In this chart collection, we explore trends in how costs affect access to healthcare in the U.S. based on National Health Interview Survey (NHIS) data through 2021.
As background, at any given point in time, most adults (90%) have health insurance, and the majority (87% of adults) also report their health as at least good. Adults in worse health (reported as fair or poor health status), and the uninsured are much more likely than others to delay or forego health care due to costs.
In the 2021 NHIS, 1 in 11 adults reported delaying or not getting medical care due to cost reasons. KFF polling from March 2022 found four in ten adults (43%) report that they or a family member in their household put off or postponed needed health care due to cost. While most adults are in good health at a given time, they may have a sick, uninsured, or underinsured family member, leading to medical bills putting a strain on their household budgets.
1 in 11 adults reported that they delayed or did not get care because of cost reasons
Most Americans do not report cost-related access barriers to health care. Still, a substantial portion of the population – about 1 in every 11 adults (9%) – said that they either delayed or did not receive medical care due to cost reasons in 2021.
The chart above is based on NHIS questions asking about missed or delayed “medical care.” There are subsequent questions that ask about missed or delayed mental health care, dental care, and prescriptions due to costs. While some people answer yes to multiple questions, others say that they only missed or delayed one type of care. As shown in later charts, adding all types of missed or delayed care results in a larger share of adults delaying or foregoing care.
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The share of adults going without medical care due to costs remained stable in 2021 through mid-2022 after declining in 2020
The share of adults reporting going without medical care or not taking medicine as prescribed due to cost declined through 2020. This is possibly a result of people foregoing care due to COVID-19.
Costs are a significant access barrier, but the pandemic has posed another significant access barrier and it is difficult to disentangle the reasons why people are missing care. In 2021, a greater share of the population attributed delaying or foregoing care due to the COVID-19 pandemic (21%) than due to cost-related reasons (9%).
Compared to 2021, in the second quarter of 2022, a similar share of adults reported going without needed medical care (6.3%), not taking medicine as prescribed (6.0%), and going without needed mental health care (4.5%) due to cost reasons. Note that respondents may answer yes or no to any of these questions so they should not be totaled.
1 in 4 adults reported delaying or foregoing care either due to cost or the pandemic
In 2021, 1 in 4 adults (26%) reported delaying or going without medical care due to either healthcare costs or the COVID-19 pandemic. A smaller share of adults (4%) delayed or went without medical care due to both costs and the pandemic.
Meanwhile, 17% of adults delayed or went without care due to the pandemic but not costs, and 5% of adults delayed or went without care due to costs but not the pandemic.
In addition to costs and the pandemic, there could be additional reasons for delaying or foregoing care, such as an inability to take time off from work, a lack of transportation, or a lack of available appointments.
Including dental care, one in four adults delayed or did not get some form of care due to cost reasons in 2020
In 2020, 28% of adults reported delaying or going without either dental care, prescription drugs, medical care, or mental health care due to cost. Almost one in four adults went without dental care (23%) due to cost that year.
In 2021, 14% of adults reported delaying or going without either prescription drugs, medical care, or mental health care due to cost. This share is not comparable to the 28% of adults who went without some form of care due to cost in 2020 because the 2021 NHIS did not ask participants about delaying or foregoing dental care due to cost.
Compared to 2020, a similar share of adults reported delaying or going without prescription drugs (6%), medical care (9%), and mental health care (5%) due to cost in 2021. Additionally, a similar share of adults reported delaying or going without any of these types of care excluding dental care in 2020 and 2021 (14% for both years).
Hispanic adults are more likely than other groups to report cost-related barriers in accessing care
Hispanic adults had higher rates of delaying or going without medical care due to costs than most other groups (11%). Other racial and ethnic groups, which include American Indian or Alaska Native people, Native Hawaiian or Other Pacific Islander people, and people who identified with other or multiple racial and ethnic groups (grouped together due to small sample size), had the highest share of adults that report delaying or foregoing care (13%). Estimates for Asian people were the lowest among all groups for delaying or foregoing care due to cost (4%). Hispanic adults had the highest rates of being worried about being able to pay medical bills in case of an illness or accident (60%). White adults had the lowest rate of being worried about paying medical bills in case of an illness or accident (40%).
Adults with incomes below 200% of the federal poverty level are more likely to go without medical care due to cost reasons
Adults with incomes below 200% federal poverty level (FPL) are more likely to delay or go without medical care than those with incomes above 200% FPL (12% versus 7%). Additionally, among people with employer-sponsored insurance, those with lower incomes spend a larger share of their incomes on insurance premiums and cost-sharing.
Adults who are in worse health are twice as likely as those in better health to delay or not get care due to cost reasons
Adults in worse health are more likely to report delaying or not getting medical care due to cost reasons compared to adults in better health (16% versus 7%). Those who are uninsured at any point in the year reported delaying or not getting care due to cost at much higher rates compared to those who are insured (27% versus 7%) or do not have a usual source of care (36% versus 8%). Meanwhile, nearly half of all adults (45%) and three in four uninsured adults (75%) report being worried about medical bills in case of an illness or accident.
Uninsured adults and those in worse health continue to report higher rates of not getting care due to costs
From 2000 to 2009, there was an increase in the share of all adults, adults who report worse health, and uninsured adults who reported delaying or going without care due to cost. However, between when the Affordable Care Act (ACA) was signed into law in 2010 and 2015, there was a decline in the share of adults who report delaying or going without care because of cost.
Starting with the 2019 NHIS, the U.S. Centers for Disease Control and Prevention (CDC) redesigned the questionnaire and updated the sampling weights methodology. As a result, changes in estimates from 2018 to 2019 cannot be attributed to actual change over time alone. We have indicated the break in the survey when presenting measures over time with the shaded gray region. The trend from 2018 to 2019 in the percent of adults delaying or foregoing care is likely at least partly due to changes to NHIS questionnaire and sampling weights, rather than actual changes in access to care alone.
Uninsured adults and adults in worse health continue to face access barriers due to cost of care. In 2021, 27% of uninsured adults reported delaying or not getting care due to cost reasons compared to 7% of insured adults.
While the share reporting delaying or not getting care due to cost reasons decreased from 2019 to 2021, part of this might be because COVID-19 presented another reason care was delayed or foregone. COVID-related stay-at-home measures, potential risk of infection at doctors’ offices and hospitals, and concerns over hospital capacity led to sharp declines in utilization. The decline in the uninsured rate from 2019 to 2021 could have also contributed to fewer adults reporting cost-related barriers to accessing care in this period.
1 in 6 insulin users rationed insulin due to costs
In 2021, 1 in 6 insulin users (17%) reported either delaying buying insulin, skipping an insulin dose, or taking less insulin than needed due to cost reasons.
Among all adults, 6% reported rationing prescribed medication due to cost and 5% did not get needed prescription medication to save money.
In 2022, after this data was collected, several measures to address medication costs for Medicare beneficiaries were signed into law as part of the Inflation Reduction Act. These provisions include a $35 monthly cap on the out-of-pocket cost of insulin for Medicare beneficiaries and federal price negotiations for certain medications covered by Medicare.
Over 1 in 5 non-elderly adults with private insurance rationed insulin due to costs
Among non-elderly adults (ages 18-64 years) with private insurance, over 1 in 5 of those taking insulin (22%) reported delaying buying, skipping, or taking less insulin to save money. This share rises to 30% among non-elderly adults without health coverage.
Uninsured adults are twice as likely to report their family had difficulty paying medical bills
Among all adults, 1 in 9 (11%) stated that they or a family member had difficulty paying medical bills. However, almost 1 in 5 uninsured adults (20%) said they or a family member had difficulty paying medical bills. Insured adults reported difficulty paying medical bills at a lower rate. Even then, 9% of insured adults reported having difficulty paying medical bills for themselves or a family member. Adults with worse health report they or a family member had difficulty paying medical bills at over twice the rate of adults with better health (23% versus 9%). Black Americans had a higher share of adults in families reporting difficulty paying medical bills compared to all other racial and ethnic groups (16%).
Nearly 2 in 3 adults with health care debt put off or postponed care they needed
According to a 2022 KFF Health Care Debt Survey, 41% of adults reported having some amount of health care debt. Among adults with health care debt, nearly 2 in 3 (64%) either put off or postponed getting care they needed, and half (51%) did not get a medical test or treatment that was recommended by a doctor. Additionally, 15% of adults with health care debt were denied care due to their debt.
While most adults in the U.S. have health insurance, cost-sharing can place financial burdens on enrollees, contribute to debt, and render care unaffordable. For example, more than 40% of U.S. households do not have enough assets to pay a typical private plan deductible. People with lower incomes, people with worse health status, Black Americans, and people living in Medicaid non-expansion states are more likely to have significant medical debt.
The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.
