; out-of-pocket costs, excluding premiums, equaled 5% or more of household income if low-income (<200% of poverty); or deductibles equaled 5% or more of household income. "Insured now, with coverage gap" refers to adults who 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. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey People who were uninsured for a year or longer were disproportionately young, Latinx/Hispanic, poor, sicker, and living in the South. Percentage distribution of adults ages 19-64 who were uninsured for one or more years, by age, race, income, health status, and region* 19-34 35-49 50-64 Black Latinx/Hispanic White Below 200% FPL 200% FPL and above Sicker Not sicker Northeast Midwest South West cheb) 32% 18% 15% RoW CYA vay VA 59% Cu 9% noe) er 20% 4 Base: Adults ages 19-64 who were insured but had a gap in coverage in the past year or were uninsured at the time of the survey. Notes: FPL = federal poverty level. "Sicker" includes respondents with fair or poor health status, or at least one of the following chronic health conditions: hypertension or high blood pressure; heart failure or heart attack; diabetes; asthma, emphysema, or lung disease; or high cholesterol. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Among the world's high-income countries, the U.S. stands alone for the complexity of its health insurance system. Americans are eligible for different types of coverage depending on whether their employer offers it, what their income level is, and what their age and health care needs are. There is no national autoenrollment mechanism for people who don't have employer coverage; they must know which program they are eligible for and then sign up for coverage. Consequently, people can experience insurance gaps at different points in their lives, like when they lose a job. In the survey, 20 percent of respondents either were uninsured at the time of the survey or were insured but reported a coverage gap in the prior year. The majority who were insured when surveyed but had had a coverage gap reported a gap of relatively short duration (data not shown). But the vast majority (79%) of people who were uninsured when surveyed had been without any coverage for a year or longer (Table 2). Across both groups, people who lacked coverage for a year or more were disproportionately poor, young, and Latinx/Hispanic; in fair or poor health or living with a chronic health problem; and/or living in the South. The Affordable Care Act (ACA) plugged holes in the system through its insurance market reforms, including a ban on excluding people from coverage because of a preexisting health condition; its subsidies for marketplace plans; and its expansion of Medicaid eligibility. But because the law was built on the existing insurance system, people can still experience coverage gaps. In addition, many people experience chronic, structural uninsurance: these include people who fall into the Medicaid coverage gap in the 12 states that have yet to expand Medicaid as well as undocumented immigrants, who are not eligible for federally subsidized coverage. These individuals still have no access to affordable coverage. Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Premium costs are the main reason people give for not buying marketplace or individual market coverage or for dropping their coverage. What was the MAIN reason you lost or "4 dropped coverage? You couldn't afford what you had to pay You missed the deadline to reenroll Your plan was no longer being offered You didn't think you needed it any longer You were not satisfied with your plan What was the MAIN reason you did not *, buy a plan? The plan was too expensive You found out you were not eligible to buy a plan The deductibles and/or copayments were too high You gained coverage through another source You found the enrollment process difficult BASE: Percentage of adults ages 19-64 who were uninsured at the time of the survey or who were insured but had a gap in coverage in the past 12 months, and previously had marketplace coverage Cty / 8% T% at AB ER a BASE: Percentage of adults ages 19-64 who tried to buy a plan in the individual market or marketplaces in the past three years but never bought a plan 63% oh) ac T% Ry x Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org To find out if they are eligible for one of the ACA's subsidized marketplace plans or for Medicaid, at any time of year Americans can go to the federal website, HealthCare.gov, enter their income and address, and see what their coverage options are. But some people who are uninsured or have experienced a coverage gap do not sign up for either Medicaid or marketplace plan. In addition, some people who search for individual- market coverage or marketplace plan never end up enrolling in one. According to our survey, not being able to afford plan premiums was the reason most often cited for not enrolling in individual market or marketplace coverage or losing such coverage. Among uninsured people or those with a coverage gap who previously had Medicaid, loss of eligibility was the main reason most often cited (data not shown). Open enrollment through the marketplaces lasts from November 1 through January 15, but people who lose their insurance, from any source, are generally eligible for a special enrollment period outside those dates. We asked people who had coverage through an employer whether they were aware they were eligible to enroll in a marketplace plan at any time if they lost their coverage. Fifty-six percent of people with employer coverage who had spent some time uninsured during the year were not aware of this enrollment flexibility (data not shown). Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Two of five people enrolled in individual-market or marketplace plans and three of 10 in employer plans were underinsured; people with low income and health problems were most at risk. Percentage of adults ages 19-64 insured all year who were underinsured" Among people who were insured all year in private health plans, 29 percent of those with coverage Individual market and marketplaces Employer through an employer and 44 percent with individual market or marketplace coverage were underinsured. This means that their coverage wasn't enough to enable affordable access to health care: either because their reported out-of-pocket costs, excluding premiums, and/or deductibles were high relative to their income (see the box, "Who Is Underinsured?"). People with low income, whether covered by employer insurance or by an individual-market or marketplace plan, were underinsured at higher rates than people with higher income (Table 3). Enrollees with health problems also were at higher risk of 52% Eta or | = a] I ra ra a] = 5 oD : : : eS a g ¢& 3 a @ g being underinsured than healthier people, though F S + a cA FF se + ao aa : sos : x 2 s Ss 4 differences were not significant for those covered in i 8 2 i 8 2 the individual market and marketplaces. The high cost sharing people face in many employer, Poverty status Health status Poverty status Health status cass g & Peop y : P y : individual-market, and marketplace plans is primarily driven by the prices that providers, especially hospitals, charge to commercial insurers and employers. These prices are the highest in the world? 4 Base: Adults ages 19-64 who were insured all year and had individual market coverage (including marketplace plans) And consumers bear the burden, in the cost of their or employer-sponsored insurance at the time of the survey. insurance, the size of their deductibles, their out-of- Notes: "Underinsured" refers to adults who were insured all year but experienced one of the following: out-of-pocket pocket maximums, and their copayments. costs, excluding premiums, equaled 10% or more of household income; out-of-pocket costs, excluding premiums, equaled 5% or more of household income if low-income (<200% of poverty); or deductibles equaled 5% or more of household income. Coverage type given at time of survey; respondent was insured all year but may not have had same insurance for full year. FPL = federal poverty level. "Sicker" includes respondents with fair or poor health status, or at least one of the following chronic health conditions: hypertension or high blood pressure; heart failure or heart attack; diabetes; asthma, emphysema, or lung disease; or high cholesterol. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Cost-related problems getting needed care were reported at the highest rates by adults who were underinsured or lacked continuous coverage. Percentage of adults ages 19-64 who in the past year had any of four problems accessing care because of cost Lack of good health insurance is a barrier to people's ability to get timely health care. Sixty-one percent =a Total mlnsured all year, not underinsured mInsured all year, underinsured Uninsured any time inthe past year of working-age adults who were underinsured and 71 percent of those who lacked continuous Four access problems coverage said they had avoided getting needed health care because of the cost of that care. This included not going to the doctor when sick, skipping a recommended follow-up visit or test, not seeing a specialist when recommended, or not filling a prescription (Table 4). While survey respondents reported delaying health care for treatment of new health conditions and for ongoing health problems - and sometimes both - somewhat more people said that the care they avoided was related to ongoing health problems (Table 4). At least one of four Had a medical Skipped Did not get needed Did not fill access problems problem, did not recommended specialist care prescription because of cost visit doctor or clinic test, treatment, or follow-up 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 household income; out-of-pocket costs, excluding premiums, equaled 5% or more of household income if low-income (<200% of poverty); or deductibles equaled 5% or more of household income. "Uninsured any time in the past year" refers to adults who were either uninsured at the time of the survey or were insured but spent some time uninsured in the past year. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Up to one-quarter of people with chronic health problems said they had not filled a prescription in the past year for their health condition because of the cost. Percentage of adults ages 19-64 with a chronic health condition who skipped or didn't fill a prescription in the past year because of the cost* 9 PAW 25% 23% vA) Asthma, Diabetes Heart failure Depression, Hypertension High cholesterol emphysema, or or heart attack anxiety, or other lung disease mental health condition 4 Base: Adults ages 19-64 with a chronic health condition. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org As much as a quarter of people with chronic health problems like diabetes said that out-of-pocket costs for prescription drugs to treat those problems had caused them to skip doses or not fill a prescription for the condition(s) they indicated. Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Medical bill problems or debt were reported at the highest rates by adults who were underinsured or lacked continuous coverage. Percentage of adults ages 19-64 who had medical bill or debt problems in the past year Americans have amassed billions of dollars in medical debt as a consequence of inadequate insurance coverage. =Total mInsured all year, not underinsured mInsured all year, underinsured m= Uninsured any time in the past year There is an estimated $88 billion of medical debt on consumer credit records, accounting for 58 percent of Types of bill or debt problems all debt-collection entries on credit reports - by far the largest single source of debt in collections.' This estimate Oa 10) : : : ~ does not include debt people owe directly to providers. In our survey, 30 percent of working-age adults reported that they had problems paying medical bills over the past year, and one-quarter said that they were paying off medical debt over time. The share of those with medical debt rose to more than one-third among people who were underinsured or lacked continuous coverage. Of people reporting medical debt, more than half (56%) said the amount was $2,000 or more (Table 5). We also found out that more than 30 percent of adults who were underinsured or who lacked continuous At least one of four Had problems Contacted by Had to change Medical bills/debt coverage said they had been contacted by a collection medical bill problems paying orunable to collection agency way of life being paid bout id medical bills. While th or or medical debt pay medical bills for unpaid medical to pay bills over time agency about unpaid medical bills. While the majority bills of adults said that the bills in collection were those they could not afford to pay, one-quarter (24%) said the bills had been the result of a billing mistake. About one-quarter of adults who were underinsured or lacked continuous coverage said they had to change their way of life to pay their medical bills. Nearly half of adults with any medical bill problem or with medical debt said their issue was related to a surprise bill: they received care at an in-network hospital Notes: "Underinsured" refers to adults who were insured all year but experienced one of the following: out-of-pocket but were billed by a doctor there who was not in their costs, excluding premiums, equaled 10% or more of household income; out-of-pocket costs, excluding premiums, , : equaled 5% or more of household income if low-income (<200% of poverty); or deductibles equaled 5% or more of plan snetwork (Table 5). The No Surprises Act has household income. "Uninsured any time in the past year" refers to adults who were either uninsured at the time of the outlawed surprise bills such as these, but the timeframe survey or were insured but spent some time uninsured in the past year. covered by the survey's questions included the period Data: Commonwealth Fund Biennial Health Insurance Survey (2022). before the law went into effect in January 2022 commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Hospital inpatient and outpatient care were the primary source of people's medical bill problems. Percentage of adults ages 19-64 who had medical bill or debt problems* Problems with paying medical bills and debt stemmed most frequently from inpatient or @) What type of care were your bills for? outpatient hospital visits. The care people received that resulted in bill problems was split equally among treatment for new health conditions and for ongoing conditions (Table 5). 10% Hospital Emergency room Doctor's office Ambulance Dental care Diagnostic inpatient or visit visit testing outpatient care 4 Base: Respondenis 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: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey People who had problems paying medical bills or were paying off medical debt experienced long-term financial consequences. Percentage of adults ages 19-64 who had medical bill or debt problems* People experienced both short- and long-term financial consequences from medical bill problems or (2) Have any of the following happened in the past two years because of medical bills? medical debt. About two of five adults who reported any medical bill problem or medical debt received a lower credit rating because of problems paying these bills, took on credit card debt to pay them, and/or used up all their savings to pay them. zat 39% KYA/) 26% Pal) to Received a Taken on Used up all Been unable Delayed Taken outa Had to declare lowercredit creditcard yoursavings topayfor educationor mortgage bankruptcy rating debt basic careerplans against your necessities home or taken like food, heat, out a loan or rent 4 Base: Respondenis 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: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey Half of adults would not be able to cover an unexpected $1,000 medical bill within 30 days; people of color and people with low income were the least likely to have funds. Percentage of adults ages 19-64 who said they would be unable to pay an unexpected The average insurance deductible for employer medical bill of $1,000 within 30 days, by income and race/ethnicity health plans with single coverage is more than $1,000 ($1,434 for all covered workers in 2021), and it's more than $2,000 ($2,825) for HealthCare.gov marketplace plans.' Out-of-pocket maximums average $4,272 for single coverage in employer plans and range up to $8,700 in marketplace plans.' These plan features <200% FPL Ly leave people with considerable cost exposure in case of a sudden illness or accident. All 49% 200%-399% FPL LL Half of survey respondents said that they would 400%+ FPL atk not have the money to cover an unexpected $1,000 medical bill within 30 days. Rates were even higher for specific groups: 68 percent for people with low income, 69 percent for Black adults, and 63 percent Black Su for Latinx/Hispanic adults. Latinx/Hispanic KL White ZU Note: FPL = federal poverty level. Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey The public is divided along partisan lines on what should be the top health care priorities for the president and Congress, but there is more agreement on lowering health care costs. Percentage of adults ages 19-64 who said each health care issue should be a top priority When asked about their top health care policy priorities for the president and Congress, survey Over the next 12 months, how much of a priority should each of the following be for the respondents were divided along partisan lines. The president and Congress? closest Democrats, Republicans, and Independents came to agreement was on the need to lower the cost of health care. Ensuring everyone has coverage, controlling COVID-19, and preparing for future pandemics were viewed as top priorities among a large majority of Democrats but fewer Independents and Republicans. mDemocrat mlndependent mRepublican 68% We 69% 55% tou) aan rr ky Lowering the cost of Ensuring that everyone _ Getting the COVID-19 Protecting people from health care has health insurance pandemic under control - future pandemics like COVID-19 Data: Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey CONCLUSION AND POLICY RECOMMENDATIONS The number of uninsured people in the U.S. has fallen by nearly half since the ACA was signed into law.' Coverage gains over the past two years have been achieved through the American Rescue Plan Act's enhanced marketplace subsidies and through the Families First Coronavirus Response Act's requirement that states keep people enrolled in Medicaid until the end of the public health emergency in exchange for enhanced federal matching funds.' Both provisions, coupled with increased outreach and advertising as well as state and federal extensions of open enrollment periods, drove enrollment in the marketplaces and Medicaid to record highs. But the end of the public health emergency, expected in 2023, will trigger a massive effort by states to redetermine Medicaid enrollees' eligibility, a process that could leave many uninsured. The findings of this survey point to two areas of policy change needed to protect and build on recent coverage gains and improve the quality of coverage. Below are some options for policymakers to consider. Covering All Americans, and Keeping Them Covered e The Inflation Reduction Act of 2022 extended the enhanced marketplace plan subsidies for three years. Congress can make them permanent. Our survey shows just how much consumers weigh the cost of premiums when deciding whether to enroll and stay enrolled in marketplace plans. e Congress could require that states conduct Medicaid eligibility redeterminations gradually, and it could phase down enhanced Medicaid matching funds rather than eliminate them immediately at the end of the public health emergency. This would help states transition people to new coverage and prevent erroneous terminations of Medicaid coverage. commonwealthfund.org © Congress could provide a federal fallback option for Medicaid- eligible people in states that have yet to expand their program; this could reduce the number of uninsured people in those states by an estimated 1.9 million.' The Urban Institute estimates that in those states, Black residents would see the biggest gains, with their uninsured rates falling by 27 percent. e Congress could make it easier for adults to stay on Medicaid by allowing states to maintain continuous eligibility, without the need to apply for a federal waiver. States currently have this option for children enrolled in Medicaid and CHIP; those implementing it have lowered their child uninsured rates." ® The Biden administration's enhanced outreach and enrollment efforts during the pandemic could be maintained and expanded." ¢ Congress could allow people to autoenroll in comprehensive health coverage, a strategy that has the potential to move the nation to near- universal coverage." Improving Insurance Design and Protecting Consumers from Medical Debt e The Biden administration or Congress could place limits on or ban short-term insurance plans and other coverage that doesn't comply with ACA benefit requirements. Consumers who enroll in these skimpy policies are often exposed to catastrophic medical costs.% By drawing healthier people out of the individual market and the marketplaces, these policies also have increased premiums for people who remain." e Congress could rein in deductibles and out-of-pocket costs in marketplace plans by enhancing cost-sharing reduction subsidies and Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey changing the benchmark plan in the ACA marketplaces from silver to gold, which offers better financial protection. Not only would these policies reduce the number of Americans who are underinsured, but these improvements could lower the number of people without insurance by 1.5 million.' e States, which regulate their fully insured employer markets, could use rate regulation to limit growth in premiums and cost sharing, as Rhode Island has." They could also explore other policy options to improve employer coverage, just as many states did prior to the ACA's passage in requiring coverage of young adults on their parent's plans." e The Biden administration recently launched new actions to protect consumers from being financially harmed by medical debt, including scrutinizing providers' bill collection practices." Congress could reinforce those actions by requiring providers to allow debt repayment grace periods following illness or during appeals processes; banning egregious hospital practices such as suing patients, garnishing their wages, or placing liens on homes; and a ban or limits on charging interest." e Federal and state policymakers could address the high health care prices driving up premiums and deductibles, such as by creating new public insurance options." The primary purpose of health insurance is to help people get health care in a timely fashion and protect them from catastrophic costs in the event of serious illness. Insurance fills these needs when coverage is continuous and comprehensive. While the ACA helped the U.S. make great strides toward better health coverage, the job is not done. commonwealthfund.org HOW WE CONDUCTED THIS SURVEY With this year's survey, the Commonwealth Fund introduces a new baseline. Historically, the Commonwealth Fund Biennial Health Insurance Survey was conducted exclusively using phone administration via stratified random- digit dial (RDD) phone sample. This year, however, we shifted to a hybrid sample design that utilized stratified address-based sample (ABS), combined with SSRS Opinion Panel, and prepaid cell phone sample. Other changes include expanding the survey to include all adults age 19 and older and making refinements to how we calculate poverty status and determine underinsurance for borderline cases. Collectively, these changes affect year- to-year differences in our trend questions. For that reason, this year's brief does not report on trends. The Commonwealth Fund Biennial Health Insurance Survey, 2022, was conducted by SSRS from March 28 through July 4, 2022. The survey consisted of telephone and online interviews in English and Spanish and was conducted among a random, nationally representative sample of 8,022 adults age 19 and older living in the continental United States. A combination of address-based, SSRS Opinion Panel, and prepaid cell phone samples were used to reach people. In all, 3,716 interviews were conducted online or on the phone via ABS, 3,656 were conducted online via the SSRS Opinion Panel, and 650 were conducted on prepaid cell phones. The sample was designed to generalize to the U.S. adult population and to allow separate analyses of responses from low-income households. Statistical results were weighted in stages to compensate for sample designs and patterns of nonresponse that might bias results. The first stage involved applying a base weight to account for different selection probabilities and response rates across sample strata. In the second stage, sample demographics were posistratified to match population parameters. The data are weighted to the U.S. adult population by sex, age, education, geographic region, family size, race/ethnicity, population density, civic engagement, and frequency of internet use, using the 2019 and 2021 U.S. Census Bureau's Current Population Survey (CPS), the 2015-2019 American Community Survey (ACS) 5-Year Estimates, and Pew Research Center's 2021 National Public Opinion Reference Survey (NPORS).?2 The resulting weighted sample is representative of the approximately 254 million U.S. adults age 19 and older. The survey has an overall maximum margin of sampling error of +/- 1.5 percentage points at the 95 percent confidence level. As estimates get further from 50 percent, the margin Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey of sampling error decreases. The ABS portion of the survey achieved an 11.4 percent response rate, the SSRS Opinion Panel portion achieved a 2 percent response rate, and the prepaid cell portion achieved a 2.9 percent response rate. This brief focuses on adults under age 65. The resulting weighted sample is representative of approximately 196.7 million U.S. adults ages 19 to 64. The survey has a maximum margin of sampling error of +/- 1.7 percentage points at the 95 percent confidence level for this age group. Refinements to Poverty Status A respondent's household size and income are used to determine poverty status. Previously, household size was determined by combining information about marital status and the presence of dependents under age 25 in the household, which resulted in a maximum possible household size of four persons. This year, we used a new survey question where respondents provided an open-ended numeric response. This allowed us to use the full U.S. Federal Poverty Guidelines up to 14 household members. To create a fully populated income variable, we used hot deck imputation to populate income ranges for respondents that did not answer income questions. We then generated random exact incomes for each respondent. Respondent incomes within each income range were assumed to be uniformly distributed and were assigned using a standard increment between each income based on the size of the income range and the number of respondents with incomes in the range. Estimates of U.S. Uninsured Rates Current uninsured rate Time frame Survey [confidence interval] Population of survey Commonwealth 8.9 U.S. adults March-July Fund Biennial Health [8.0, 9.9] ages 19-64 2022 Insurance Survey?? National Health 11.8 U.S. adults January- Interview Survey [10.3, 13.3] ages 18-64 March 2022 (NHIS)?4 Current Population 11.6 U.S. adults February- Survey (CPS)?6 [11.3, 11.9] ages 19-64 April 2022 commonwealthfund.org The more precise household size and random exact incomes were used to determine poverty status for all respondents according to the 2021 U.S. Federal Poverty Guidelines. Refinements to Underinsurance Components Underinsured adults are individuals who are insured all year but report at least one of three indicators of financial exposure relative to income: 1) out-of-pocket costs, excluding premiums, are equal to 10 percent or more of household income; or 2) out-pocket-costs, excluding premiums, are equal to 5 percent or more of household income (if living under 200 percent of the federal poverty level); or 3) their deductible is 5 percent or more of household income. For each of the three underinsurance component measures, there are borderline cases for which the income ranges provided are too imprecise to categorize the respondent into "less than" or "more than" the stated underinsurance component. Previously, the Fund redistributed borderline cases for each component by conducting a 50/50 split into the "less than" and "more than" categories. This year we leveraged the imputed income ranges and random exact incomes generated to determine poverty status to categorize borderline cases. Additionally, for those respondents who provided deductibles, we duplicated the methodology used to determine random exact incomes to compute random exact deductibles. These exact deductibles were compared to exact incomes to categorize borderline cases for the component of underinsurance that relates deductible to income. Time frame ofreference Sample frame Atthetime of Address-based probability sample supplemented with SSRS interview probability panel, prepaid cell phone probability sample; online and telephone interviews Atthetime of Multistage area probability design; personal household interview interviews25 Previous Probability-selected sample; personal and telephone calendar year interviews?' Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey NOTES 1 SaraR. Collins, "Americans Are on the Brink of Experiencing Premium Pain Holahan et al., Filling the Gap in States That Have Not Expanded Medicaid and Health Insurance Loss," To the Point (blog), Commonwealth Fund, July 13, Eligibility (Commonwealth Fund, June 2021, updated Oct. 5, 2021). 2022. 10 Sarah Sugar et al., Medicaid Churning and Continuity of Care: Evidence and 2 SaraR. Collins, Status of U.S. Health Insurance and Policy Levers to Expand Policy Considerations Before and After the COVID-19 Pandemic, HHS/ASPE Coverage and Lower Consumer Costs, invited testimony, U.S. House issue brief no. HP-2021-10 (Office of the Assistant Secretary for Planning and of Representatives Committee on Oversight and Reform, Hearing on Evaluation, U.S. Department of Health and Human Services, Apr. 2021). Examining Pathways to Universal Health Coverage," Mar. 29, 2022. 11 Rachel Schwab, Rachel Swindle, and Justin Giovannelli, Record Enrollment 3 Consumer Financial Protection Bureau, Medical Debt Burden in the United Underscores Importance of Marketplace Outreach to Promote More Affordable States (CFPB, Feb, 2022). Plans (Commonwealth Fund, forthcoming). 4 Jack Hoadley, Madeline O'Brien, and Kevin Lucia, No Surprises Act: A 12 Evena less comprehensive, more narrowly targeted autoenrollment Federal-State Partnership to Protect Consumers from Surprise Medical Bills mechanism could significantly reduce the number of people without (Commonwealth Fund, forthcoming). insurance. Under this approach, the federal government would treat all legal residents as insured, 12 months a year, regardless of whether they actively enrolled in a health plan. Income-related premiums would be collected through the tax system. See Linda J. Blumberg, John Holahan, and Jason Levitis, How ** Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues (Commonwealth Fund, June 2021). 5 D.Keith Branham et al., Health Insurance Deductibles Among HealthCare. Gov Enrollees, 2017-2021, HSS/ASPE issue brief no. HP-2022-02 (Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Jan. 13, 2022). 6 Gary Claxton et al., Employer Health Benefits 2021 Annual Survey (Henry J. Kaiser Family Foundation, Nov. 2021); and Jesse C. Baumgartner, Munira Z. Gunja, and Sara R. Collins, The New Gold Standard: How Changing 13. Emily Curran et al, "In the Age of COVID-19, Short-Term Plans Fall Short for Consumers," To the Point (blog), Commonwealth Fund, May 12, 2020. the Marketplace Coverage Benchmark Could Impact Affordability 14 Mark A. Hall and Michael J. McCue, "Short-Term Health Insurance and the (Commonwealth Fund, Sept. 2022). ACA Market," To the Point (blog), Commonwealth Fund, Mar. 16, 2022. 7 Robin A.Cohen and Amy E. Cha, Health Insurance Coverage: Early Release of 15 Abill introduced by Senator Jeanne Shaheen (D-N.H.) would raise the Quarterly Estimates from the National Health Interview Survey, January 2021- cost-protection of the marketplace benchmark plan and make more people March 2022 (National Center for Health Statistics, July 2022). eligible for cost-sharing subsidies (Improving Health Insurance Affordability Act of 2021, S. 499, 117th Cong. (2021), S. Doc. 1-6). This could eliminate 8 Sara. Collins, "Americans Are on the Brink," 2022. deductibles for some people and reduce them for others by as much as $1,650 9 John Holahan and Michael Simpson, Next Steps in Expanding Health Coverage a year. See Linda J. Blumberg et al., From Incremental to Comprehensive and Affordability: What Policymakers Can Do Beyond the Inflation Reduction Health Insurance Reform: How Various Reform Options Compare on Coverage Act (Commonwealth Fund, Sept. 2022); Sara Rosenbaum, "Expanding and Costs (Urban Institute, Oct. 2019); and Baumgartner et al., A New Gold Health Coverage to the Poorest Residents of States That Have Not Expanded Standard, 2022. Medicaid," To the Point (blog), Commonwealth Fund, Feb. 1, 2022; and John commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey 16 17 18 19 20 21 Holahan and Simpson, Next Steps in Expanding, 2022; Rosenbaum, "Expanding Health Coverage," 2022; and Holahan et al., Filling the Gap, 2021. Christopher F. Koller, "Health Care Costs - Mapping the Forest and Finding a Path," View from Here (blog), Milbank Memorial Fund, Feb. 21, 2019. Sara R. Collins and Jennifer L. Kriss, Rite of Passage: Young Adults and the Affordable Care Act of 2010 (Commonwealth Fund, May 2010). "Fact Sheet: The Biden Administration Announces New Actions to Lesson the Burden of Medical Debt and Increase Consumer Protection," The White House, Apr. 11, 2022. Chi Chi Wu, Jenifer Bosco, and April Kuehnhoff, Model Medical Debt Protection Act (National Consumer Law Center, Sept. 2019); and Christopher T. Robertson, Mark Rukavina, and Erin C. Fuse Brown, "New State Consumer Protections Against Medical Debt," JAMA Network 327, no. 2 (Jan. 11, 2022): 121-22. Choose Medicare Act, H.R. 5011, 117th Cong. (2021), H.R. Doc. 1-32; Medicare-X Choice Act of 2021, H.R. 1227, 117th Cong. (2021), H.R. Doc. 1-24; Medicare-X Choice Act of 2021, S. 386, 117th Cong. (2021), S. Doc. 1-25; State Public Option Act, H.R. 4974, 117th Cong. (2021), H.R. Doc. 1-27; State Public Option Act, S. 2639, 117th Cong. (2021), S. Doc. 1-27; Public Option Deficit Reduction Act, H.R. 2010, 117th Cong. (2021), H.R. Doc. 1-17; CHOICE Act, S. 983, 117th Cong. (2021), S. Doc. 1-12; Health Care Improvement Act of 2021, S. 352, 117th Cong. (2021), S. Doc. 1-75; State-Based Universal Health Care Act of 2021, H.R. 3775, 117th Cong. (2021), H.R. Doc. 1-30; Christine H. Monahan, Justin Giovannelli, and Kevin Lucia, "HHS Approves Nation's First Section 1332 Waiver for a Public Option-Style Health Care Plan in Colorado," To the Point (blog), Commonwealth Fund, July 12, 2022; Christine H. Monahan, Justin Giovannelli, and Kevin Lucia, "Update on State Public Option-Style Laws: Getting to More Affordable Coverage," To the Point (blog), Commonwealth Fund, Mar. 29, 2022; and Ann Hwang et al., State Strategies for Slowing Health Care Cost Growth in the Commercial Market (Commonwealth Fund, Feb. 2022). commonwealthfund.org 22 23 24 25 26 27 Weights for sex, age, education, geographic region, family size, and race/ ethnicity were determined using the 2021 Annual Social and Economic Supplement for the CPS; population density using the 2015-2019 ACS 5-Year Estimates; civic engagement using the 2019 Volunteering and Civic Life Supplement of the CPS; and frequency of internet use using Pew Research Center's 2021 NPORS. Commonwealth Fund Biennial Health Insurance Survey, 2022. Cohen and Cha, Health Insurance Coverage: Early Release, 2022. National Center for Health Statistics, "About the National Health Interview Survey," updated Jan. 16, 2019. Katherine Keisler-Starkey and Lisa N. Bunch, Health Insurance Coverage in the United States: 2021 (U.S. Census Bureau, Sept. 2022). Bureau of Labor Statistics, Design and Methodology: Current Population Survey - America's Source for Labor Force Data, Technical Paper 77 (U.S. Census Bureau, Oct. 2019). Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 1 Insurance Status by Demographics, 2022 (base: adults ages 19-64) Insured all year Uninsured Uninsured any time in the past year Total Insured oe (19-64) all year Insured all year, Insured all year, any time in Insured now, Uninsured not underinsured underinsured the past year had a gap now Point Point Point Point Point Point estimate Cl estimate Cl estimate cl estimate Cl estimate cl estimate Cl 18.7%, 55.0%, 22.0%, 18.6%, 10.0%, 8.0%, Percent distribution 100% = 801% - gia% 68% = EB 37% = 734% = - agg = 99% - a3 = 0% time' 89% gan Unweighted n 6,301 5,091 3,657 1,434 1,210 723 487 Gender Male 48 78 59 20 22 1 1 Female 51 82 55 27 18 11 Age NOTES 19-34 36 71 48 23 29 7 12 Cl = confidence interval. The 35-49 32 81 61 20 19 10 9 survey has an overall maximum 50-64 32 89 62 7 11 6 5 margin of sampling error of +/- Race/Ethnicity V7 percentage points at the 95 Non-Hispanic White 58 85 58 26 15 9 7 peice ee Non-Hispanic Black 8 74 58 16 26 7 9 estimates get further from 50 : . percent, the margin of sampling Hispanic 19 68 47 21 32 15 a error decreases. "Insured all year" Hispanic, U.S.-born 13 0 53 22 25 15 10 refers to adults who were insured Hispanic, Foreign-born 6 53 5) 18 47 15 32 for the full year up to and on the Asian/Pacific Islander T 85 62 23 15 10 ) survey field date; "Underinsured" Other/Mixed D) 81 58 93 19 13 T is defined as insured all year but Poverty status experienced one of the following: Below 183% poverty 36 68 42 26 32 7 15 Seis iene cou sled Sevag a a = ze " " 10% or more of household o- 0 income; out-of-pocket expenses, 400% poverty or more 25 94 83 11 6 4 | excluding premiums, equaled 5% Under 200% poverty 50 70 43 28 30 16 14 or more of household income if 200% poverty or more 50 90 7 19 10 6 4 low income (<200% of poverty); Fair/Poor health status, or any chronic condition* or Geauetbles See or No al 80 59 20 20 10 "Insured now, had a gap" refers Yes 59 80 55 26 20 N 8 to adults who were insured at Adult work status the time of the survey but were Not working 32 18 53 25 22 12 10 uninsured at any point during the Full-time 56 83 61 22 17 10 T year before the survey field date; Part-time ah 72 46 26 28 14 14 "Uninsured now" refers to adults Employer size* who reported being uninsured at 119 employees 22 70 46 24 30 13 7 the time of the survey. 20-49 employees 10 72 49 22 28 15 14 * At least one of the following 50-99 employees 7 76 53 23 24 15 10 health problems: hypertension or 100 or more employees 60 88 65 22 12 8 4 high blood pressure; heart failure Medicaid expansion or heart attack; diabetes; asthma, Did not expand Medicaid 32 74 47 27 26 i 15 See ecu ame ool Expanded Medicaid 68 83 61 22 7 1 6 gh cholesterol. U.S. Census region ** Base: Full- and part-time Northeast 7 85 63 23 15 10 5 employed adults ages 19-64. Midwest 20 84 58 26 16 10 6 South 38 75 50 25 25 12 13 DATA West 24 81 62 19 19 a 8 Commonwealth Fund Biennial Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 2 Duration of Gap in Coverage by Demographics, 2022 (base: adults ages 19-64) Uninsured any time in the past year Uninsured now Uninsured any time in 3 months 4-11 1year Uninsured 11 months 1year the past year orless months or more now orless or more Percent distribution 100% 20% 23% 55% 100% 20% 79% Unweighted n 1,210 280 305 612 487 118 364 Gender Male 51 49 45 5) 56 50 57 Female 47 50 52 44 43 50 43 Age 19-34 52 57 58 49 50 52 49 35-49 30 29 27 32 32 37 32 50-64 17 14 14 18 18 1 19 Race/Ethnicity Non-Hispanic White 44 49 45 42 43 45 43 Non-Hispanic Black 7 7 21 15 13 18 12 Hispanic 31 20 27 36 37 28 39 NOTES Hispanic, U.S.-born 16 15 7 7 15 15 15 "Uninsured any time in the Hispanic, Foreign-born 15 5) 10 19 22 12 24 past year" refers to adults who Asian/Pacific Islander 6 12 5 4 4 8 3 were insured at the time of the Other/Mixed 2 3 3 2 2 O 2 survey but were uninsured at Poverty status ay point orn Year before 9, e survey field date or who one oem oe oe Be oa oe * reported being uninsured at the time of the survey. There were 13 250%-399% a 12 14 8 10 15 9 respondents who were uninsured 400% poverty or more 7 16 5 4 3 6 3 any time in the past year who did Under 200% poverty 74 64 val 79 76 66 78 not provide a duration of time 200% poverty or more 26 36 29 21 24 34 22 without lene reupeuree Fair/Poor health status, or any chronic condition* rworted being cninsered at the No 42 42 46 4 44 51 43 time of the survey. There were five Yes 58 58 54 59 56 49 57 respondents who were uninsured Adult work status at the time of the survey who did Not working 36 36 30 37 37 34 37 nor orowiee EES Full-time 49 52 49 47 46 39 48 annie a Part-time 16 11 Dy 15 7 26 15 * At least one of the following Employer size" health problems: hypertension or high blood pressure; heart failure 119 employees 35 22 25 44 44 ~ 48 ant heart an diabetes; asthma, 20-49 employees 15 15 13 16 16 - 7 emphysema, or lung disease; or 50-99 employees 10 10 14 8 9 - 7 high cholesterol. HI ne stn ESS 40 53 47 31 30 - 27 ** Base: Full- and part-time Medicaid expansion employed adults ages 19-64. Did not expand Medicaid 41 27 35 50 52 50 53 , Expanded Medicaid 58 73 64 50 48 50 46 _ ara SHO GOST 9 Ie ieeT U.S. Census region , Northeast 12 7 7 9 9 8 10 Micwest 6 '6 6 '6 4 4 1S Searcy Fund Biennial aa oa o> ss a > Oe on Health Insurance Survey (2022). commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 3 Underinsured Indicators, 2022 (base: adults insured all year, ages 19-64) Out-of-pocket medical Out-of-pocket medical Unweighted n expenses equal expenses equal 5% Either out- Deductible equals (Insured 10% or more of or more of household of-pocket 5% or more of Underinsured all year) household income income if low income* indicator household income rate Percent distribution 100% 14% 14% 19% 18% 29% Base for rates above: 5,091 5,091 5,091 5,091 5,091 5,091 Gender Male 2,004 1 10 14 16 25 Female 3,041 17 17 23 19 33 Age 19-34 1,536 16 7 21 20 32 35-49 4,773 12 12 16 13 25 50-64 1,772 16 12 19 19 30 Race/Ethnicity Non-Hispanic White 2,310 15 13 19 19 31 Non-Hispanic Black 996 12 14 16 10 22 Hispanic 1,179 16 19 22 16 30 Hispanic, US-born 899 14 18 21 16 29 Hispanic, Foreign-born 280 21 22 26 16 33 Asian/Pacific Islander 367 1 10 15 19 7 ores | vear" ret ul Other/Mixed 208 7 19 23 16 29 Dee ue le aS Poverty status who were insured for the full year Below 133% poverty 1316 22 32 32 18 38 reser ee ca 1338%-249% 1,100 7 18 25 27 42 . delay eineuaeienens 250%-399% 986 8 - 8 2 28 ilnsigirichay a raacadag one of the following: out-of-pocket 400% poverty or more 1,689 5 - 5 8 12 expenses, excluding premiums, Under 200% poverty 1,968 21 31 31 20 39 equaled 10% or more of 200% poverty or more 3,123 10 - 10 16 21 household income; out-of-pocket Fair/Poor health status, or any chronic condition" expenses, excluding premiums, No 2,078 a an] 15 17 25 equaled 5% or more of household Yes 3,013 17 16 22. 18 32 income if low income (<200% of Adult work status poverty); or deductibles equaled Not working 1,435 19 20 25 17 32 5% or more of household income. Full-time 3,178 1 9 14 18 26 EL Woviincanneaudetinecdtas Part-time 473 19 23 28 20 36 <200% of the federal poverty Employer size** level. 1-19 employees 605 16 13 19 21 34 20-49 employees 286 15 18 22 a 31 ** At least one of the following 50-99 employees 270 13 13 18 19 30 health problems: hypertension or 100 or more employees 2,480 11 9 15 16 25 high blood pressure; heart failure Medicaid expansion or heart attack; diabetes; asthma, Did not expand Medicaid 1,580 19 18 24 23 37 emphysema, or lung disease; or Expanded Medicaid 3,499 13 12 7 15 26 high cholesterol. U.S. Census region ** Base: Full- and part-time Northeast 899 14 13 18 15 27 employed adults ages 19-64. Midwest 1,021 14 12 19 21 31 . South 1.913 17 16 22 20 33 eae West 1.246 1 12 16 13 23 survey. Insurance type*** - No data. Analysis restricted to Employer 3,415 13 10 17 19 29 respondents with incomes below Medicare 340 19 24 25 12 32 200% of poverty. Medicaid 751 16 23 24 5 26 Individual (including Marketplace) 375 7 17 23 36 44 DATA Other 210 12 10 14 12 20 commonwealthfund.org Commonwealth Fund Biennial Health Insurance Survey (2022). Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 4 Access Problems, by Insurance Continuity, Insurance Adequacy, and Demographics, 2022 (base: adults ages 19-64) Uninsured at Uninsured any time in the Poverty Insured all year at any past 12 months Race/Ethnicity status time Insured all Insured in the Insured Non- Non- Under 200% Total Insured year, not all year, past 12 now, Uninsured Hispanic Hispanic 200% FPLor (19-64) allyear underinsured underinsured* months hadagap now White Black Hispanic FPL more NOTES Percent distribution 100% 80% 57% 23% 20% 11% 9% 58% 13% 19% 50% 50% . *"Underinsured" is defined as Unweighted n 6,307 5,097 3,657 1,434. 1,210 723 487 2,714 1,253 1,673 2,769 3,532 insured all year but experienced Access problems in past year one of the following: out-of-pocket Went without needed care in past year expenses, excluding premiums, because of costs: equaled 10% or more of : . ae household income; out-of-pocket Did not fill prescription 23 20 15 31 36 39 33 22 25 27 27 19 expenses, excluding premiums, Skipped recommended test, treatment, equaled 5% or more of household or follow-up 3 26 18 ae a ae 53 30 28 35 33 28 income if low income (<200% of Had a medical problem, did not visit poverty); or deductibles equaled doctor or clinic ° 33 26 9 44 59 56 63 32 27 37 37 28 5% or more of household income. Did not get needed specialist care 28 23 16 40 48 47 49 28 23 30 31 24 ** Base: Respondents with /eieesionaciiienn Pano any cost-related access east one of Tour access problems 46 40 32 61 71 70 71 46 44 52 51 4 problem, defined as did not because of cost : an ; fill a prescription for medcine Dental care 43 38 32 53 65 62 69 42 43 52 52 35 because of cost, skipped a Reason for skipped or delayed medical test, treatment or follow- medical care because of cost* up recommended by a doctor . because of cost, had a medical New health condition 30 32 SS) 30 26 24 28 30 26 29 28 32 problem but did not go to a doctor Ongoing health condition 39 40 4 40 36 39 33 39 44 37 38 40 or clinic because of cost, or did not see a specialist when they or New and ongoing health conditions 30 27 25 30 37 37 37 31 28 33 32 28 their doctor thought they needed Preventive care one because of cost. Regular source of care 88 93 92 93 68 82 51 89 91 84 85 90 ¥ In past year if respondent . has hypertension or high blood = eal 86 90 90 89 72 77 66 89 88 70 «82-Ct«O pressure. i i ¥¥ In past year if respondent Received mammogram in past two years fiemales age 40+) 3 66 70 72 65 38 43 31 65 73 63 58 72 has hypertension or high blood Received pap test in past three years ee ee lc (females ages 21-64) 64 68 val 63 46 52 39 63 66 65 58 70 cholesterol. Received colon cancer screening in past 'Base: Respondens with at five years (age 50+) gine 64 67 68 65 39 49 28 64 69 62 60 67 least one of the following health . . problems: hypertension or high Cholesterol checked in past five years" 66 72 val 74 42 48 35 68 64 62 56 76 blood pressure; heart failure or Seasonal flu shot in past 12 months 49 55 55 54 26 31 20 50 41 46 42 56 heart attack; diabetes; asthma, emphysema, or lung disease; At least one dose of COVID vaccine 76 80 80 179 61 65 57 74 13 Tl 68 84 high cholesterol; or depression, Access problems for people with anxiety, or other mental health health problems problem. Unweighted n 4,242 3,457 2,408 1,049 785 495 290 1,890 891 1,035 1940 2302 FPL = federal poverty level. Skipped does or not filled prescription for medications for the health problem(s)... DATA because of the cost of the medicines? 19 15 10 27 36 35 37 17 22 23 24 14 Commonwealth Fund Biennial commonwealthfund.org Health Insurance Survey (2022). Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 5 Medical Bill Problems by Insurance Continuity, Insurance Adequacy, and Demographics, 2022 (base: adults ages 19-64) Uninsured at Uninsured any time in the Poverty Insured all year at any past 12 months Race/Ethnicity status time Insured all Insured in the Insured Non- Non- Under 200% Total Insured year, not all year, past 12 now, Uninsured Hispanic Hispanic 200% FPLor (19-64) allyear underinsured underinsured* months hadagap now White Black Hispanic FPL more Percent distribution 100% 80% 57% 23% 20% 11% 9% 58% 13% 19% 50% 50% Unweighted n 6,307 5,097 3,657 1,434 1,210 723 487 2,714 1,253 1,673 2,769 3,532 Medical bill problems in past year Had problems paying or unable to pay medical bills 30 25 16 45 49 50 48 28 34 36 36 23 Contacted by collection agency for unpaid medical bills 23 19 15 31 37 38 35) 21 33 27 29 7 Bill sent to collection agency because of billing mistake ¥ 24 30 34 25 13 17 8 27 7 21 19 34 Bill sent to collection agency because unable to pay the bill ¥ 75 70 66 75 87 83 92 73 81 78 81 66 Had to change way of life to pay bills 15 12 T 23 25 26 24 12 7 21 19 ai Any of above three bill problems 36 32 23 53 BS 57 53 33 46 43 44 29 Medical bills/debt being paid off over time 25 24 7 39 33 36 30 25 30 27 27 24 Any bill problem or medical debt 42 37 27 60 60 62 57 39 51 48 48 35) Base: Any bill problem or medical debt Unweighted n 2,749 2,012 1126 886 737 453 284 1,054 658 791 1430 1,379 How much are the medical bills that are being paid off over time? Less than $2,000 43 44 52 36 42 39 47 4 51 45 45 42 $2,000 to less than $4,000 28 29 28 31 25 27 21 29 25 29 26 30 NOTES » . *"Underinsured" is defined as $4,000 to less than $8,000 16 16 12 20 17 21 1 17 13 14 15 18 insured all year but experienced $8,000 to less than $10,000 11 one of the following: out-of-pocket , , expenses, excluding premiums, $10,000 or more 5 10 equaled 10% or more of Was this for care received in the past household income; out-of-pocket year or earlier? expenses, excluding premiums, equaled 5% or more of household Past year 47 47 49 46 45 47 43 48 44 43 al 54 income if low income (<200% of Earlier year 32 33 37 29 30 32 28 30 34 39 36 27 poverty); or deductibles equaled 5% or more of household income. Both 21 20 14 25 24 21 29 22 22 7 23 19 What type of care was this for?" ** Respondents could select more than one type of care. Hospital inpatient or outpatient care 49 50 45 57 44 47 40 51 49 43 46 53 eas ¥ Base: Adults ages 19-64 who Doctor's office visit 36 36 33 40 36 36 35 36 4 33 36 37 indicated they were contacted Emergency room visit 39 34 33 36 49 48 50 36 47 39 44 32 ee cece agency for unpaid Ambulance 10 10 9 1 12 14 8 1 12 8 12 8 : FPL = federal poverty level. Dental 4 Diagnostic testing 3 3 2 3 3 3 DATA commonwealthfund.org Commonwealth Fund Biennial Health Insurance Survey (2022). Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey TABLE 5 (CONTINUED) Medical Bill Problems by Insurance Continuity, Insurance Adequacy, and Demographics, 2022 (base: adults ages 19-64) Uninsured at Uninsured any time in the Poverty Insured all year at any past 12 months Race/Ethnicity status time Insured all Insured in the Insured Non- Non- Under 200% Total Insured year, not all year, past 12 now, Uninsured Hispanic Hispanic 200% FPLor (19-64) allyear underinsured underinsured* months hadagap now White Black Hispanic FPL more Percent distribution 100% 80% 57% 23% 20% 11% 9% 58% 13% 19% 50% 50% Unweighted n 6,307 5,097 3,657 1,434 1,210 723 487 2,714 1,253 1,613 2,769 3,532 Base: Any bill problem or medical debt Unweighted n 2,749 2,012 1126 886 737 453 284 1,054 658 791 1430 1,319 Was this for a new or ongoing health condition? New condition 36 35) 40 29 37 S15) 40 37 34 33 32 40 Ongoing condition 34 36 36 36 29 30 28 32 37 36 34 35 Both new and ongoing conditions 28 27 22 33 32 33 30 29 26 29 31 24 Insurance status of a person/s at time care was provided Insured at time care was provided 66 81 82 80 28 37 17 71 58 54 52 84 Uninsured at time care was provided 22 10 n 9 52 40 68 18 28 31 32 9 More than one person with medical bill problems and one person uninsured and 4 3 2 4 3) 6 4 3} 4 4 6) 2 the other insured Medical bills from both insured and 8 uninsured time periods 5 4 r 8 15 NI v 8 9 9 5 Were some or all medical bills the result of a surprise bill? Yes 48 48 48 48 47 54 38 46 50 46 48 47 No 52 52 52 52 52 46 60 54 50 93 51 93 Percent reporting that the following NOTES happened in the past two years "Under d" is defined because of medical bills: _ eNCennsured'' Is erined as ; 7 insured all year but experienced Unable to pay for basic necessities (food, 26 29 16 28 36 36 36 a 24 36 34 15 one of the following: out-of-pocket heat, or rent) expenses, excluding premiums, Used up all savings 37 36 26 46 40 40 40 38 32 36 4 32 equaled 10% or more of ; household income; out-of-pocket Took out a mortgage against your home 8 7 4 10 10 Tl 8 6 6 10 9 6 expenses, excluding premiums, or took out a loan equaled 5% or more of household Took on credit card debt 39 40 32 48 RY 4 39 34 41 30 37 35 45 income if low income (<200% of poverty); or deductibles equaled Had to declare bankruptcy 4 4 3 5 6 6 7 4 3 6 6 3 5% or more of household income. Delayed education or career plans 22 18 15 23 30 29 32 20 18 25 26 16 FPL = federal poverty level. Received a lower credit rating 4 39 37 4 47 47 48 44 46 36 45 36 DATA Any financial problems resulting from Commonwealth Fund Biennial ee 72 69 63 77 78 76 80 73 70 72 75 68 Health Insurance Survey (2022) commonwealthfund.org Data Brief September 2022 The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey ABOUT THE AUTHORS Sara R. Collins, Ph.D., is Senior Scholar and vice president for Health Care Coverage and Access at the Commonwealth Fund. An economist, Dr. Collins directs the Health Care Coverage and Access program as well as the Fund's research initiative on Tracking Health System Performance. Since joining the Fund in 2002, Dr. Collins has led several multiyear national surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage, health reform, and the Affordable Care Act. She has provided 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, anda senior health policy analyst in the New York City Office of the Public Advocate. She holds an A.B. in economics from Washington University anda Ph.D. in economics from George Washington University. Lauren A. Haynes, M.P.H., C.P.H., is the Health Care Coverage and Access researcher at the Commonwealth Fund. In this role she is responsible for providing research and analytic support to the program. Prior to joining the Fund, Haynes served as director of Quality and Evaluation at Public Health Solutions, where she was responsible for telling stories with data, evaluating program impact, and developing a culture of continuous quality improvement across Public Health Solutions' portfolio of 14 community-based public health and social service programs. She simultaneously served as project director and principal investigator for What Matters to You, a project that assessed WIC participants for their highest-priority needs, connected participants with community-based services, and evaluated the associated impact on benefits utilization and retention in the WIC program. Previously, she served as program coordinator for the Integrated Mental Health in Primary Care Program at New York-Presbyterian Hospital, and as a social science research analyst at the U.S. Department of Health and Human Services, Office of the Inspector General. Haynes received her M.P.H. in health policy and management from Columbia University's Mailman School of Public Health, with an advanced certificate (C.P.H.) in social determinants of health. commonwealthfund.org Relebohile Masitha, M.S., is program assistant for Health Care Coverage and Access at the Commonwealth Fund. She is responsible for providing daily support for the program, with responsibilities ranging from administration and grants management to tracking health reform policy developments and working on research projects. Masitha received her M.S. degree in global health policy and management (health economics and analytics) from the Heller School for Social Policy and Management at Brandeis University in May 2021. She received her B.A. in public health and economics from Agnes Scott College, where she worked as a public health learning assistant and a writing and speaking tutor. Masitha also served as a tuberculosis surveillance intern for the Centers for Disease Control and Prevention's Division of Tuberculosis. As a research intern with the Noguchi Memorial Institute for Medical Research, she also spent a summer conducting qualitative HIV research in Ghana, Editorial support was provided by Christopher Hollander. ACKNOWLEDGMENTS The authors thank Robyn Rapoport, Rob Manley, Elizabeth Sciupac, and Jonathan Best of SSRS; and David Blumenthal, Melinda Abrams, Chris Hollander, Paul Frame, Jen Wilson, Elisa Mirkil, Munira Gunja, Jesse Baumgartner, Evan Gumas, and Celli Horstman, all of the Commonwealth Fund. For more information about this brief, please contact: Sara R. Collins Senior Scholar, Vice President, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund src@cmwf.org Data Brief September 2022 The Commonwealth Fund Affordable, quality health care. For everyone. 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.