KFF survey shows complexity, bureaucracy, denials, confusion rivaling affordability as an issue for insured consumers, with some saying it has led them to opt out or delay care

KFF survey shows complexity, bureaucracy, denials, confusion rivaling affordability as an issue for insured consumers, with some saying it has led them to opt out or delay care

The majority (58%) of people with health insurance say they have experienced at least one problem using their coverage in the past year, with even higher shares of people with the greatest health care needs reporting such problems, find a new KFF survey on consumer experiences with health insurance.

Those issues vary between types of insurance, but include things like denied claims for care they thought were covered, trouble finding an in-network doctor or other provider, and delays and denials of care that resulted in prior authorization from the insurer .

At least half within each of the four major employer types of health coverage, Medicaid, the Affordable Care Acts market and Medicare say they have had a problem using their coverage in the past year.

Such problems are more common among people with greater health care needs. For example:

• Two-thirds (67%) of consumers who rate their health as fair or poor have experienced a problem in the last year.
• About three-quarters (74%) of those who received mental health care in the past year reported a problem.
• More than three-quarters (78%) of those who received a lot of healthcare (more than 10 provider visits in the last year) reported a problem.

The survey shows that the sheer complexity of insurance is as big an issue as affordability, particularly for those with the greatest needs, said KFF president and CEO Drew Altman. People report an obstacle course of denied claims, limited in-network providers and a maze of red tape, with many saying it has prevented them from getting the care they need.

Today’s report compiles key findings from a nationally representative survey of 3,605 people with health coverage through an employer, Medicare, Medicaid or the Affordable Care Acts markets. Future reports will delve into the experiences of people with these types of coverage, as well as people with specific chronic conditions and needs across the types of insurance.

How often people encounter specific insurance problems varies by type of coverage. For example, people with employer and market coverage report denied claims more often than people with Medicare or Medicaid, and people with Medicaid and market coverage report problems finding providers in the network more often.

Insurance problems can contribute to unexpected costs, with more than a quarter (28%) of those reporting problems saying they need to pay more for their care. This includes about a third of those with market or employer coverage who have reported problems in the last year.

Of those who report recent insurance problems, half say they were able to resolve the issue satisfactorily, while nearly as many say the issue was resolved in a way they didn’t like (28%) or remained unresolved (19 %). The majority of insured adults (60%) are unaware that they have statutory recourse rights and three-quarters (76%) are unaware of which government agency to ask for help managing their insurance.

Consumers’ insurance problems can affect their ability to get timely and needed care. Of those who have had recent problems, about one in six say they have not been able to receive recommended care (17%), have experienced a significant delay in receiving it (17%) or that their health has deteriorated (15 %) as a direct result.

About half (51%) of insured adults report some difficulty understanding at least one aspect of their health insurance, such as what their insurance will cover (36%), how much they will have to pay out-of-pocket for treatment (30%), or what their explanation of the benefit statement means (30%). About a quarter say they have difficulty understanding terms like deductible or copay (25%) and figuring out which doctors, hospitals and other providers are in the network (23%).

People with mental health problems have more problems

The report also analyzes the challenges faced by policyholders who rate their mental health as fair or poor, regardless of whether they have sought or obtained mental health care. This includes about one in five of all people with insurance and one in three of those with Medicaid coverage.

Substantial shares of enrollees in this group rate the availability (45%) and quality (37%) of the therapists and mental health providers covered by their insurance as fair or scarce.

Of those who say their mental health is fair or poor, 43% say there has been a time in the past year when they have not received needed mental health care. Among young adults under 30 who describe their mental health as fair or poor, more than half (55%) say they have not received needed mental health care in the past year.

People cite various reasons for not getting much-needed mental health care, but insurance has been a factor for many. Of all insured adults who have not received needed mental health care, more than four in 10 (44%) say they could not afford the cost and more than a third say it was because their insurance did not cover it.

• One in six (16%) of all policyholders say they have had trouble paying or unable to pay their medical bills in the past year, including similar shares of those with marketplaces (19%), employers (17% ) and Medicaid (16%) coverage, as do 12% of people with Medicare.
• Rewards can also be an issue for consumers, especially those with employer and market plans. About half of those with market or employer coverage give their insurance plan low marks for the amount they pay in premiums and the amount they pay out-of-pocket to see a doctor. Far fewer those with Medicare or Medicaid rate these aspects of their coverage negatively.
• Despite the problems people report using their insurance, a large majority (81%) give excellent or good ratings when asked to rate their insurance overall.
• The large majority of consumers with insurance say they would support requirements for insurers that could make it easier to avoid or resolve insurance problems. These include requirements to maintain accurate and up-to-date information about who is in their network (91%) and to provide simpler, easier-to-read statements explaining coverage decisions and how to appeal if you disagree (94% ), all of which were enacted by Congress though not all of which were implemented.

Designed and analyzed by public opinion researchers at KFF, the KFF Survey of Consumer Experiences with Health Insurance was conducted February 21-March 14, 2023, online and by telephone among a representative sample of 3,605 adults in the United States with health insurance coverage, including 978 adults with employer-sponsored insurance, 815 adults with Medicaid coverage, 885 adults with Medicare, and 880 adults with market insurance. Interviews were conducted in English and Spanish. The margin of sampling error is plus or minus 2 percentage points for the entire sample. For results based on subgroups, the margin of sampling error may be higher.