The U.S. health insurance market has undergone enormous change since passage and partial implementation of the Patient Protection and Affordable Care Act (ACA). Family physicians and their patients have felt the seismic shift as millions of consumers shopped for health insurance for the first time, millions more changed policies, and coverage grew to encompass universal wellness and preventive services.
Furthermore, according to federal government projections, as many as 12 million more Americans could gain private health insurance in coming years.
Enter researchers from the Associated Press-NORC Center for Public Affairs Research,(www.norc.org) who set about talking with some of those consumers about their private health plans and asking specific questions about issues such as cost and utilization of health insurance.
The survey and ensuing report -- Privately Insured in America: Opinions on Health Care Costs and Coverage(www.apnorc.org) -- were funded by the Robert Wood Johnson Foundation. The research team conducted phone interviews from July 22 to Sept. 3 with 1,004 privately insured adults ranging in age from 18 to 64.
Report Details Key Findings
Overall, the researchers discovered that when Americans were shopping for health insurance either through their employers or on the private market, they based their purchasing decisions on three main concerns: coverage of health care services, the physician network and premium prices.
- Researchers surveyed more than 1,000 consumers with private health insurance to collect information about their perceptions on cost, coverage and utilization of health care.
- The survey results showed that nearly one-quarter of consumers with private plans still worried about paying for a major health event, and another 20 percent didn't seek medical care when they were sick or injured because of worries about cost.
- Concerns about out-of-pocket costs were highest among high-deductible health plan holders; the relative percentage of high-deductible plan holders has more than doubled since 2007.
On a more granular level, the survey report included a number of key findings, such as
- 25 percent of adults surveyed said they worried about the financial consequences of an unexpected major medical event,
- nearly 20 percent said they didn't seek medical care when they were sick because they worried about the cost,
- 52 percent preferred to pay higher premiums to limit their out-of-pocket costs, and
- 40 percent said they would trade lower premiums for higher out-of-pocket costs.
Authors found that most respondents had experience with switching from one health plan to another. Of those who had changed insurance, 41 percent said their costs went up, but only 18 percent of the same group said they received higher-quality care in exchange for higher costs.
In addition, researchers reported that consumers with high-deductible health plans were less likely than other privately insured adults to seek out a physician for acute care or to follow through on a recommended medical treatment. These same consumers also were more likely to dip into their savings to pay for medical care.
When researchers translated percentages into real numbers, they found that nearly 24 million privately insured adults had skipped going to the doctor or accessing preventive care because of costs.
Researchers noted that enrollment in high-deductible plans had increased from about 17 percent of privately insured individuals in 2007 to about 36 percent of this group at the time the survey was conducted.
However, the authors pointed out that 29 percent of high-deductible plan holders did not go to the doctor when sick or injured versus 15 percent of those who held insurance with higher premiums but lower out-of-pocket costs.
"Even among the privately insured, people lack confidence in their ability to pay for major unexpected expenses -- a worry that is more pronounced among those who report having a HDHP (high-deductible health plan)," wrote the authors.
Researchers also found that overall, 59 percent of consumers who were enrolled in their insurance plans for less than a year were satisfied with their coverage versus an 84 percent satisfaction rate for people who had held the same health plan for five years or longer.
Researcher Discusses Survey
Jennifer Benz, Ph.D., senior research scientist with the independent research organization NORC at the University of Chicago, took some time to discuss the survey findings with AAFP News. Here are some highlights of that conversation:
Q. Why did you conduct the survey at this time?
A. The country is in the middle of a critical time in the ACA's implementation. Health care consumers -- both those consumers with experience and those who are new to the (health insurance) market -- are trying to make decisions about their coverage.
We wanted to assess the factors that go into those consumer decisions, particularly as they relate to cost and quality issues, and to try and understand the impacts of plan type and costs on decision-making and health care utilization.
Q. What is the most important takeaway point from this research?
A. I think it was certainly a good reminder that having private health insurance does not completely insulate people from high health care costs and the implications those costs can have on health care decision-making and on people's lives in general.
Q. Is there a need for more consumer education about the health care market overall and, in particular, about high-deductible health plans?
A. We didn't ask about this specifically, but I don't think it's controversial to say that the health insurance market in this country is confusing, and there are lots of terms and terminology. We asked explicitly about whether people understood what their plans covered and what their out-of-pocket costs were.
Even though about half said that they understood it (their plan) well or extremely well, another 12 percent to 14 percent told us they didn't understand what their plans covered or what their out-of-pocket costs likely would be. This was especially true among younger Americans, and that suggests that there may be an educational component to this.
Q. Do the survey findings indicate a lack of consumer understanding about the importance of wellness and prevention?
A. We didn't ask people about that specifically; all we were able to get at is that people sometimes think they need to forgo those services because of their concerns about the costs.
We know that nearly 20 percent of people said that because of costs, they weren't getting preventive services that were indeed covered (by their insurance plan).
We don't know if that's because they didn't understand that preventive services are now covered under the ACA or if it's sort of a broader concern. Perhaps patients think that even if they go in for something free, it's still going to cost them -- like when they take their car to the mechanic for maintenance and he finds something else wrong.
From all the tomes and tomes of prevention literature, we know that deferring preventive care can well lead to more costly medical care in the future for the patient and the health care system as a whole. So this is one area that points to the role of (consumer) education.
Q. Is any follow-up research in the works?
A. We don't have another funded project in the works, but certainly it is a topic that the center is interested in. This study just came out, and so we are still wrapping our heads around all of the results. I will say that any good research answers a lot of questions but also poses a lot of new questions. Certainly this study lends itself to some follow-on research.