Despite significant progress in expanding health insurance coverage since the enactment of the Affordable Care Act (ACA), millions of people still face critical gaps in access and affordability.

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Despite significant progress in expanding health insurance coverage since the enactment of the Affordable Care Act (ACA), millions of Americans still face critical gaps in access and affordability to health care.¹ In 2023, 8% of Americans, or 26 million people, were still uninsured, a marked improvement from the 16% uninsured rate before the ACA.

While a record 21 million people enrolled in marketplace plans, by 2024, nearly one in four working-age adults remained underinsured, saddled with high out-of-pocket costs and deductibles that make timely care inaccessible. Results of The Commonwealth Fund released today reveal alarming trends: 57% of underinsured adults have avoided needed medical care due to cost, 2 in 5 have reported worsening health, and nearly 30% are burdened by medical debt – the half owe $2,000 or more.

The ACA brought sweeping reforms, such as protecting pre-existing conditions, extending parental coverage to young adults up to age 26, and ensuring gender equity in premiums. Yet in 2024, 9% of adults lacked health insurance, and an additional 12% reported coverage gaps in the past year. A majority (56%) had continuous and adequate coverage; Regardless, nearly a quarter (23%) were underinsured and faced significant out-of-pocket costs or deductibles.

The underinsured

The survey defined underinsured individuals as those whose out-of-pocket expenses or deductibles represented a substantial portion of their income after premiums were excluded.

The results show that the emphasis on employer-sponsored insurance fails to protect against the growing trend toward higher deductibles and cost sharing in these plans. This year, among insured working-age Americans, 66% were in employer-sponsored plans, 16% were covered by Medicaid or Medicare, and 14% were enrolled in the ACA marketplace or individual plans.

Many underinsured adults faced financial barriers to accessing care, with 57% avoiding needed health services due to cost and 44% having medical or dental debt.

Consequences of cost barriers

The financial strain of being uninsured or underinsured was demonstrated by 41% of adults who delayed care due to costs and reported worsening health conditions. Nearly 30% of adults with chronic illnesses have skipped prescriptions due to expense. Adults without continued coverage experienced the highest rates of unmet dental and mental health needs.

For many, medical debt compounds these challenges. About 48% of people in debt owed $2,000 or more, often because of hospital stays or ongoing treatment for chronic illnesses. The stress of debt has led a third of affected adults to avoid additional care or prescriptions.

Need to improve coverage and affordability policies

Coverage extension

The report called for the permanent extension of enhanced tax credits. The grants drove record enrollments in the ACA marketplaces. Permanent tax credits could stabilize premiums and prevent coverage losses.

Closing the Medicaid coverage gap was also indicated, as federal options have the potential to expand Medicaid-like coverage to 1.5 million uninsured people in non-expansion states. Streamlining continued coverage would allow policies that extend Medicaid eligibility by 12 months to reduce gaps caused by administrative churn. Implementing automatic enrollment would make it easier for people to qualify for Medicaid or Marketplace plans and could significantly reduce uninsured rates.

Fighting underinsurance and financial protections

Reducing deductibles and out-of-pocket costs by adjusting the ACA’s benchmark plans from silver to gold could significantly improve affordability for middle-income households, providing better financial protection. The report says employers can also play a role in reducing the burden on low-income workers by increasing premiums and deductibles based on employees’ wages, ensuring that health care costs are more equitable .

Additionally, strengthening medical debt protections through federal and state measures, such as banning medical debt from appearing on credit reports and improving hospital financial assistance programs, can help solve the growing debt crisis and ease financial pressure on individuals and families.

Leverage purchasing power, consider public plans

The report calls on public and private payers to address the root cause of high health care costs linked to provider and pharmaceutical prices. With the option of a public plan, federal and state policymakers could introduce public insurance solutions to increase competition and reduce costs.

“The relentless growth in the cost of health care, driven primarily by the prices commercial insurers and employers pay to providers and pharmaceuticals, is driving the nation’s medical debt and affordability crisis commercial insurance,” the authors said. “Ultimately, private payers will need to better leverage their purchasing power to slow cost growth in commercial markets. Federal and state policymakers could help, for example, by creating new public plan options.”

Looking ahead to health care in the United States

The United States has made significant progress in expanding access to health insurance, but gaps in affordability and coverage persist for millions of Americans. The report’s findings highlight that strengthening protections under the ACA, addressing high costs, and closing gaps in Medicaid and marketplace coverage are critical steps to achieving a more equitable health care system. Without sustained policy action, the risk of a reversal of coverage gains looms, threatening the health and financial security of many Americans.

References

1. Collins SR, Gupta A. The state of health insurance coverage in the United States: results from the 2024 Commonwealth Fund Biennial Health Insurance Survey. The Commonwealth Fund. November 21, 2024. Accessed November 21, 2024.