A majority of insured Americans have struggled with a wide array of stumbling blocks when trying to get coverage for their healthcare needs, a new national survey shows.
All told, the KFF report uncovered numerous obstacles to coverage with all types of health insurance, including an inability to find a covered in-network provider; delays in getting needed care; unexpected out-of-pocket costs; problems meeting pre-authorization requirements; and outright denial of claims.
“We found that most people — about 60% — experience problems when they try to use their coverage,” noted survey lead Karen Pollitz, a senior fellow for health reform and private insurance at KFF and co-director of KFF’s program on patient and consumer protections.
“We also found consumers can only fix their health insurance problems about half of the time, while about 30% of those with problems don’t try at all or give up,” she added.
Other main findings included that most consumers (51%) have difficulty understanding their coverage and how it works; that most (60%) are unaware that they have legal rights to appeal a denied claim; and that most (76%) don’t know what government agency to call when they have problems with their insurance.
And while some coverage issues “may just end up being a pain in the neck,” Pollitz stressed that “for some consumers, the consequences can be serious.”
For instance, among those who experienced coverage problems in the last year, roughly 1 in 6 said the result was delayed care or no care at all. And one-quarter said that when they did get care, it cost more out-of-pocket than they had been expecting.
David Allen, director of communications and public affairs for America’s Health Insurance Plans (AHIP, an advocacy and trade association of health insurance companies), countered the new KFF findings by citing positive patient feedback from AHIP’s own surveys.
For instance, he pointed to AHIP data suggesting that about 6 in 10 of 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 that 84% are able to gain regular access to needed care.
“Every American deserves access to affordable, comprehensive, high-quality care and health 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.
Still, the KFF findings do not sit well with Sara Collins, senior scholar and vice president of healthcare coverage and access & tracking health system performance with The Commonwealth Fund (a foundation that aims to promote a high-performing, equitable healthcare system).
Her take on the results: “The purpose of health insurance is to enable people access to the healthcare 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 that conclusion, Pollitz and her team conducted an online and phone survey of more than 3,600 people between February and March that focused on four groups of patients: those who get their primary insurance through their job (978 patients); those covered by Medicare (885); those covered by insurance they buy directly through the Affordable Care Act (Obamacare) marketplace (880); and those covered by Medicaid (815).
On the upside, most of those surveyed (81%) said their health coverage was either “good” or “excellent” overall.
That figure dipped in lockstep with declining health, however, falling to just 67% among those who indicated their health was “fair” or “poor.”
And even while expressing a generally positive view of their insurance, most of those surveyed said they’d had some problems with their coverage.
While about 6 in 10 of all respondents said they’d run into an insurance problem in the prior year, that figure rose to about 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.
Among those who experienced insurance problems, about 1 in 6 said they couldn’t get the care they needed as a result. About 15% said their health actually got worse as a consequence of such problems, and nearly 3 in 10 said when they did get care they shelled out more money for it than anticipated.
About one-quarter of patients said they struggled to figure out what was meant by “deductibles” and/or “copays.” A similar amount said they struggled to ascertain which caregivers and facilities were in-network.
Insurance type also seemed to be linked to the type of problem experienced, with claim denials more common among those with employer and/or Affordable Care Act insurance. By contrast, finding in-network providers was more of 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 care or drugs they needed. About 1 in 5 said a specific psychiatric treatment they needed was not covered by their plan.
As to how to make things better, Pollitz said that the survey 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, she pointed to the potential of “consumer assistance programs” (CAPs), which were authorized by Congress back in 2010 to provide free consumer assistance in appealing insurance denials.
The problem: Congress has failed to fund CAPs since then, so many have closed or scaled back their services.
There’s more on health insurance rights at HealthCare.gov.
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