Nationally, consumer worry about healthcare affordability has been well documented, but now—for the first time a new survey looks specifically at how affordability concerns and ideas for action play out in Indiana.

Key Findings

• A survey of 1,249 Indiana adults, conducted from October 6 to October 11, 2022, found that:
• Nearly 3 in 4 (72%) of respondents agreed or strongly agreed that “the system needs to change.”
• More than 3 in 5 (63%) experienced at least one healthcare affordability burden in the past year;
• More than 4 in 5 (83%) worry about affording healthcare in the future;
• Lower-income respondents and respondents with disabilities are more likely to go without care and incur debt due to healthcare costs; and
• Across party lines, respondents express strong support for government-led solutions.

A Range of Healthcare Affordability Burdens

Like many Americans, Indiana adults experience hardship due to high healthcare costs. All told, well over half (63%) of respondents¹ experienced one or more of the following healthcare affordability burdens in the prior 12 months:

1) Being Uninsured Due to High Premium Costs

Nearly one-half (49%) of uninsured respondents cited “too expensive” as the major reason for not having coverage, far exceeding other reasons like “don’t need it” and “don’t know how to get it.”

2) Delaying or Forgoing Healthcare Due to Cost

More than half (56%) of all respondents reported delaying or going without healthcare during the prior 12 months due to cost:

• 37%—Skipped needed dental care
• 33%—Delayed going to the doctor or having a procedure done
• 30%—Cut pills in half, skipped doses of medicine or did not fill a prescription²
• 27%—Avoided going to the doctor or having a procedure done altogether
• 26%—Skipped a recommended medical test or treatment
• 19%—Had problems getting mental healthcare or addiction treatment
• 13%—Skipped or delayed getting a medical assistive device

Moreover, 24% of all respondents cited cost as the most frequently cited reason for them or a family member not getting needed medical care in the past year, exceeding a host of other barriers like difficulty getting an appointment, transportation and lack of childcare.

3) Struggling to Pay Medical Bills

Other times, respondents got the care they needed but struggled to pay the resulting bill. Two in five (40%) experienced one or more of these struggles to pay their medical bills:

• 19%—Were contacted by a collection agency
• 15%—Used up all or most of their savings
• 13%—Were unable to pay for basic necessities like food, heat or housing
• 11%—Racked up large amounts of credit card debt
• 11%—Borrowed money, got a loan or another mortgage on their home
• 9%—Were placed on a long-term payment plan

Of the various types of medical bills, the ones most frequently associated with an affordability barrier were doctor bills, dental bills and prescription drugs. The high prevalence of affordability burdens for these services likely reflects the frequency with which Indiana respondents seek these services. Trouble paying for dental bills likely reflects lower rates of coverage for these services.

High Levels of Worry About Affording Healthcare in the Future

Indiana respondents also exhibit high levels of worry about affording healthcare in the future. Four in five (83%) reported being “worried” or “very worried” about affording some aspect of healthcare in the future, including:

• 66%—Cost of nursing home or home care services
• 66%—Health insurance will become unaffordable
• 64%—Medical costs when elderly
• 63%—Medical costs in the event of a serious illness or accident
• 55%—Prescription drugs will become unaffordable
• 54%—Cost of dental care
• 34%—Cost of treatment for coronavirus/COVID-19

While two of the most common worries—affording the cost of nursing home or home care services and medical costs when elderly—are applicable predominantly to an older population, they were most frequently reported by respondents ages 35-54. This finding suggests that Indiana respondents may be worried about affording the cost of care for both aging parents and themselves.

Worry about affording healthcare, generally, was highest among respondents living in lower- and middle-income households, respondents of color and those living in households with a person with a disability (see Table 1). More than 4 in 5 (85%) of respondents with household incomes of less than $50,000 per year³ reported worrying about affording some aspect of coverage or care in the past year. Still, the vast majority of Indiana respondents of all incomes, races, ethnicities and levels of ability statewide are somewhat or very concerned.

Concern that health insurance will become unaffordable is also more prevalent among certain groups of Indiana respondents. By insurance type, respondents with coverage that they have purchased on their own through the healthcare marketplace and not through their employer, most frequently reported worrying about affording coverage, followed by respondents with coverage through their employer and those with Indiana Medicaid (see Figure 1).

Respondents with household incomes below $50,000 per year reported the highest rates of worry about losing coverage, while those with household incomes between $50,000 and $75,000 reported the highest rates of worry about affording coverage. Non-rural respondents and those living in households with a person with a disability were more likely to be concerned about losing health insurance specifically than their rural and non-disabled counterparts (see Table 2).

Concerns about affording coverage exceeded fears about losing coverage across all income groups, disability statuses, geographic settings and coverage types.

Differences in Healthcare Affordability Burdens

The survey also revealed differences in how Indiana respondents experience healthcare affordability burdens by income, age, geographic setting and disability status.

Income and Age

Unsurprisingly, respondents at the lowest end of the income spectrum most frequently reported experiencing one or more healthcare affordability burdens, with nearly three-quarters (72%) of those earning less than $50,000 per year reporting struggling to afford some aspect of coverage or care in the past 12 months (see Figure 2). This may be due, in part, to respondents in this income group reporting high rates of going without care and rationing their medication due to cost (see Figure 3).

Further analysis found that Indiana respondents ages 18-44 were more likely to go without care due to cost than respondents ages 45 and up (see Figure 4). Respondents ages 18-44 also most frequently reported rationing medication due to cost, compared to other age groups.

Insurance Type

Respondents with Indiana Medicaid coverage reported the highest rates of going without care due to cost and rationing medication (see Table 3). Still, over half of respondents with private insurance coverage went without care due to cost (53%).

Race

Indiana respondents of color reported higher rates of rationing medication and forgoing care than white respondents. Fifty-nine percent of respondents of color reported going without care due to cost, compared to 55% of white respondents (see Table 3). Further analysis showed that respondents of color also reported slightly higher rates of challenges receiving mental health care, challenges receiving addiction treatment and skipping needed dental care (see Figure 5).

Disability Status

Of all the demographic groups measured, respondents living in households with a person with a disability reported the highest rates of going without care and rationing medication due to cost in the past 12 months. Nearly 7 in 10 (68%) respondents in this group reported going without some form of care and 40% reported rationing medication, compared to 50% and 25% of respondents living in households without a person with a disability, respectively (see Table 3). Respondents living in households with a person with a disability also more frequently reported delaying or skipping getting mental healthcare, addiction treatment and dental care, among other healthcare services, than those in households without a person with a disability due to cost concerns (see Table 4).

Those with disabilities also face healthcare affordability burdens unique to their disabilities—22% of respondents reporting a disability in their household reported delaying getting a medical assistive device such as a wheelchair, cane/walker, hearing aid or prosthetic limb due to cost. Just 9% of respondents without a person with a disability, who may have needed such tools temporarily or may not identify as having a disability, reported having this experience.

Encountering Medical Debt

The survey also showed differences in the prevalence of financial burdens due to medical bills, including going into medical debt, depleting savings and being unable to pay for basic necessities (like food, heat and housing) by income, race, disability status and geographic setting. Fifty-five percent of respondents of color reported going into debt, depleting savings or going without other needs due to medical bills, compared to 38% of white respondents (see Table 5).

The rate of financial burden is even higher for respondents who have or live with a person with a disability, with more than half (53%) reporting going into debt or going without other needs due to medical bills, compared to 35% of respondents living in households without a disabled member.

Geographically, Indiana respondents living in non-rural counties reported higher rates of going into debt or going without other needs due to medical bills (43%) than respondents from rural counties (40%). In addition, respondents with Indiana Medicaid reported the highest rate of the above financial burdens due to medical bills (53%) compared to respondents with all other insurance types.

Dissatisfaction with the Health System and Support for Change

In light of Indiana respondents’ healthcare affordability burdens and concerns, it is not surprising that they are dissatisfied with the health system:

• Just 28% of respondents agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
• While 72% of respondents agreed or strongly agreed that “the system needs to change.”

To investigate further, the survey asked about both personal and governmental actions to address health system problems.

Personal Actions

Indiana respondents see a role for themselves in addressing healthcare affordability. When asked about specific actions they could take:

• 54% of respondents reported researching the cost of a drug beforehand, and
• 80% said they would be willing to switch from a brand name to an equivalent generic drug ifgiven the chance.

When asked to select the top three personal actions they felt would be most effective in addressing healthcare affordability (out of ten options), the most common responses were:

• 69%—Take better care of my personal health
• 41%—Research treatments myself, before going to the doctor
• 31%—Do more to compare doctors on cost and quality before getting services
• 27%—There is not anything I can do personally to make our health system better

Government Actions

But far and away, Indiana respondents see government as the key stakeholder that needs to act to address health system problems. Moreover, addressing healthcare problems is one of the top priorities that respondents want their elected officials to work on.

At the beginning of the survey, respondents were asked what issues the government should address in the upcoming year. The top vote getters were:

• 50%—Economy/Joblessness
• 48%—Healthcare
• 34%—Taxes

When asked about the top three healthcare priorities the government should work on, the top vote getters were:

• 53%—Address high healthcare costs, including prescription drugs
• 35%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition
• 33%—Get health insurance to those who cannot afford coverage⁴
• 32%—Improve Medicare, coverage for seniors and those with serious disabilities

Of more than 20 options, Indiana respondents believe the reason for high healthcare costs is unfair prices charged by powerful industry stakeholders:

• 75%—Drug companies charging too much money
• 72%—Hospitals charging too much money
• 69%—Insurance companies charging too much money

When it comes to tackling costs, respondents endorsed a number of strategies, including:

• 93%—Make it easy to switch insurers if a health plan drops your doctor
• 92%—Require insurers to provide up-front cost estimates to consumers
• 92%—Show what a fair price would be for specific procedures
• 92%—Require hospitals and doctors to provide up-front cost estimates to consumers
• 92%—Require drug companies to provide advanced notice of prices increases and information to justify those increases
• 92%—Ensure patients can’t be charged out-of-network prices if they encounter an out-ofnetwork provider through no fault of their own
• 91%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription price hikes
• 91%—Expand health insurance options so that everyone can afford quality coverage
• 91%—Cap out-of-pocket costs for life-saving medications, such as insulin

Support for Action Across Party Lines

There is also remarkable support for change regardless of respondents’ political affiliation (see Table 6).

The high burden of healthcare affordability, along with high levels of support for change, suggest that elected leaders and other stakeholders need to make addressing this consumer burden a top priority. Moreover, the COVID crisis has led state residents to take a hard look at how well health and public health systems are working for them, with strong support for a wide variety of actions. Annual surveys can help assess whether or not progress is being made.

Notes

1. Percentages included in this brief are out of total number of respondents (N = 1,249) unless stated otherwise.
2. Of the current 56% of Indiana respondents who encountered one or more cost-related barriers to getting
   healthcare during the prior 12 months, 24% did not fill a prescription, while 18% cut pills in half or skipped doses of medicine due to cost.
3. Median household income in Indiana was $58,235 (2016-2020). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts: Indiana
4. Nearly 2 in 3 (65%) of respondents said that they would consider using their tax forms to sign up for free or low-cost health insurance if they or their family needed it. This high level of interest persisted across racial, and income groups, with the highest levels of interest among Black/African American group respondents (72%) and those earning less than $50k annually (66%).

Methodology

Altarum’s Consumer Healthcare Experience State Survey (CHESS) is designed to elicit respondents’ unbiased views on a wide range of health system issues, including confidence using the health system, financial burden, and views on fixes that might be needed. 

This survey, conducted from October 6 to October 11, 2022, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,335 respondents who live in Indiana. The survey was conducted in English or Spanish and restricted to adults ages 18 and older. Respondents who finished the survey in less than half the median time were excluded from the final sample, leaving 1,249 cases for analysis. After those exclusions, the demographic composition of respondents was as follows, although not all demographic information has complete response rates: