More Americans than ever have health insurance, but a new Commonwealth Fund survey finds many still lack adequate financial protection, due to high premiums, large deductibles, and cost sharing that shifts more charges to consumers.

Despite historically high levels of health insurance coverage, 46 percent of working-age adults skipped or delayed care because of cost in the past year, and 42 percent struggled to pay medical bills or were paying off medical debt, according to findings from the latest Commonwealth Fund Biennial Health Insurance Survey.

Analysts predict the picture will worsen after the COVID-19 public health emergency period (PHE) ends unless policymakers act soon. Once the PHE ends, which is likely to occur next year, it will trigger states to redetermine Medicaid enrollees’ eligibility—a process that could cause nearly 16 million people to lose coverage, with many becoming uninsured.

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The survey was primarily conducted online March 28 and July 4, and the findings spotlight growing health care costs—particularly for hospital inpatient and outpatient services—that are squeezing Americans whose insurance doesn’t provide adequate financial protection, even as overall coverage continued to improve. The nationally representative survey, which included more than 8,000 adults ages 19 and older living in the continental United States, is part of a series conducted by the Commonwealth Fund since 2001.

Here are four key findings from the survey:

Forty-three percent of working-age adults are inadequately insured

  • This includes people who are uninsured (9 percent), had a gap in coverage over the past year (11 percent), or are underinsured, meaning that their coverage does not provide them with affordable access to health care (23 percent).
  • More than one-quarter (29 percent) of continuously insured people with employer coverage and 44 percent of those with coverage purchased in the individual market or marketplaces are underinsured because of high out-of-pocket costs and deductibles, relative to their income.
  • People who are inadequately insured are more likely to report problems affording needed care as well as problems paying medical bills.

High out-of-pocket maximums are leaving people with considerable cost exposure

  • Half (49 percent) of people surveyed 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.
  • Up to one-quarter of people with chronic health problems like diabetes said that out-of-pocket costs for prescription drugs had caused them to skip doses or not fill a prescription at all.

Chronic uninsurance persists among specific populations

  • People who were uninsured for a year or longer were disproportionately young, Latinx/Hispanic, poor, sicker, and living in the South.

Asked to name their health policy priorities, Americans agree on the need to lower health care costs

  • 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.

“This survey demonstrates that having health insurance isn’t enough for millions of Americans who need good coverage, with affordable premiums and manageable out-of-pocket costs, which protects them from long-term financial problems, Sara Collins, lead author of the survey brief and Commonwealth Fund senior scholar and vice president for health care coverage and access & tracking health system performance , said in the study announcement. “The Affordable Care Act made great strides toward better health insurance, but more work is needed to fill the remaining coverage gaps and design health plans that encourage people to get the health care they need to live productive and fulfilling lives.”

Necessary policy actions

To keep Americans covered, study authors said Congress could make permanent the enhanced marketplace plan subsidies extended for three years under the Inflation Reduction Act of 2022. The Commonwealth Fund survey shows that premium costs figure heavily in consumers’ decisions to enroll and stay enrolled in marketplace plans.

Congress also could provide a path to coverage for Medicaid-eligible people in states that have yet to expand the program; this could reduce the number of uninsured people in those states by an estimated 1.9 million. The Urban Institute estimates that Black people would make the biggest gains in those states, with uninsured rates falling by 27 percent.

To help protect consumers from medical debt, Congress could ban short-term plans and other coverage that doesn’t comply with the benefit requirements of the Affordable Care Act. It also could rein in deductibles and out-of-pocket costs in marketplace plans. In addition, states could use rate regulation to limit growth in premiums and cost sharing.