Data Brief | No. 149 | January 2023

California Respondents Struggle to Afford High Healthcare Costs; Worry about Affording Healthcare in the Future; Support Government Action across Party Lines

Key Findings

A survey of more than 1,100 California adults, conducted from November 3 to November 15, 2022, found that:

• Nearly 3 in 5 (57%) experienced at least one healthcare affordability burden in the past year;
• More than 4 in 5 (81%) worry about affording healthcare in the future;
• Lower-income respondents and respondents with disabilities reported higher rates of going without care and incurring 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, California respondents experience hardship due to high healthcare costs. All told, well over half (57%) of respondents experienced one or more of the following healthcare affordability burdens in the prior 12 months:  

1) Being Uninsured Due to High Costs 

Nearly one-half (45%) 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 Going Without Healthcare Due to Cost 

Half (50%) of all respondents reported doing one or more of the following to during the prior 12 months due to cost:

• 32%—Skipped needed dental care 
• 28%—Delayed going to the doctor or having a procedure done 
• 23%—Cut pills in half, skipped doses of medicine or did not fill a prescription1 
• 22%—Skipped a recommended medical test or treatment 
• 23%—Avoided going to the doctor or having a procedure done altogether 
• 20%—Had problems getting mental healthcare or addiction treatment 
• 12%—Skipped or delayed getting a medical assistive device 

Moreover, when asked about the most common reason for not getting needed medical care, cost exceeded a host of other barriers such as getting time off work, transportation and a lack of childcare.

3) Struggling to Pay Medical Bills 

Other times, respondents got the care they needed but struggled to pay the resulting bill. Over one-third (35%) experienced one or more of these struggles to pay their medical bills: 

• 15%—used up all or most of their savings
• 12%—were unable to pay for necessities like food, heat or housing
• 11%—were contacted by a collection agency
• 11%—borrowed money, received a loan or took out another mortgage on their home
• 10%—racked up large amounts of credit card debt
• 6%—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 California respondents seek these services. Trouble paying for dental bills likely reflects lower rates of coverage for these services. Similarly, 6% of respondents reported struggling to afford the cost of a hospitalization in the past twelve months. Although hospital bills are less prevalent than other medical bills, the costs associated with hospitalization often eclipse those of doctor bills, dental bills and prescription drugs. 

High Levels of Worry About Affording Healthcare in the Future 

California respondents also exhibit high levels of worry about affording healthcare in the future. Four in five (81%) reported being “worried” or “very worried” about affording some aspect of healthcare in the future, including: 

• 63%—Cost of nursing home or home care services 
• 63%—Health insurance will become unaffordable 
• 61%—Medical costs when elderly 
• 59%—Medical costs in the event of a serious illness or accident 
• 57%—Cost of dental care 
• 51%—Prescription drugs will become unaffordable 
• 37%—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 25-54. This finding suggests that California respondents may be worried about affording the cost of care for both aging parents and themselves.  

Worry about affording healthcare was highest among respondents living in lower- and middle-income households and among those living in households with a person with a disability (see Table 1). More than 4 in 5 (88% of) respondents with household incomes of less than $50,000 per year2 reported worrying about affording some aspect of coverage or care in the past year.  Still, most California respondents of all incomes, races, ethnicities, geographic setting and levels of ability are somewhat or very concerned.  

Concern that health insurance will become unaffordable is also more prevalent among certain groups of California respondents. By insurance type, respondents with coverage that they have purchased on their own, not through their employer, most frequently reported worrying about affording coverage, along with respondents with California Medicaid (Medi-Cal) (see Figure 1). 

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Respondents with household incomes below $50,000 per year reported the highest rates of worry about losing coverage as well as affording coverage. California respondents living in the more rural areas of California (the Central Valley, High Sierra and Central Coast regions) and those living in households with a person with a disability were most frequently concerned about losing health insurance compared to respondents living in other regions of the state or those living in a household without a person with a disability (see Table 2).  

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

Differences in Healthcare Affordability Burdens 

The survey also revealed differences in how California respondents experience healthcare affordability burdens by income, age, geographic setting, race, ethnicity 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-fourths (70%) 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 higher rates of going without care and rationing their medication due to cost (see Figure 3). 

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Further analysis found that California respondents ages 18-44 reported higher rates of going 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.  

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Insurance Type 

Respondents with Medi-Cal coverage reported the highest rates of going without care due to cost and rationing medication, followed by respondents with insurance they purchase on their own (see Figure 5). Still, over two-fifths of respondents with Medicare went without care due to cost in the twelve months prior to taking the survey. 

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Race and Ethnicity 

California respondents of color reported higher rates of rationing medication and forgoing care than white respondents. Fifty-seven percent of Black respondents, 52% of BIPOC respondents and 55% of Hispanic/Latino/a (all races) went without care due to cost in the past twelve months compared to 37% of white, non-Hispanic/Latino/a respondents (see Table 3).  Further analysis showed that respondents of color also reported higher rates of challenges receiving mental healthcare and skipping needed dental care (see Figure 6, 7, and 8). 

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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. Seven in ten (70% of) respondents in this group reported going without some form of care and 41% reported rationing medication, compared to 43% and 17% 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). 

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Those with disabilities also face healthcare affordability burdens unique to their disabilities—27% 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 7% 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 necessities (like food, heat and housing) by income, race, ethnicity, disability status and geographic setting.  

Thirty-eight percent of BIPOC respondents and 41% of Hispanic/Latino/a respondents reported going into debt, depleting savings or going without other needs due to medical bills, compared to 18% of white, non-Hispanic/Latino/a respondents (see Table 5).  

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The rate of financial burden is even higher for respondents who have or live with a person with a disability, with nearly three-fifths (56%) reporting going into debt or going without other needs due to medical bills, compared to 27% of respondents living in households without a disabled member. Geographically, respondents in the more rural areas of California (the Central Valley, High Sierra and Central Coast regions) and Los Angeles Metro Area reported similar rates of going into debt, depleting savings or going without other needs due to medical bills. In addition, respondents who purchased health insurance coverage on their own, not through their employer or family member’s employer, reported the highest rate of the above financial burdens due to medical bills (51%) compared to respondents with all other insurance types. 

Dissatisfaction with the Health System and Support for Change 

Considering California respondents’ healthcare affordability burdens and concerns, it is not surprising that they are dissatisfied with the health system:  

• Just 28% agreed or strongly agreed that “we have a great healthcare system in the U.S.,” 
• While 70% 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  

California respondents have tried to individually respond to affordability issues in a variety of ways. When asked about specific actions they could take: 

• 50% of respondents reported researching the cost of a drug beforehand, and 
• 70% said they would be willing to switch from a brand name to an equivalent generic drug if given 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:  

• 73%—Take better care of my personal health  
• 45%—Research treatments myself, before going to the doctor  
• 32%—Do more to compare doctors on cost and quality before getting services  
• 22%—There is not anything I can do personally to make our health system better 

Government Actions  

Far and away, California 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: 

• 51%—Economy/Joblessness 
• 42%—Affordable Housing 
• 40%—Healthcare  

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

• 44%—Address high healthcare costs, including prescription drugs  
• 40%—Get health insurance to those who cannot afford coverage3 
• 31%—Improve Medicare, coverage for seniors and those with serious disabilities 

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

• 72%—Drug companies charging too much money  
• 69%—Hospitals charging too much money  
• 67%—Insurance companies charging too much money  

When it comes to tackling costs, respondents endorsed several strategies, including:   

• 92%—Make it easy to switch insurers if a health plan drops your doctor   
• 91%—Require insurers to provide up-front cost estimates to consumers 
• 91%—Show what a fair price would be for specific procedures 
• 91%­—Cap out-of-pocket costs for life-saving medications, such as insulin 
• 91%—Require drug companies to provide advanced notice of prices increases and information to justify those increases 
• 91%—Ensure patients can’t be charged out-of-network prices if they encounter an out-of-network provider through no fault of their own 
• 91%—Expand health insurance options so that everyone can afford quality coverage 
• 90% - Fund home and community-based programs for people with disabilities to ensure everyone can access affordable long-term services and supports, regardless of income 
• 89%—Require hospitals and doctors to provide up-front cost estimates to consumers 
• 89%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription price hikes 

Support for Action Across Party and Racial/Ethnic Lines 

There is also remarkable support for change regardless of respondents' political affiliation, race or ethnicity (see Table 6 and 7).  

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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 progress is being made.   

Notes 

1. Of the current 50% of California respondents who encountered one or more cost-related barriers to getting healthcare during the prior 12 months, 17% did not fill a prescription, while 16% cut pills in half or skipped doses of medicine due to cost. 
2. Median household income in California was $78,672 (2016-2020). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts: California 
3. Over 2 in 3 (70% 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 BIPOC group respondents (73%) and those earning between $50k-$75k annually (77%). 

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 possible policy solutions. This survey, conducted from November 3 to November 15, 2022, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,249 respondents who live in California. Information about Dynata’s recruitment and compensation methods can be found here. 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 1,129 cases for analysis. After those exclusions, the demographic composition of respondents was as follows, although not all demographic information has complete response rates:

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Percentages in the body of the brief are based on weighted values, while the data presented in the demographic table is unweighted. An explanation of weighted versus unweighted variables is available here. 

Altarum does not conduct statistical calculations on the significance of differences between groups in findings. Therefore, determinations that one group experienced a significantly different affordability burden than another should not be inferred. Rather, comparisons are for conversational purposes. The groups selected for this brief were selected by advocate partners in each state based on organizational/advocacy priorities. We do not report any estimates under N=100 and a co-efficient of variance more than 0.30.