THURSDAY, June 15, 2023 (HealthDay News) — The majority of insured Americans struggled with a wide variety of hurdles when trying to get coverage for their health care needs, a new national survey shows.
All told, the KFF report uncovered numerous barriers to coverage with all types of health insurance, including the inability to find a covered in-network provider; delays in getting needed care; unexpected out-of-pocket costs; problems meeting pre-authorization requirements; and total denial of the claims.
We found that the majority of people, about 60 percent, experience problems when trying to use their coverage, noted Karen Pollitz, survey manager, senior researcher for health reform and private insurance at KFF and co-director of the KFF program on patient and consumer protection.
We also found that consumers can only fix their health insurance issues about half the time, while about 30 percent of those with issues either don’t try at all or give up, he added.
Other key findings included that the majority of consumers (51%) have difficulty understanding their coverage and how it works; that the majority (60%) are unaware that they have a legal right to appeal a denied claim; and that most (76%) don’t know which government agency to call when they have problems with their insurance.
And while some coverage issues could end up being a pain in the neck, Pollitz stressed that for some consumers, the consequences can be serious.
For example, among those who have had coverage problems in the past year, about 1 in 6 said that the result was delayed or no care. And a quarter said that when they got help, it cost more out of pocket than they expected.
David Allen, director of communications and public affairs for American Health Insurance Plans (AHIP, an advocacy and trade association of health insurance companies), countered the new KFF findings citing positive patient feedback from surveys of the AHIP.
For example, he pointed to AHIP data suggesting that about 6 in 10 adults with employer-based insurance are both satisfied with their coverage and rate the quality of their plan as high.
As for Medicaid patients, Allen said AHIP’s research suggests 84 percent are able to get regular access to needed care.
Every American deserves access to affordable, comprehensive, high-quality health care and coverage, Allen said. When people have an experience that isn’t the best it can be, health insurance providers take that feedback, learn from it, build on what works and fix what doesn’t, he added.
However, the KFF findings don’t sit well with Sara Collins, a senior scholar and vice president of health coverage and access and health system performance monitoring with The Commonwealth Fund (a foundation that aims to promote an equitable health system and High performance) .
His take on the findings: The purpose of health insurance is to enable people to access the health care they need to maintain their health,” she said. “This study shows that our health insurance system is failing many patients, especially those who need it most.
To arrive at this conclusion, Pollitz and his team conducted an online and telephone survey of more than 3,600 people between February and March, focusing on four patient groups: those who get their primary insurance through their jobs (978 patients); those covered by Medicare (885); those covered by insurance purchase directly through the Affordable Care Act (Obamacare) marketplace (880); and those covered by Medicaid (815).
On the upside, the majority of respondents (81%) said their health coverage was overall good or excellent.
That figure has fallen in tandem with the decline in health, however, dropping to just 67% among those who indicated their health was fair or poor.
And while expressing a generally positive view of their insurance, most respondents said they had some problems with their coverage.
While around 6 in 10 respondents said they had had an insurance problem in the previous year, that figure rose to around 67% among adults in poor or fair health. By comparison, only about 56% of those in good health reported a recent negative experience with their coverage.
Of those who have had problems with their insurance, about 1 in 6 said they couldn’t get the care they needed. Around 15% said their health had actually deteriorated as a result of such problems, and nearly 3 in 10 said they forked out more money than expected when they received treatment.
About a quarter of patients said they struggled to understand what was meant by deductibles and/or copays. A similar amount said they struggled to ascertain which healthcare providers and facilities were in the network.
The type of insurance also appeared to be related to the type of problem encountered, with denied claims more common among those with employer and/or Affordable Care Act insurance. a problem among those with Medicare or Medicaid.
The survey revealed that more than 4 in 10 of those who said their mental health was poor or fair reported not getting the treatment or medication they needed. About 1 in 5 said a specific psychiatric treatment they needed was not covered by their plan.
As for how to make things better, Pollitz said the poll also revealed overwhelming bipartisan support for measures to make insurance easier to use and understand and to make insurance problems easier to fix or avoid.
In particular, he highlighted the potential of Consumer Assistance Programs (CAPs), which were authorized by Congress in 2010 to provide free assistance to consumers in claims of denied insurance.
The problem: Congress has since failed to fund CAPs, so many have shut down or cut back on their services.
More information
There’s more about health insurance rights at HealthCare.gov.
SOURCES: Karen Pollitz, senior fellow, health reform and private insurance, and co-director, patient and consumer protection programme, KFF; Sara Collins, PhD, senior fellow and vice president, health coverage and access and health system performance monitoring, The Commonwealth Fund; David Allen, director, communications and public affairs, Americas Health Insurance Plans (AHIP); KFF survey, June 15, 2023
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