Data Brief | | August 2024

Oregon Survey Respondents Struggle to Afford High Health Care Costs; Worry about Affording Health Care in the Future; Support Government Action Across Party Lines

Key Findings

A survey of more than 1,400 Oregon adults, conducted from June 6 to June 17, 2024, found that:

• Over 3 in 4 (76%) experienced at least one health care affordability burden in the past year;
• Over 4 in 5 (83%) worry about affording health care in the future;
• Nearly 3 in 4 (74%) of all respondents delayed or went without health care due to cost in the last twelve months;
• Low-income respondents and those with disabilities had higher rates of going without care due to cost and incurring medical debt, depleting savings, and/or sacrificing basic needs due to medical bills; and
• Across party lines, respondents express strong support for government-led solutions.

A Range of Health Care Affordability Burdens

Like many Americans, Oregon adults experience hardship due to high health care costs. In the past twelve months, seven out of ten (76%) respondents experienced at least one of the following health care
affordability burdens:

1) Being Uninsured Due to High Costs

Nearly two in five (39%) uninsured respondents cited cost (“too expensive”) as the primary reason for
being uninsured, surpassing other potential responses such as “don’t need it” and “don’t know how to
get it.” Likewise, 42% of respondents without dental insurance and 34% of those without vision insurance
cited cost as the main reason for not having coverage.

2) Delaying or Going Without Health Care Due to Cost

Nearly three quarters (74%) of all respondents reported delaying or going without health care during the
prior 12 months due to cost:

• 27%—Skipped needed dental care
• 27%—Cut pills in half, skipped doses of medicine or did not fill a prescription¹
• 25%—Delayed going to the doctor or having a procedure done
• 22%—Skipped a recommended medical test or treatment
• 24%—Had problems getting mental health care or addiction treatment²
• 18%—Skipped needed vision services
• 17%—Avoided going to the doctor or having a procedure done altogether
• 7%—Skipped needed hearing services
• 7%—Skipped or delayed getting a medical assistive device

Moreover, respondents most frequently cited cost and an inability to get an appointment as the reasons
for them or their family members not getting care in the last year, exceeding other barriers like getting
time off work, transportation, and lack of childcare.

3) Struggling to Pay Medical Bills

Other times, respondents got the care they needed but experienced a cost burden due to the resulting
medical bill(s). Over two-fifths (43%) of respondents reported experiencing one or more of these
struggles to pay their medical bills:

• 14%—Used up all or most of their savings
• 14%—Were unable to pay for basic necessities like food, heat or housing
• 12%—Were contacted by a collection agency
• 12%—Borrowed money, got a loan or another mortgage on their home
• 10%—Racked up large amounts of credit card debt
• 8%—Were placed on a long-term payment plan
• 8% - Asked for donations (GoFundMe campaigns)

High Levels of Worry About Affording Health Care in the Future

Oregon respondents also exhibit high levels of worry about affording health care in the future. Over four
in five (83%) reported being “worried” or “very worried” about affording some aspect of health care in the
future, including:

• 67%—Cost of nursing home or home care services
• 64%—Medical costs when elderly
• 61%—Medical costs in the event of a serious illness or accident
• 60%—Health insurance will become unaffordable
• 51%—Prescription drugs will become unaffordable
• 57%—Cost of dental care
• 52%—Cost of needed vision services
• 50%—Cost of needed hearing services

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 younger respondents. Respondents aged 25-34 reported the highest worry about
medical costs in old age, and those aged 18-34 and 55-64 were most concerned about affording nursing
home or home care costs. This suggests that Oregon respondents may be worried about affording the
cost of care for both aging relatives and themselves.

Likewise, worry about affording health care was highest among respondents living in both low-income and
middle-income households, those with a disabled household member, those in the Portland Metro area,
and respondents of color (see Table 1). Overall, 86% of respondents with an annual household income
between $75,00 and under $100,000 reported worrying about affording some aspect of coverage or
care in the past year. However, 82% of those earning over $100,000 per year also reported concerns.³
In fact, concerns existed across all respondent income levels, education levels, races, ethnicities, geographic settings, and abilities.

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Respondents reported worry about insurance becoming unaffordable more frequently than worry about
losing coverage across all income levels, regions, races/ethnicities, and coverage types.

Concern that health insurance will become unaffordable was most prevalent among those with insurance
purchased through their employer (see Figure 1), those earning $75,000 - $100,000, and those in the
Willamette Valley, North Coast, and Portland Metro Area. Likewise, respondents of color and those living
in a household that includes a person with a disability also reported the highest rates of concern that
health insurance will become unaffordable (see Table 2).

Although concerns about affording coverage surpassed fears about losing coverage, certain respondents
were more concerned about losing health insurance coverage than others. Concerns about losing health
insurance coverage were most prevalent among those with insurance purchased independently (see
Figure 1), those earning $75,000 - $100,000, those in Eastern Oregon*, Hispanic/Latino respondents, and
those with a disabled household member compared to their respective counterparts (see Table 2).

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Differences in Health Care Affordability Burdens

The survey also revealed differences in how Oregon respondents experience health care affordability burdens by income, age, geographic setting, disability, race, and ethnicity.

Income and Age

Respondents at the lowest end of the income spectrum most frequently reported experiencing one or more health care affordability burdens, however rates of going without care and rationing medication were similarly high among middle-income and even high-income respondents. Nearly four out of five (79%) respondents earning less than $50,000 per year reported struggling to afford some aspect of coverage or care in the past 12 months, as did 76% of those earning $50,000 - $100,000 (see Figure 2). This may be related, in part, to respondents in lower- and middle-income groups reporting higher rates of going without care and rationing their medication due to cost (see Figure 3). Still, 73% of those earning over $100,000 also reported experiencing healthcare affordability burdens.

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Further analysis found that Oregon respondents aged 18-24 reported the highest rates of forgoing care
due to cost. However, at least 7 in 10 respondents aged 18-54 reported going without care due to financial barriers, signaling that the issue extends across age groups. Likewise, respondents aged 18-44 most frequently reported rationing medication due to cost compared to other age groups (see Figure 4).

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Disability

Respondents living in households with a person with a disability reported the highest rates forgoing care
and rationing medication due to cost. Of those included in this group, 84% reported going without some
form of care and 35% reported rationing medication due to cost in the past year. In contrast, fewer
respondents living in a household without a person with a disability reported forgoing care (69%) and
rationing medication (23%) due to cost (see Table 3).

Additionally, respondents living in households with a person with a disability more frequently reported
skipping necessary mental health, addiction treatment, vision and dental care services due to cost
compared to respondents living in households without a person with a disability (see Table 3).

Those with disabilities also face health care affordability burdens unique to their disabilities— 9% of
respondents with a disabled household member reported delaying getting a medical assistive device such
as a wheelchair, cane/walker, hearing aid, or prosthetic limb due to cost. Only 7% of respondents in
households without a disabled person reported this experience.

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Insurance Type

People with different types of insurance navigate the health care system in varying ways. Those with
private insurance may face higher premiums and out-of-pocket costs, while individuals enrolled in
Medicaid or Medicare generally have lower costs but may encounter limited provider options, greater
restrictions around covered services, and longer wait times for services.

In Oregon, respondents with private insurance purchased independently reported the highest rates of
going without care due to cost and rationing medication, followed by respondents enrolled in Medicaid
(see Table 4). Still, over half (56%) of respondents with Medicare coverage also went without care due to
cost in the twelve months prior to taking the survey.

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Race and Ethnicity

Respondents of Color reported going without care due to cost and rationing medication due to cost more
frequently than white, alone non-Hispanic respondents. There are a variety of potential consequences
related to postponing health care and medication rationing, highlighting the importance of addressing
cost-related barriers to address health disparities.

In Oregon, eighty-eight percent (88%) of Hispanic/Latino respondents reported going without care due
to cost in the past twelve months compared to 71% of white alone, non-Hispanic/Latino respondent (see
Table 4). Further analysis showed that Respondents of Color also reported higher rates of rationing
medication due to cost and problems receiving behavioral health care compared to white, alone non-
Hispanic respondents (see Figure 5).

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In an effort to explore the impact high health costs have on individuals, respondents were also asked to
describe a time that they were unable to get health care due to cost (see Table 5). These anecdotes
highlight affordability challenges, underscore the impact of health care costs on individuals, and
emphasize the need for solutions to reduce financial barriers to care.

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Encountering Medical Debt

In the absence of affordable care options, individuals may find themselves burdened by medical costs. To
explore the impact of unaffordable medical care, survey participants were asked whether they have had to
do any of the following due to the cost of medical bills in the past twelve months: use up all or most of
their savings; sacrifice basic necessities, such as food, heat, or housing; borrow money, get a loan or take out another mortgage; use a crowdfunding platform to solicit donations; interact with a collections
agency; go into credit card debt; be placed on a long-term payment plan; or declare bankruptcy.

The survey results revealed that Respondents of Color reported experiencing at least one of the previous
medical cost burdens more frequently than white respondents. Likewise, respondents who have or live
with a person with a disability also reported navigating medical cost burdens more frequently than
respondents without a disabled household member, and respondents with insurance they purchase on
their own reported the highest rates of the above burdens due to medical bills (60%) compared to
respondents with all other insurance types (see Table 6).

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Impact of and Worry Related to Hospital Consolidation

In addition to the above healthcare affordability burdens, a small share of Oregon respondents reported
being negatively impacted by health system consolidation. In 2018 there was 1 change in ownership
involving hospitals through mergers, acquisitions, or CHOW in Oregon.^4,5
Oregon requires that the State Attorney General and Oregon Health Authority be notified of all hospital transactions and grants the authority to approve or deny transactions.⁶

In the past year, 35% of respondents reported that they were aware of a merger or acquisition in their
community—of those respondents, 30% reported that they or a family member were unable to access
their preferred health care organization because of a merger that made their preferred organization out-
of-network. Out of those who reported being unable to access their preferred healthcare provider due to
a merger:

• 40% changed their preferred doctor or hospital to one that is in-network,
• 31% skipped recommended follow-up visits due to a merger,
• 30% skipped filling a prescription, and
• 26% delayed or avoided going to the doctor or having a procedure done because they could no longer access their preferred health care organization due to a merger.

Out of those who reported that the merger caused an additional burden for them or their families, the top
three most frequently reported issues were:

• 27% — The merger created an added wait time when searching for a new provider,
• 20% — The merger created a gap in the continuity of my care,
• 20% —The merger created an added transportation burden, and
• 18% — The merger created an added financial burden.

While a smaller portion of respondents reported being unable to access their preferred health care
organization because of a merger, far more respondents (66%) reported being somewhat, moderately or
very worried about the impacts of mergers in their health care organizations. When asked about their
largest concern respondents most frequently reported:

• 29% — I’m concerned I will have to pay more to see my doctor,
• 25% — I’m concerned I will have fewer choices of where to receive care,
• 25% — I’m concerned my doctor may no longer be covered by my insurance,
• 13% — I’m concerned I will have a lower quality of care, and
• 8% — I’m concerned I will have to travel farther to see my doctor.

Dissatisfaction with the Health System and Support for Change

In light of Oregon respondents’ health care affordability burdens and concerns, it is not surprising that
they are dissatisfied with the health system. Of the respondents surveyed:

• Just 34% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
• While 75% agreed or strongly agreed that “the system needs to change."

To investigate further, the survey asked respondents to share their perspectives on both personal and
governmental actions to address the high health costs.

Personal Actions

Oregon respondents see a role for themselves in addressing health care affordability. When asked about
specific actions they could take:

• 54% of respondents reported researching the cost of a drug beforehand, and
• 72% 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 health care affordability (out of ten options), the most common responses were:

• 58% — Take better care of my personal health
• 42% — Research treatments myself before going to the doctor
• 30% — Do more to compare provider cost and quality before getting services
• 27% — Contact my state representatives asking them to address high healthcare prices and lack of affordable coverage options
• 24% — There is nothing I can do personally to make our health system better

Government Actions

Oregon respondents see government as the key stakeholder that needs to act to address health system
problems. Moreover, addressing health care 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. Respondents most frequently chose:

• 51% — Health care
• 44% — Affordable Housing
• 41% — Economy/Joblessness

When asked about the top three health care priorities the government should address, respondents most
frequently chose:

• 46% — Address high health care costs, including prescription drugs,
• 33% — Get health insurance to those who cannot afford coverage,
• 31% — Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition, and
• 31% — Improve Medicare, coverage for seniors and those with serious disabilities.

Out of fifteen possible options, Oregon respondents most frequently reported believing that the reason
for high health care costs is unfair prices charged by powerful industry stakeholders, such as:

• 70% — Drug companies charging too much money,
• 65% — Insurance companies charging too much money, and
• 64% — Hospitals charging too much money.

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

• 93% — 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 insurers to provide up-front cost estimates to consumers
• 92% — Cap out-of-pocket costs for life-saving medications, such as insulin
• 91% — Set standard prices for drugs to make them affordable
• 91% — Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription drug price hikes
• 91% — Require drug companies to provide advanced notice of price increases and information to justify those increases,
• 91% — Fund home and community-based programs for people with disabilities to ensure everyone can access affordable long-term services and supports, regardless of income
• 90% — Expand health insurance options so that everyone can afford quality coverage.

Support for Action Across Party Lines

There is support for change regardless of respondents' political affiliation (see Table 7). The high burden of health care 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. Annual surveys can help
assess whether progress is being made.

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Notes

1. During the past twelve months, 18% of respondents did not fill a prescription and 14% cut pills in half or skipped doses of medicine due to cost.
2. Eighteen percent (18%) had problems getting mental health care and 9% had problems getting addiction treatment.
3. Median household income in Oregon is $75,657 (2022 American Community Survey 1-Year Estimates). U.S. Census, Quick Facts. Oregon - Census Bureau Profile
4. Centers for Medicare and Medicaid Services. (2023). Hospital Change of Ownership. Retrieved June 27, 2024, from https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-change-of-ownership
5. A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner's identification number and provider agreement (including any Medicare outstanding debt of the old owner) to the new owner…An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been purchased by another enrolled provider. Only the purchaser's CMS Certification Number (CCN) and tax identification number remain. Acquisitions/mergers are different from CHOWs. In the case of an acquisition/merger, the seller/former owner's CCN dissolves. In a CHOW, the seller/former owner's CCN typically remains intact and is transferred to the new owner. A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new business entity. Consolidations are different from acquisitions/mergers. In an acquisition/merger, two entities combine but the CCN and tax identification number (TIN) of the purchasing entity remains intact. In a consolidation, the TINs and CCN of the consolidating entities dissolve and a new TIN and CCN are assigned to the new, consolidated entity. Source: Missouri Department of Health and Senior Services, Change of Ownership Guidelines—Medicare/State Certified Hospice. Retrieved August 23, 2023, from https://health.mo.gov/safety/homecare/pdf/CHOW-Guidelines-StateLicensedHospice.pdf
6. The Source on Healthcare Price and Competition, Merger Review, Retrieved July 8, 2024 from
   https://sourceonhealthcare.org/market-consolidation/merger-review/

Methodology

Altarum’s Consumer Healthcare Experience State Survey (CHESS) is designed to elicit respondents’ 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 June 6 to June 17, 2024, used a web panel from Dynata with a demographically balanced sample of approximately 1,551 respondents who live in Oregon. 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 1,499 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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