Key Findings

A survey of more than 1,400 North Carolina adults, conducted from October 18 to October 23, 2023,
found that:

• Over 2 in 3 (68%) experienced at least one health care affordability burden in the past year;
• Over 4 in 5 (85%) worry about affording health care in the future;
• Over 3 in 5 (61%) 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, North Carolina adults experience hardship due to high health care costs. Overall, over two-thirds (68%) 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

Over half (54%) of uninsured respondents cited “too expensive” as the main reason for not having health insurance, far exceeding other reasons like “don’t need it” and “don’t know how to get it.” In addition, 54% of respondents without dental insurance cited cost as the main reason for not having coverage, and 44% those without vision insurance cited cost as the main reason for not having coverage.

2) Delaying or Going without Health Care Due to Cost

Over 3 in 5 (61%) of all respondents reported delaying or going without health care during the prior 12 months due to cost:

• 38%—Skipped needed dental care
• 35%—Delayed going to the doctor or having a procedure done
• 33%—Cut pills in half, skipped doses of medicine, or did not fill a prescription¹
• 31%—Skipped a recommended medical test or treatment
• 29%—Avoided going to the doctor or having a procedure done altogether
• 28%—Skipped needed vision services
• 22%—Had problems getting mental health care or addiction treatment
• 13%—Skipped needed hearing services
• 12%—Skipped or delayed getting a medical assistive device

Moreover, respondents reporting a barrier to getting care in the past year, most frequently cited cost (29%) followed by not being able to get an appointment (19%), 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. One-third (43%) of respondents reported experiencing one or more of these struggles to pay their medical bills:

• 20%—Were contacted by a collection agency
• 17%—Used up all or most of their savings
• 15%—Were unable to pay for basic necessities like food, heat, or housing
• 12%—Incurred large amounts of credit card debt
• 10%—Borrowed money, got a loan, or another mortgage on their home
• 8%—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 North Carolina respondents seek these services. Trouble paying for dental bills likely reflects lower rates of coverage for these services (33% of respondents reported that said they were partially or completely without dental coverage in the past year).

High Levels of Worry About Affording Health Care in the Future

North Carolina respondents also exhibit high levels of worry about affording health care in the future. Over four in five (85%) reported being “worried” or “very worried” about affording some aspect of health care in the future, including:

• 70%—Cost of nursing home or home care services
• 68%—Medical costs when elderly
• 67%—Health insurance will become unaffordable
• 65%—Medical costs in the event of a serious illness or accident
• 58%—Prescription drugs will become unaffordable
• 56%—Cost of dental care
• 51%—Cost of needed vision services
• 48%—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 North Carolina respondents may be worried about affording the cost of care for both aging relatives and themselves.

Worry about affording health care was highest among respondents living in low-income households, among those living in households with a person with a disability, and those living in non-rural regions (see Appendix) of North Carolina (see Table 1). Overall, 88% of respondents with household incomes less than $50,000 a year reported worrying about affording some aspect of coverage or care in the past year, as did 85% of those earning $50,000 to $75,000 per year.²  Still, most North Carolina respondents of all incomes, races, ethnicities, geographic setting, and levels of ability were somewhat or very concerned.

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Concern that health insurance will become unaffordable is also more prevalent among certain groups of North Carolina respondents. By insurance type, respondents with Medicaid coverage most frequently reported worrying about affording coverage, followed by respondents with coverage they buy on their own and respondents with coverage through an employer (see Figure 1).

Respondents living in rural areas reported the highest rate of worry about affording insurance in the future, compared to residents in other geographic areas. Likewise, respondents of color, respondents with household incomes below $50,000 per year, and respondents living in households with a person with a disability reported the highest rates of worry about losing coverage and not being able to afford coverage in the future (see Table 2).

Concerns about affording coverage exceeded fears about losing coverage across all income groups, disability statuses, geographic settings, races/ethnicities, and coverage types.

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Differences in Health Care Affordability Burdens

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

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 over three-fourths (76%) 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).

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Further analysis found that North Carolina respondents ages 25-34 reported higher rates of going without care due to cost than respondents in other age groups (see Figure 4). Respondents ages 25-34 also most frequently reported rationing medication due to cost compared to other age groups. 

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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. Almost three-quarters (74%) of respondents in this group reported going without some form of care and 48% reported rationing medication, compared to 56% and 27% 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 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—26% 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. Just 6% of respondents without a person with a disability in their household (who may have needed such tools temporarily or may not identify as having a disability) reported this experience.

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Insurance Type

Respondents with North Carolina Medicaid coverage reported the highest rates of going without care due to cost and rationing medication, followed by respondents with insurance bought on their own, such as through the Health Insurance Marketplace (see Table 4). Still, over two-fifths (46%) 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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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).

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Race and Ethnicity

North Carolina respondents of color reported higher rates of rationing medication and forgoing care than white alone, non-Hispanic/Latino respondents. Sixty-two percent of Black or African American respondents and 70% of Hispanic/Latino respondents reported going without care due to cost in the past twelve months compared to 59% of white alone, non-Hispanic/Latino respondents (see Table 4). Further analysis showed that BIPOC respondents also reported higher rates of challenges accessing addiction treatment and skipping needed dental care (see Figure 5).

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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-one percent of Black or African American respondents and 58% of Hispanic/Latino respondents reported going into debt, depleting savings, or going without other needs due to medical bills, compared to 38% of white alone, non-Hispanic/Latino respondents (see Table 6).

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The rate of financial burden is even higher for respondents who have or live with a person with a disability, with over three in five (62%) reporting going into debt or going without other needs due to medical bills, compared to 35% of respondents without a disabled household member. Geographically, residents in rural areas reported higher rates of going into debt or going without other needs due to medical bills than those living in the Black Belt or non-rural regions. In addition, respondents with Medicaid coverage reported the highest rate of the above financial burdens due to medical bills (63%), compared to respondents with all other insurance types.

Impact and Worry Related to Hospital Consolidation*

In addition to the above health care affordability burdens, a small share of North Carolina respondents were negatively impacted by health system consolidation. From 2016 to 2021, there were 27 changes in ownership involving hospitals through mergers, acquisitions, or changes of ownership (CHOW) in North Carolina.^3,4  North Carolina requires that the State Attorney General be notified of nonprofit hospital transactions and the state requires Attorney General or court approval for nonprofit hospital merger transactions.⁵

In the past year, 26% of respondents reported that they were aware of a merger or acquisition in their community—of those respondents, 20% 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 health care provider due to a merger:

• 45% 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;
• 31% skipped recommended follow-up visits due to a merger; and
• 32% changed their preferred doctor or hospital.

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:

• 45%—The merger created an added financial burden
• 18%—The merger created a gap in their continuity of care
• 16%—The merger created an added wait time when searching for a new provider

While a small portion of respondents reported being unable to access their preferred health care organization because of a merger, far more respondents (58%) reported that, if mergers were happening in their community, they would be somewhat, moderately or very concerned. When asked about their largest concern respondents most frequently reported:

• 27%—I’m concerned I will have to pay more to see my doctor
• 26%—I’m concerned my doctor may no longer be covered by my insurance
• 24%—I’m concerned I will have fewer choices of where to receive care
• 14%—I’m concerned I will have a lower quality of care
• 9%—I’m concerned I will have to travel farther to see my doctor

*Note: The sample size of respondents who said they were affected by a merger was not large enough to report reliable estimates; the values in this section should be interpreted with caution.

Dissatisfaction with the Health System and Support for Change

In light of North Carolina 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 75% 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

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

• 59% of respondents reported researching the cost of a drug beforehand, and
• 80% 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:

• 72%—Take better care of my personal health
• 41%—Research treatments myself before going to the doctor
• 32%—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
• 23%—Write to or call my state representative asking them to take action on high health care prices and lack of affordable coverage options

Government Actions

But far and away, North Carolina 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:

• 48%—Economy/Joblessness
• 48%—Health care
• 38%—Affordable housing

When asked about the top three health care priorities the government should work on, respondents most often chose:

• 54%—Address high health care costs, including prescription drugs
• 37%—Get health insurance to those who cannot afford coverage
• 34%—Improve Medicare, coverage for seniors and those with serious disabilities
• 32%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition

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

• 77%—Drug companies charging too much money
• 73%—Hospitals charging too much money
• 70%—Insurance companies 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%—Cap out-of-pocket costs for life-saving medications, such as insulin
• 92%—Require drug companies to provide advanced notice of price increases and information to justify those increases
• 92%—Make it easy to switch insurers if a health plan drops your doctor
• 91%—Require insurers to provide up-front cost estimates to consumers
• 91%—Require hospitals and doctors to provide up-front cost estimates to consumers
• 91%—Expand health insurance options so that everyone can afford quality coverage
• 91%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription drug price hikes
• 90%—Set standard prices for drugs to make them affordable
• 90%—Create a Prescription Drug Affordability Board to examine the evidence and establish acceptable costs for drugs

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 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 systems are working for them, with strong support for a wide variety of actions. Annual surveys can help assess whether progress is being made.

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Notes

1. Twenty-six percent (26%) did not fill a prescription and 21% cut pills in half or skipped doses of medicine due to cost.
2. Median household income in North Carolina was $60,516 (2017-2021). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts, https://www.census.gov/quickfacts/fact/table/NC,US/PST045222.
3. Centers for Medicare and Medicaid Services. (2023). Hospital Change of Ownership. Retrieved November 9, 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 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#:~:text=Acquisitions%2Fmergers%20are %20different%20from%20CHOWs.%20In%20the%2
   0case,providers%20consolidate%20to%20form%20a%20new%20business%20entity.
5. The Source on Healthcare Price and Competition, Merger Review, Retrieved November 9, 2023 from
   https://sourceonhealthcare.org/market-consolidation/merger-review/

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 October 18 to October 23, 2023, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,500 respondents who live in North Carolina. 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 1,455 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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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

Black Belt	Non-Rural	Rural
Anson County, North Carolina	Alamance County, North Carolina	Alleghany County, North Carolina
Bertie County, North Carolina	Alexander County, North Carolina	Ashe County, North Carolina
Bladen County, North Carolina	Brunswick County, North Carolina	Avery County, North Carolina
Columbus County, North Carolina	Buncombe County, North Carolina	Beaufort County, North Carolina
Cumberland County, North Carolina	Burke County, North Carolina	Camden County, North Carolina
Duplin County, North Carolina	Cabarrus County, North Carolina	Carteret County, North Carolina
Edgecombe County, North Carolina	Caldwell County, North Carolina	Caswell County, North Carolina
Franklin County, North Carolina	Catawba County, North Carolina	Cherokee County, North Carolina
Gates County, North Carolina	Chatham County, North Carolina	Chowan County, North Carolina
Granville County, North Carolina	Craven County, North Carolina	Clay County, North Carolina
Greene County, North Carolina	Currituck County, North Carolina	Cleveland County, North Carolina
Halifax County, North Carolina	Davidson County, North Carolina	Dare County, North Carolina
Hertford County, North Carolina	Davie County, North Carolina	Graham County, North Carolina
Hoke County, North Carolina	Durham County, North Carolina	Harnett County, North Carolina
Lenoir County, North Carolina	Forsyth County, North Carolina	Hyde County, North Carolina
Martin County, North Carolina	Gaston County, North Carolina	Jackson County, North Carolina
Nash County, North Carolina	Guilford County, North Carolina	Lee County, North Carolina
Northampton County, North Carolina	Haywood County, North Carolina	McDowell County, North Carolina
Pitt County, North Carolina	Henderson County, North Carolina	Macon County, North Carolina
Richmond County, North Carolina	Iredell County, North Carolina	Mitchell County, North Carolina
Robeson County, North Carolina	Johnston County, North Carolina	Montgomery County, North Carolina
Sampson County, North Carolina	Jones County, North Carolina	Moore County, North Carolina
Scotland County, North Carolina	Lincoln County, North Carolina	Pasquotank County, North Carolina
Tyrrell County, North Carolina	Madison County, North Carolina	Perquimans County, North Carolina
Vance County, North Carolina	Mecklenburg County, North Carolina	Polk County, North Carolina
Warren County, North Carolina	New Hanover County, North Carolina	Rutherford County, North Carolina
Washington County, North Carolina	Onslow County, North Carolina	Stanly County, North Carolina
Wayne County, North Carolina	Orange County, North Carolina	Surry County, North Carolina
Wilson County, North Carolina	Pamlico County, North Carolina	Swain County, North Carolina
	Pender County, North Carolina	Transylvania County, North Carolina
	Person County, North Carolina	Watauga County, North Carolina
	Randolph County, North Carolina	Wilkes County, North Carolina
	Rockingham County, North Carolina	Yancey County, North Carolina
	Rowan County, North Carolina
	Stokes County, North Carolina
	Union County, North Carolina
	Wake County, North Carolina
	Yadkin County, North Carolina