Data Brief | No. 99 | September 2021

North Carolina Residents Struggle to Afford High Healthcare Costs; COVID Fears Add to Support for a Range of Government Solutions Across Party Lines

Nationally, consumer worry about healthcare affordability is well documented in the U.S., but now—for the first time—a new survey reveals how affordability concerns and ideas for action play out in North Carolina.

Key Findings

A survey of more than 950 North Carolina adults, conducted from April 29, 2021 to May 25, 2021, found that:

  • More than 3 in 5 (63%) experienced healthcare affordability burdens in the past year;
  • More than 3 in 4 (78%) are worried about affording healthcare in the future;
  • Over half (54%) are worried about affording treatment for COVID-19 if they need it; and
  • Across party lines, respondents express strong support for government-led solutions.

Survey context: During the survey period, North Carolina residents were beginning to emerge from the public health mandates issued in the wake of the third COVID-19 surge. On April 28, Governor Roy Cooper removed the outdoor face covering requirement and relaxed restrictions on social gatherings by executive order.1 Initial steps at reopening began two months before on February 20, when, by Executive Order 195, the Governor lifted the Modified Stay at Home Order and eased restrictions on businesses and gatherings.2 New COVID-19 cases, hospitalizations and deaths had been on the decline since January and had reached an annual low of 892 daily cases as of March 13.3 Weekly initial unemployment claims averaged 49,486 in late April and 47,290 in late May 2021, compared to 547,988 in May 2020.4 

A Range of Healthcare Affordability Burdens

Like many Americans, North Carolina adults currently experience hardship due to high healthcare costs. All told, more than 3 in 5 (63%) of North Carolina adults experienced one or more of the following healthcare affordability burdens in the prior 12 months: 

1.) Being Uninsured Due to High Premium Costs

Well over one-third (37%) of uninsured adults 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 (55%) of North Carolina adults encountered one or more cost-related barriers to getting healthcare during the prior 12 months, including:

  • 34%—Delayed going to the doctor or having a procedure done
  • 32%—Skipped needed dental care
  • 31%—Cut pills in half, skipped doses of medicine or did not fill a prescription5
  • 29%—Skipped a recommended medical test or treatment
  • 28%—Avoided going to the doctor or having a procedure done altogether
  • 24%—Had problems getting mental healthcare or addiction treatment

Moreover, cost was by far the most frequently cited reason for not getting needed medical care, exceeding a host of other barriers like transportation, difficulty getting an appointment and lack of childcare. 

Of the various types of medical bills, the ones most frequently associated with an affordability barrier were doctor bills, dental bills and prescription drugs, likely reflecting the frequency with which North Carolina adults seek these services—or, in the case of dental, perhaps lower rates of coverage for these services. 

3.) Struggling to Pay Medical Bills

Other times, North Carolina adults got the care they needed but struggled to pay the resulting bill. Over 1 in 3 (39%) of North Carolina adults experienced one or more of these struggles to pay their medical bills: 

  • 18%—Contacted by a collection agency
  • 13%—Unable to pay for basic necessities like food, heat or housing 
  • 12%—Used up all or most of their savings 
  • 11%—Borrowed money, got a loan or another mortgage on their home
  • 8%—Racked up large amounts of credit card debt
  • 8%—Placed on a long-term payment plan

High Levels of Worry About Affording Healthcare in the Future

North Carolina adults also exhibit high levels of worry about affording healthcare in the future. Overall, 3 in 4 (78%) report being “worried” or “very worried” about affording some aspect of healthcare in the future, including:

  • 63%—Cost of affording nursing home or home care services
  • 61%—Health insurance will become too expensive
  • 61%—Medical costs when elderly
  • 59%—Medical costs in the event of a serious illness or accident

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 between the ages of 25-54. This finding indicates that residents may be worried about affording the cost of care for aging parents, in addition to themselves. 

Furthermore, 41% of respondents are “worried” or “very worried” about losing their health insurance. These concerns vary by type of insurance coverage, with people covered through Medicaid and those who buy health insurance on their own being most concerned about losing their coverage. Concerns about affording health insurance exceeded fears about losing coverage across all insurance types (see Figure 1). 

DB 99 Figure 1_.png

Income Differences in Healthcare Affordability Burdens

The survey also revealed income differences in how North Carolina adults experience healthcare affordability burdens. 

Affordability burdens affect families quite far up the income ladder, with nearly half (47%) of residents with household incomes of $100,000 per year or more struggling to afford healthcare in the past 12 months (see Figure 2). North Carolina residents earning less than $50,000 per year6 face the greatest burden, with 73% reporting affordability problems. 

Residents in the lower income brackets also report higher levels of worry about affording healthcare costs in the future; however, even households making more than $100,000 per year are worried about affording coverage and care (see Table 1). 

DB 99 Figure 2_.png

DB 99 Table 1_.png

Geographic Differences in Healthcare Affordability Burdens

Large shares of North Carolina adults living in rural and non-rural areas report high levels of worry about affording healthcare in the future. Overall, 78% of both rural and non-rural residents say they are “worried” or “very worried” (see Table 2). 

DB 99 Table 2.png

However, a closer look shows variation in types of worry across geographic areas. Rural residents report higher levels of worry about affording the cost of dental care, prescription drugs and losing their health insurance. Non-rural residents report higher levels of worry about health insurance becoming too expensive, affording nursing home and home care services, medical costs when elderly and the cost of a serious illness or accident.

Despite equal levels of worry overall, people in rural areas are more likely to have experienced at least one healthcare affordability burden in the prior 12 months. Sixty-eight percent of rural respondents report having been unable to afford some aspect of coverage or care, compared to 58% of non-rural adults. 

COVID Worries

In addition to affordability worries, North Carolina adults were asked about their top worries related to the COVID crisis.7 When asked about “Affording treatment of coronavirus/COVID-19 if you need it,” 54% of respondents were somewhat “worried” or “very worried.” 

Separately, out of twelve possible responses, respondents were asked to pick the top three things they were most worried about (see Table 3). “Becoming ill from the virus” was not only most frequently selected by respondents, but it exceeded other worries by a wide margin. Forty-six percent of respondents selected “Becoming ill from the virus” as one of their top three concerns, while 28% of respondents selected the next most common worry, “Struggling with anxiety/depression/other mental health issues,” as a top three concern. 

DB 99 Table 3.png

In smaller numbers, North Carolina adults worry about many other issues, including: decreased value of retirement savings (19%), job loss and resulting loss of health coverage (17%), safety at work—not getting the virus at work (16%) and unavailability of COVID treatment if they or a family member gets sick (11%).

Though the increased availability of COVID-19 vaccines may have somewhat lessened respondents’ worries surrounding the virus, it is important to note that over half of respondents remain somewhat or very worried.

Dissatisfaction with the Health System and Support for Change

In light of these healthcare affordability and COVID concerns, it is not surprising that North Carolina adults were generally dissatisfied with the health system. Statewide: 

  • Just 30% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
  • While 66% agreed or strongly agreed that “the system needs to change.” 

The survey asked about both personal and governmental actions to address health system problems. 

Personal Actions

North Carolina adults see a role for themselves in addressing healthcare affordability. Respondents reported specific actions they had already taken, like researching the cost of a drug beforehand (62%), as well as action they should be taking—73% said they would switch from a brand name to an equivalent generic drug if given a chance.

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

  • 68%—Take better care of my personal health
  • 39%—Research treatments myself, before going to the doctor
  • 32%—Write or call my STATE representative asking them to take action
  • 30%—Do more to compare doctors on cost and quality before getting services

Government Actions

But far and away, North Carolina residents see government as the key stakeholder that needs to act to address health system problems. Moreover, addressing healthcare problems is a top priority that North Carolina residents want their elected representatives 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:

  • 58%—Healthcare
  • 54%—Economy/Joblessness
  • 38%—Taxes

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

  • 46%—Address high healthcare costs, including prescription drugs 
  • 33%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition
  • 33%—Improve Medicare, coverage for seniors and those with serious disabilities

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

  • 63%—Drug companies charging too much money 
  • 63%—Hospitals charging too much money 
  • 60%—Insurance companies charging too much money 

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

  • 88%—Make it easy to switch insurers if a health plan drops your doctor
  • 87%—Show what a fair price would be for specific procedures
  • 87%—Require hospitals and doctors to provide up-front cost estimates to consumers
  • 87%—Ensure the cost of widely needed vaccines are affordable for all

There were also high levels of support for strategies to lower prescription drug costs:

  • 86%—Require drug companies to provide advance notice of price increases and information to justify those increases
  • 86%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription drug price hikes
  • 85%—Set standard prices for drugs to make them affordable
  • 84%—Prohibit drug companies from charging more in the U.S. than abroad

Support for Action Across Party Lines

What is remarkable about these findings is high support for change regardless of respondents’ political affiliation (see Tables 4 and 5). 

DB 99 Table 4.png

DB 99 Table 5.png

Policies to Address COVID Concerns

In addition to residents’ views on the policies and approaches above, respondents were asked about support for and against policies related to the COVID crisis. Out of eleven possible responses, respondents were asked to pick the top three policies that would help address COVID-related problems. There was significant diversity in the policies supported, with the highest percentages of respondents selecting “Improved Public Health Emergency Preparedness” and “Universal Health Coverage for All” as a top three priority (see Table 6). “More financial help for large businesses” received the least support, as it was a priority for only a small percentage of respondents.

DB 99 Table 6.png

When respondents were asked about which policies they did NOT support, 32% indicated that they did not support “More financial help for large businesses.” Trailing behind that (with 25% of respondents selecting) was “Universal health coverage for all,” although a higher percentage of respondents indicated support. In this area, there was a lack of agreement across party lines, with Republicans far more likely to NOT support “Universal health coverage for all” as a means to address COVID-19 concerns, compared to Democrats and those not affiliated with either party (see Table 7). It is important to note, however, that when asked generically about “Expanding health insurance options so that everyone can afford quality coverage,” 85% of respondents agreed or strongly agreed with this policy as a means of improving affordability, with high levels of support across party lines.

DB 99 Table 7.png

When asked about the policies they did NOT support, respondents were given the option of selecting “I support all of the policies listed.” Thirty-one percent of respondents selected this option.

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 current COVID crisis is leading 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. 


1. Executive Order No. 209, Removing the Outdoor Face Covering Requirement, Relaxing Restrictions on Gatherings, and Extending the Capacity and Social Distancing Measures of Executive Order No. 204, April 28, 2021.

2. Executive Order No. 195, Lifting the Modified Stay at Home Order and Easing Certain Restrictions on Businesses and Gatherings, Feb. 24, 2021.

3. North Carolina Department of Health and Human Services, Cases, (accessed on Sept. 10, 2021).

4. Unites States Department of Labor, Unemployment Insurance Weekly Claims Data - Report r539cy, (accessed on Sept. 10, 2021).

5. Of the current 55% of North Carolina adults who encountered one or more cost-related barriers to getting healthcare during the prior 12 months, 24% did not fill a prescription, while 22% cut pills in half or skipped doses of medicine due to cost.

6. Median household income in North Carolina was $54,602 (2015-2019). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts: North Carolina

7. COVID-19 is the disease caused by the coronavirus, which was characterized as a pandemic by the World Health Organization on March 11, 2020. For a comparison of how respondents from Connecticut, Kentucky, Mississippi and New Jersey answered our COVID questions, please see Healthcare Value Hub, How COVID Has Shaped Residents’ Broader Attitudes Towards the Health System, Data Brief No. 86.


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. 

The survey used a web panel from Dynata with a demographically balanced sample of approximately 1,000 respondents who live in North Carolina. 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 981 cases for analysis. After those exclusions, the demographic composition of respondents was as follows, although not all demographic information has complete response rates:

NC Demo Table.png