It's Not Just You: Many Americans Face Insurance Obstacles Over Medical Care and Bills

A majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills and a dearth of doctors in their plans, according to a new survey from KFF, a nonprofit health research group. As a result, some people delayed or skipped treatment.

Those who were most likely to need medical care — people who described themselves as in fair or poor health — reported more trouble; three-fourths of those receiving mental health treatment experienced problems.

“The consequences of care delayed and missed altogether because of the sheer complexity of the system are significant, especially for people who are sick,” said Drew Altman, the chief executive of KFF, formerly known as the Kaiser Family Foundation.

The survey also underscored the persistent problem of affordability as people struggled to pay their share of health care costs. About 40 percent of those surveyed said they had delayed or gone without care in the last year because of the expense. People in fair or poor health were more than twice as likely to report problems with paying medical bills than those in better health, and Black adults were more likely than white adults to indicate they had trouble.

Why It Matters: Delayed care can endanger health.

Nearly half of those who encountered a problem with their insurance said they could not satisfactorily resolve it. Some could not obtain the care they had sought, while others said they paid more than expected. Among the nearly 60 percent who reported difficulty with their insurance coverage, 15 percent said their health had declined.

“This survey shows it’s not enough to just get a card in your pocket — the insurance has to work or it’s not exactly coverage,” said Karen Pollitz, the co-director for KFF’s patient and consumer protections program.

People have a hard time understanding their coverage and benefits, with 30 percent or more reporting difficulty figuring out what they will be required to pay for care or what exactly their insurance will cover.

“Insurances are way more complicated than they should be,” said Amanda Parente, a 19-year-old college student in Nashville who is covered under her mother’s employer plan. She was surprised to find that her out-of-pocket costs spiked recently when she sought treatment for strep throat. While she realized her co-payments would be higher, “I guess we didn’t know how drastic it was going to be,” she said.

Background: Insurance coverage is confusing to everyone.

Navigating the intricacies of coverage and benefits were similar regardless of what kind of insurance people had. At least half of those surveyed with private coverage, through an employer, those with an Obamacare plan, or a government program like Medicare or Medicaid, said they experienced difficulties.

People might be unhappy with their coverage because they were already concerned about higher inflation and potential layoffs, said Christopher Lis, the managing director of global health care intelligence at J.D. Power, which found that consumer satisfaction with insurers had declined in a recent study. “We’ve got economic conditions that set the stage for concern around coverage and benefits,” he said.

Insurers say people generally report being happy with their plan, and 81 percent of those surveyed by KFF gave their insurance high ratings. “Health insurance providers are committed to improving access, affordability and convenience for all Americans and will continue to find innovative solutions to work toward this common goal,” said David Allen, a spokesman for AHIP, a trade group that represents insurers.

What’s Next: How to haggle with insurers or appeal?

Also striking among the survey’s findings was how unaware people were about pursuing appeals of denied coverage and how to go about doing so.

“Most people don’t know who to call,” Ms. Pollitz said. Sixty percent of insured adults surveyed did not know they had a legal right to appeal, and about three-fourths said they did not know which government agency to contact for help, particularly respondents with private insurance.

State insurance regulators oversee fully insured policies sold to individuals and small businesses, and the federal Department of Labor has jurisdiction over employer-sponsored insurance.

Many of the problems people have with their insurance could be solved by enforcing existing rules, like federal regulations requiring private insurers to issue understandable explanations of benefits and to maintain accurate, current lists of doctors and hospitals within their networks.

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson