New Survey: Two of Five Working-Age Adults Do Not Have Stable Health Coverage; More Than One-Third Have Medical Bill Problems

In the first half of 2020, 43 percent of working-age adults did not have stable health insurance coverage. The reasons for the instability varied — some were uninsured at the time of the survey (12.5%), some experienced a coverage gap (9.5%), and some were insured for the full year but had such high out-of-pocket costs or deductibles relative to their income that they were effectively “underinsured” (21%), according to results from the Commonwealth’s Fund’s latest Biennial Health Insurance Survey.

The survey, fielded between January and June 2020, offers a big-picture look at Americans’ health insurance, including the quality and extent of their coverage and whether or not they could afford health care. It is part of the Fund’s Biennial Health Insurance Survey series conducted since 2001.

Key findings include:

People of color, small-business workers, people with low incomes, and young adults had the highest uninsured rates.
- More than one-third of Latino adults, small-business workers, and adults with low incomes were either uninsured or spent some time uninsured in the past year.

The growth in the underinsured since 2010 has been driven by employer health plans with inadequate coverage.
- One-quarter of adults with employer plans were underinsured.
- In 2010, only 7 percent of people in private plans, either employer or individual market, had deductibles that amounted to 5 percent or more of income. This is a key indicator of underinsurance. By 2016, the share had doubled (15%).
- Between 2010 and 2020, the share of privately insured adults with deductibles of $1,000 or more doubled — from 22 percent to 46 percent.

Many U.S. adults struggle to pay their medical bills, though people with inadequate coverage tend to have more problems.
- One-quarter of working-age adults with adequate coverage for the full year reported medical bill problems or debt in the past year.
- Half of adults who spent any time uninsured or underinsured reported problems paying medical bills or that they were paying off medical debt over time.
- Blacks were significantly more likely than whites to report problems with medical bills (45% vs. 35%).

Medical debt leaves people with lingering financial problems. Among adults who reported any medical bill or debt problem:
- thirty-seven percent said they had used up all their savings to pay their bills.
- forty percent had received a lower credit rating as a result of their medical debt.
- one-quarter (26%) were unable to pay for basic necessities such as food, heat, or their rent.

Implications

The authors note several policy options at the federal and state levels that could move the nation toward universal, comprehensive coverage and provide relief to U.S. families during the pandemic. These include:

The full report will be available after the embargo lifts at: https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/looming-crisis-health-coverage-2020-biennial.

From the Experts:

Sara Collins, lead author of the study and Commonwealth Fund Vice President for Health Care Coverage and Access

“The survey shows a persistent vulnerability among U.S. working-age adults in their ability to afford coverage and health care. That vulnerability could worsen if the COVID-19 pandemic and related economic downturn continue. Coverage inadequacy is compromising people’s ability to get the care they need and leaving many with medical debt at a moment of widespread health and financial insecurity, and an uncertain future.”

David Blumenthal, M.D., Commonwealth Fund President

“This survey examined Americans’ health insurance as our country slid into the worst public health and economic crisis in generations. What we found is troubling. Even before the pandemic, people were struggling with inadequate health coverage and mounting medical debt. It has never been more important to ensure that all U.S. residents have affordable, comprehensive coverage to survive this pandemic and beyond.”

How We Conducted This Study

The Commonwealth Fund Biennial Health Insurance Survey, 2020, was conducted by SSRS from January 14 through June 5, 2020. The survey consisted of telephone interviews in English and Spanish and was conducted among a random, nationally representative sample of 4,272 adults ages 19 to 64 living in the continental United States. A combination of landline and cellular phone random-digit dial (RDD) samples was used to reach people.

Statistical results are weighted to correct for the stratified sample design, the overlapping landline and cellular phone sample frames, and disproportionate nonresponse that might bias results. 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 of sampling error of +/– 2.0 percentage points at the 95 percent confidence level. The RDD landline portion of the survey achieved a 7.7 percent response rate and the RDD cellular phone component achieved a 6.5 percent response rate.

We also report estimates from the 2010, 2012, 2014, 2016, and 2018 Commonwealth Fund Biennial Health Insurance Surveys. The surveys through 2016 were conducted by Princeton Survey Research Associates International using the same stratified sampling strategy that was used in 2018 and 2020 by SSRS. In 2010, the survey was conducted from July 14 to November 30, 2010, among 3,033 adults ages 19 to 64; in 2012, the survey was conducted from 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 adults ages 19 to 64; in 2016, the survey was conducted from July 12 to November 20, 2016, among 4,186 adults ages 19 to 64; and in 2018, the survey was conducted from June 27 to November 11, among 4,225 adults ages 19 to 64.