Key Findings

A survey of more than 1,300 Florida adults, conducted from May 3 to May 23, 2023, found that:

• Over 3 in 5 (63%) experienced at least one health care affordability burden in the past year;
• 4 in 5 (80%) worry about affording health care in the future;
• Lower-income respondents and respondents with disabilities are more likely to go without care and incur debt due to health care costs; and
• Across party lines, respondents express strong support for government-led solutions.

A Range of Healthcare Affordability Burdens 

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

1) Being Uninsured Due to High Costs 

Nearly one-half (48%) 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 

Over half (55%) of all respondents reported delaying or going without health care during the prior 12 months due to cost:

• 36%—Skipped needed dental care
• 32%—Delayed going to the doctor or having a procedure done
• 29%—Skipped a recommended medical test or treatment
• 28%—Cut pills in half, skipped doses of medicine or did not fill a prescription¹
• 27%—Avoided going to the doctor or having a procedure done altogether
• 24%—Skipped needed vision services
• 19%—Had problems getting mental health care or addiction treatment
• 16%—Skipped needed hearing services
• 14%—Skipped or delayed getting a medical assistive device

Moreover, 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 getting time off work, 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. Nearly two in five (39%) experienced one or more of these struggles to pay their medical bills:

• 16%—Used up all or most of their savings
• 15%—Were contacted by a collection agency
• 13%—Were unable to pay for basic necessities like food, heat or housing
• 12%—Racked up large amounts of credit card debt
• 11%—Borrowed money, got a loan or another mortgage on their home
• 7%—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 Florida 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 

Florida respondents also exhibit high levels of worry about affording health care in the future. Four in five (80%) reported being “worried” or “very worried” about affording some aspect of health care in the future, including:

• 63%—Cost of nursing home or home care services
• 62%—Health insurance will become unaffordable
• 62%—Medical costs when elderly
• 60%—Medical costs in the event of a serious illness or accident
• 56%—Cost of dental care
• 53%—Prescription drugs will become unaffordable
• 49%—Cost of needed vision services
• 47%—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 respondents ages 35-54. This finding suggests that Florida respondents may be worried about affording the cost of care for both aging parents and themselves.

Worry about affording health care was highest among respondents living in lower-income households and among those living in households with a person with a disability (see Table 1). More than 4 in 5 (86% 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 Florida 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 Florida respondents. By insurance type, respondents with coverage that they have purchased on their own, not through an employer, most frequently reported worrying about affording coverage, followed by respondents with coverage through their employer and those with Medicaid coverage (see Figure 1).

Respondents with household incomes below $50,000 per year reported the highest rates of worry about losing coverage and affording coverage. Rural respondents and those living in households with a person with a disability were more likely to be concerned about losing health insurance than respondents living in non-rural areas and 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 (see Appendix A), races, ethnicities, and coverage types.  

Differences in Healthcare Affordability Burdens 

The survey also revealed differences in how Florida respondents experience health care 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 health care affordability burdens, with nearly three-fourths (74%) 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 Florida respondents ages 18-44 were more likely to go without care due to cost than respondents ages 45 and older (see Figure 4). Respondents ages 18-44 also most frequently reported rationing medication due to cost, compared to other age groups.  

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. Over 7 in 10 (74% of) respondents in this group reported going without some form of care and 44% reported rationing medication, compared to 47% and 21% of respondents living in households without a person with a disability, respectively (see Table 4). Respondents living in households with a person with a disability also more frequently reported delaying or skipping getting mental health care, addiction treatment, and dental care, among other health care services, than those in households without a person with a disability due to cost concerns (see Table 3). 

Those with disabilities also face health care affordability burdens unique to their disabilities—29% 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.

Insurance Type 

Respondents with Florida Medicaid coverage reported the highest rates of going without care due to cost and rationing medication, followed by respondents with private insurance (see Table 4). Still, over two-fifths of respondents with Medicare coverage went without care due to cost in the twelve months prior to taking the survey. 

Survey respondents also had the opportunity to share their own stories about going without care due to cost in the past year. Notably, respondents with both private insurance and Medicaid coverage reported challenges affording care (see Table 5). 

Race and Ethnicity 

Florida respondents of color reported higher rates of rationing medication and forgoing care than white respondents. Fifty-eight percent of Black respondents and 58% of Hispanic/Latino(a) respondents reported going without care due to cost in the past twelve months (see Table 4). Further analysis showed that respondents of color also reported higher rates of challenges receiving mental health care and skipping needed dental care (see Figure 5). 

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, ethnicity, disability status, and geographic setting. Fifty-two percent of Black respondents and 49% of Hispanic/Latino(a) respondents reported going into debt, depleting savings, or going without other needs due to medical bills, compared to 33% of white alone, non-Hispanic respondents (see Table 6).  

The rate of financial burden is even higher for respondents who have or live with a person with a disability, with nearly three-fifths (57%) reporting going into debt or going without other needs due to medical bills, compared to 31% of respondents living in households without a disabled member. Geographically, rural residents across Florida reported higher rates of going into debt or going without other needs due to medical bills. In addition, respondents with Medicaid coverage reported the highest rate of the above financial burdens due to medical bills (57%), compared to respondents with all other insurance types. 

Impact of Hospital Consolidation

In addition to the above health care affordability burdens, 9% of respondents reported that they or someone in their household were unable to access their preferred health care organization because of a merger that made their preferred organization out-of-network. When asked about the greatest burden hospital mergers had created for respondents and their families, the top three most frequently reported issues were:

• 34%—Additional financial burden
• 26%—Added wait time when searching for a new provider accepting patients
• 21%—Gap in my continuity of care (my former provider knew me and now I have to explain everything again)

Dissatisfaction with the Health System and Support for Change 

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

• Just 30% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
• While 68% 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  

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

• 55% of respondents reported researching the cost of a drug beforehand, and
• 73% 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:

• 74%—Take better care of my personal health
• 45%—Research treatments myself, before going to the doctor
• 33%—Do more to compare doctors on cost and quality before getting services
• 25%—There is not anything I can do personally to make our health system better

Government Actions  

But far and away, Florida 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. The top vote getters were:

• 50%—Economy/Joblessness
• 47%—Health care
• 35%—Affordable Housing

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

• 49%—Address high health care costs, including prescription drugs
• 34%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition
• 32%—Get health insurance to those who cannot afford coverage
• 30%—Improve Medicare, coverage for seniors and those with serious disabilities

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

• 72%—Drug companies charging too much money
• 69%—Hospitals charging too much money
• 66%—Insurance companies charging too much money  

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

• 91%—Require insurers to provide up-front cost estimates to consumers
• 91%—Show what a fair price would be for specific procedures
• 90%—Set standard prices for drugs to make them affordable
• 90%—Cap out-of-pocket costs for life-saving medications, such as insulin
• 90%—Require drug companies to provide advanced notice of prices increases and information to justify those increases
• 89%—Require hospitals and doctors to provide up-front cost estimates to consumers
• 89%—Make it easy to switch insurers if a health plan drops your doctor
• 89%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription price hikes
• 88%—Expand health insurance options so that everyone can afford quality coverage

Support for Action Across Party and Racial/Ethnic Lines 

There is also remarkable 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. 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 55% of Florida respondents who encountered one or more cost-related barriers to getting health care during the prior 12 months, 22% did not fill a prescription, while 19% cut pills in half or skipped doses of medicine due to cost.
2. Median household income in Florida was $61,777 (2017-2021). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts: Florida

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 May 3 to May 23, 2023, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,514 respondents who live in Florida. 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 1,376 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.

Appendix A 

The state was divided into rural and non-rural regions, by county.

Rural	Non-Rural
Baker County, Florida	Alachua County, Florida
Bradford County, Florida	Bay County, Florida
Calhoun County, Florida	Brevard County, Florida
Columbia County, Florida	Broward County, Florida
DeSoto County, Florida	Charlotte County, Florida
Dixie County, Florida	Citrus County, Florida
Franklin County, Florida	Clay County, Florida
Gadsden County, Florida	Collier County, Florida
Gilchrist County, Florida	Duval County, Florida
Glades County, Florida	Escambia County, Florida
Gulf County, Florida	Flagler County, Florida
Hamilton County, Florida	Hernando County, Florida
Hardee County, Florida	Hillsborough County, Florida
Hendry County, Florida	Indian River County, Florida
Highlands County, Florida	Lake County, Florida
Holmes County, Florida	Lee County, Florida
Jackson County, Florida	Leon County, Florida
Jefferson County, Florida	Manatee County, Florida
Lafayette County, Florida	Marion County, Florida
Levy County, Florida	Martin County, Florida
Liberty County, Florida	Miami-Dade County, Florida
Madison County, Florida	Okaloosa County, Florida
Monroe County, Florida	Orange County, Florida
Nassau County, Florida	Osceola County, Florida
Okeechobee County, Florida	Palm Beach County, Florida
Putnam County, Florida	Pasco County, Florida
Sumter County, Florida	Pinellas County, Florida
Suwannee County, Florida	Polk County, Florida
Taylor County, Florida	Santa Rosa County, Florida
Union County, Florida	Sarasota County, Florida
Wakulla County, Florida	Seminole County, Florida
Walton County, Florida	St. Johns County, Florida
Washington County, Florida	St. Lucie County, Florida
	Volusia County, Florida