A survey of more than 1,100 California adults, conducted from November 3 to November 15, 2022, found that:
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:
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:
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.
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:
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).
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).
Concerns about affording coverage exceeded fears about losing coverage across all income groups, disability statuses, geographic settings, race, ethnicity and coverage types.
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).
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.
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.
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).
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).
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).
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.
Considering California respondents’ healthcare affordability burdens and concerns, it is not surprising that they are dissatisfied with the health system:
To investigate further, the survey asked about both personal and governmental actions to address health system problems.
California respondents have tried to individually respond to affordability issues in a variety of ways. When asked about specific actions they could take:
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:
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:
When asked about the top three healthcare priorities the government should work on, the top vote getters were:
Of more than 20 options, California respondents believe the reason for high healthcare costs is unfair prices charged by powerful industry stakeholders:
When it comes to tackling costs, respondents endorsed several strategies, including:
There is also remarkable support for change regardless of respondents' political affiliation, race or ethnicity (see Table 6 and 7).
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.
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:
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.