KFF: Over Half of Insured Adults Face Problems with Health Insurance

More than half of adults experienced problems with their health insurance, with issues ranging from payment discrepancies to limited mental healthcare coverage, a KFF survey found.

The survey was conducted online between February 21 and March 14, 2023, and includes responses from 3,605 adults who had employer-sponsored health plans, Medicaid, Medicare, Affordable Care Act (ACA) marketplace plans, or a Military plan.

Around eight in ten insured adults rated their health insurance plan as “good” or “excellent.” Positive ratings were the most common among Medicare beneficiaries, including those enrolled in traditional Medicare and Medicare Advantage plans.

Insured adults who described their physical health as “fair” or “poor” were more likely to give their health plan a negative rating.

Despite most respondents giving positive ratings to their health plans, nearly 60 percent reported facing a problem with their insurance in the past year. A similar share of people with employer-sponsored insurance (60 percent), Medicaid (58 percent), and marketplace coverage (56 percent) reported experiencing issues, while just over half of Medicare beneficiaries faced a problem.

The types of problems people faced varied depending on their insurance, KFF found.

Almost 30 percent of adults noted a time when their health insurance paid less than expected for a medical bill, while 18 percent said there was a time when their insurance did not pay anything after thinking the care would be covered. Adults with Medicare and Medicaid were less likely to experience these payment issues compared to those with employer-sponsored insurance and marketplace plans.

Respondents also dealt with issues surrounding provider networks. Around a quarter of adults (26 percent) said there was a time when an in-network doctor they needed to see didn’t have any available appointments and 14 percent noted a time when a doctor or hospital they needed was not covered by their plan.

Individuals with marketplace or Medicaid plans tended to experience provider network problems more often than those with Medicare or employer-sponsored plans.

Sixteen percent of insured adults reported that their health insurance denied or delayed prior approval for healthcare services they needed in the past year. This figure ranged from 11 percent of Medicare beneficiaries to 22 percent of Medicaid beneficiaries.

Prescription drug coverage also led to problems for some, with 23 percent of respondents indicating their insurance did not cover a needed prescription medication or charge a high copay. Medicare beneficiaries were most likely to encounter this issue.

One in ten people noted times when their health insurance did not cover a mental health therapist or treatment they needed.

Insurance problems were more common among adults with poor mental health. For example, nearly 70 percent of people with fair or poor mental health reported insurance problems, while 55 percent of those with good mental health experienced issues.

Among adults who reported having fair or poor mental health, 43 percent did not get needed mental health services or medication in the past year, while 45 percent gave their health plan a negative ranking for its ability or mental health providers.

About half of adults who faced insurance problems said their biggest issue was not resolved (19 percent) or resolved in an unsatisfactory way (28 percent). This outcome was most common among people with marketplace coverage.

In addition to facing problems with their health plans, insured adults struggle to understand their insurance. Over a third of adults said it was difficult to understand what their insurance will and will not cover, while 30 percent struggle to comprehend what they will owe out-of-pocket after receiving care.

Between 20 and 30 percent of respondents also reported confusion with understanding the explanation of benefits (EOBs), basic health insurance terminology, and provider networks.

Experiencing insurance problems can limit access to care and lead to unexpected costs, the survey highlighted. The majority of respondents supported policies to prevent issues with insurance, such as offering simple EOBs, ensuring provider network directories are accurate, and disclosing claims denial rates.