Key Findings

A survey of more than 1,400 Louisiana adults, conducted from July 19 to July 29, 2023, found that:

• Nearly 7 in 10 (67%) experienced at least one healthcare affordability burden in the past year;
• Nearly 4 in 5 (78%) worry about affording healthcare in the future;
• Lower-income respondents and respondents with disabilities reported higher rates of going without care and incur 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, Louisiana adults experience hardship due to high healthcare costs. All told, over two-thirds (67%) of respondents experienced one or more of the following healthcare affordability burdens in the prior 12 months:

1) Being Uninsured Due to High Premium Costs

Over one-third (35%) 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 Forgoing Healthcare Due to Cost

Over half (60%) of all respondents reported delaying or going without healthcare during the prior 12 months due to cost:

• 38%—Skipped needed dental care
• 34%—Delayed going to the doctor or having a procedure done
• 30%—Skipped a recommended medical test or treatment
• 30%—Avoided going to the doctor or having a procedure done altogether
• 36%—Cut pills in half, skipped doses of medicine or did not fill a prescription¹
• 23%—Had problems getting mental healthcare or addiction treatment
• 27%—Skipped needed vision services
• 21%—Skipped needed hearing services
• 19%—Skipped or delayed getting a medical assistive device

Moreover, of respondents who reported a delay or foregoing healthcare, the most cited reason for them or a family member not getting needed medical care in the past year was cost, exceeding a host of other barriers like getting an appointment, 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. Over two in five (43%) experienced one or more of these struggles to pay their medical bills:

• 15%—Were contacted by a collection agency
• 15%—Used up all or most of their savings
• 17%—Were unable to pay for basic necessities like food, heat or housing
• 10%—Racked up large amounts of credit card debt
• 11%—Borrowed money, got a loan or another mortgage on their home
• 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 Louisiana 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

Louisiana respondents also exhibit high levels of worry about affording healthcare in the future. Over three in four (78%) reported being “worried” or “very worried” about affording some aspect of healthcare
in the future, including:

• 58%—Medical costs when elderly
• 60%—Cost of nursing home or home care services
• 56%—Medical costs in the event of a serious illness or accident
• 55%—Health insurance will become unaffordable
• 53%—Cost of dental care
• 52%—Prescription drugs will become unaffordable
• 48%—Cost of vision services
• 46%—Cost of 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 45-54. This finding suggests that Louisiana respondents may be worried about affording the cost of care for both aging relatives 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 $75,000 per year² reported worrying about affording some aspect of coverage or care in the past year. Still, most Louisiana 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 Louisiana respondents. By insurance type, respondents with Louisiana Medicaid most frequently reported worrying about affording coverage, followed by respondents with coverage through their employer (see Figure 1).

Respondents with household incomes below $75,000 per year reported the highest rates of worry about losing coverage, as well as the highest rates of worry about affording coverage. Black/African American respondents and those living in households with a person with a disability reported higher rates of both worrying about losing insurance and worry about health insurance becoming unaffordable in the future compared to white alone, non-Hispanic respondents and those not living with a disabled household member (see Table 2). Respondents with Medicaid and those purchasing health insurance on their own (such as through the health insurance marketplace) reported the highest rates of worrying about losing their insurance compared to those with employer-based insurance or Medicare. 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 Louisiana respondents experience healthcare affordability burdens by income, age, geographic setting and disability status.

Income and Age

Unsurprisingly, respondents at the lower end of the income spectrum most frequently reported experiencing one or more healthcare affordability burdens, with 75% of those earning less than $75,000 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). Still, 57% of those earning more than $100,000 per year reported experiencing affordability burdens, demonstrating that people across the income spectrum experience these challenges.

Further analysis found that Louisiana respondents ages 18-44 reported higher rates of going without care due to cost than respondents ages 45 and up (see Figure 4). In addition, respondents ages 18-44 also more frequently reported rationing medication due to cost compared to other age groups. 

Disability

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 3 in 4 (77% of) respondents in this group reported going without some form of care and 49% reported rationing medication, compared to 56% and 28% 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 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 3).

Those with disabilities may also face healthcare affordability burdens unique to their disabilities—35% 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 10% 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.

Race

Louisiana respondents of color reported higher rates of rationing medication and forgoing care than white respondents. Fifty-nine percent of respondents of color reported going without care due to cost, compared to 55% of white respondents (see Table 3). Further analysis showed that respondents of color also reported slightly higher rates of challenges receiving mental health care, challenges receiving addiction treatment and skipping needed dental care (see Figure 5).

Insurance Type

Respondents with health insurance they bought on their own reported the highest rates of going without care due to cost and rationing medication, followed by respondents with Louisiana Medicaid coverage and those with employer-sponsored insurance (see Table 4). Still, over half of respondents with Medicare 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 reported challenges
affording care (see Table 5).

Race and Ethnicity

Louisiana respondents of color reported slightly higher rates of rationing medication and forgoing care than white respondents. Sixty-one percent (61%) of respondents of color went without care due to cost, including 69% of Hispanic/Latino respondents, compared to 59% of white alone, non-Hispanic respondents (see Table 4). Further analysis showed that Hispanic/Latino respondents reported higher rates of challenges receiving mental health care and avoiding going to the doctor or getting a procedure altogether (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-four percent of respondents of color reported going into debt, depleting savings or going without other needs due to medical bills, including 60% of Hispanic/Latino respondents, compared to 42% of white 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 over 3 in 5 (65%) reporting going into debt or going without other needs due to medical bills, compared to 30% of respondents living in households without a disabled member. In addition, respondents with Louisiana Medicaid and those who purchased health insurance on their own reported the highest rate of the above financial burdens due to medical bills (48% and 47%, respectively) compared to those with other insurance types.

Impact of Hospital Consolidation

In addition to the above healthcare affordability burdens, some Louisiana respondents have been impacted by health system consolidation. In between 2019, 2020, and 2022 nineteen hospitals in the state changed ownership through either a merger, acquisition, or change of ownership (CHOW).^3,4 Relative to other states, Louisiana has strict regulations surrounding hospital change of ownership, with provisions requiring notice, review or approval of any health care acquisitions mergers or consolidations. Such as anti-competitive contract terms, certificate of need, and certificate of public advantage approvals.⁵

In the past year, 12% of all respondents 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:

• 58% 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,
• 28% skipped recommended follow-up visits due to a merger, and
• 16% skipped filling a prescription medication due to a merger.

Out of those who reported that the merger caused an additional burden for them or their families, when asked about the greatest burden hospital mergers had created for respondents and their families, the top three most frequently reported issues were:

• 36%—Created an added financial burden,
• 35%—Created an added wait time when searching for a new provider,
• 12%—Created an added transportation burden.

Dissatisfaction with the Health System and Support for Change

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

• Just 31% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
• While 59% 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

Louisiana respondents see a role for themselves in addressing healthcare affordability. When asked about specific actions they could take:

• 59% of respondents reported researching the cost of a drug beforehand, and
• 63% 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:

• 65%—Take better care of my personal health
• 43%—Research treatments myself, before going to the doctor
• 30%—Do more to compare doctors on cost and quality before getting services
• 23%—There is not anything I can do personally to make our health system better

Government Actions

But far and away, Louisiana 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:

• 46%—Economy/Joblessness
• 40%—Healthcare
• 31% – Taxes
• 31%—Affordable Housing

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

• 42%—Address high healthcare costs, including prescription drugs
• 31%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition
• 33%—Get health insurance to those who cannot afford coverage
• 32%—Improve Medicare, coverage for seniors and those with serious disabilities

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

• 65%—Drug companies charging too much money
• 60%—Hospitals charging too much money
• 59%—Insurance companies charging too much money

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

• 86%—Require hospitals and doctors to provide up-front cost estimates to consumers
• 87%—Require insurers to provide up-front cost estimates to consumers
• 88%—Show what a fair price would be for specific procedures
• 87%—Set standard prices for drugs to make them affordable
• 85%—Make it easy to switch insurers if a health plan drops your doctor
• 87%—Require drug companies to provide advanced notice of price increases and information to justify those increases
• 85%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription price hikes
• 85% – Create a Prescription Drug Affordability Board to examine the evidence and establish acceptable costs for drugs
• 86%—Cap out-of-pocket costs for life-saving medications, such as insulin

Support for Action Across Party Lines

There is also remarkable support for change regardless of respondents’ political affiliation (see Table 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.

Notes

1. Within the current 67% of Louisiana respondents who encountered one or more cost-related barriers to getting healthcare during the prior 12 months, 26% did not fill a prescription, while 25% cut pills in half or skipped doses of medicine due to cost.
2. Median household income in Louisiana was $53,571 (2017-2021). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts: Louisiana
3. Centers for Medicare and Medicaid Services. (2023). Hospital Change of Ownership. Retrieved July 17, 2023, from https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-change-of-ownership
4. 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 Medicare Identification Number and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The regulatory citation for CHOWs can be found at 42 CFR § 489.18. If the purchaser (or lessee) elects not to accept a transfer of the provider agreement, then the old agreement should be terminated and the purchaser or lessee is considered a new applicant. Most changes of ownership fall into this category. (Centers for Medicare and Medicaid Services. (2023, September). Medicare Fee-For-Service Provider Enrollment – Hospital Change of Ownership: Data Guidance. Retrieved July 17, 2023, from https://data.cms.gov/sites/default/files/202301/Hospital_CHOW_Data_Guidance_2023.12.30.pdf)
5. National Conference of State Legislatures. (2023, February 22). Health System Consolidation. Retrieved July 17, 2023, from https://www.ncsl.org/health/health-system-consolidation

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 views on fixes that might be needed. 

This survey, conducted from July 19 to July 29, 2023, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,507 respondents who live in Louisiana. 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 1,417 cases for analysis. After those exclusions, the demographic composition of respondents was as follows,
although not all demographic information has complete response rates: