Summary

Health care is expensive in the U.S., and Tennessee is no exception. Nearly three in every four respondents (74%) reported experiencing at least one health care affordability burden in the last year; such as being uninsured due to cost, delaying, or forgoing needed health services entirely due to cost or finding themselves in financial burden due to medical care.

A Range of Health Care Affordability Burdens

In Tennessee, nearly 3 in 4 (72% of) respondents reported that they, or a family member, skipped or delayed medical care due to cost. Among those reporting affordability challenges, the most common experiences were:

• 31%—Cut pills in half, skipped doses of medicine or did not fill a prescription;¹
• 25%—Skipped needed dental care;
• 24%—Skipped a recommended medical test or treatment;
• 23%—Delayed going to the doctor or having a procedure done;
• 18%—Avoided going to the doctor or having a procedure done altogether;
• 18%—Had problems getting mental health care or addiction treatment;² and
• 7%—Skipped or delayed getting a medical assistive device
• 4%—Skipped needed maternity or reproductive health care;

While cost was the most commonly cited reason for delaying or foregoing care (27%), factors such as the inability to get an appointment (14%), not being able to get time off of work (12%), and not having insurance (11%), also contributed to instances of patients delaying or forgoing care.

Although the vast majority of Tennessee survey respondents (90%) reported having some form of health insurance, cost emerged as the most significant obstacle to coverage for those who are uninsured. Among uninsured respondents, 51% cited the high cost of insurance as the primary reason they remained without coverage – surpassing other common reasons such as “I don’t need it” and “I don’t know how to get it.”

Differences in Health Care Affordability Burdens

The frequency and severity of health care affordability burdens may be influenced by an individual’s characteristics, such as their age or income. Survey results from Tennessee reveal trends in how different populations experience several common affordability burdens; such as affording mental health and addiction treatment, dental and vision care, primary care visits, surgical procedures, and purchasing medical assistive devices.

Income and Employment

Income is one of the most consistent predictors of an individual’s ability to afford health care. ³ Over four out of every five respondents (81%) with an annual household income of less than $50,000 reported experiencing at least one health care affordability burden in the last year. These respondents also reported delaying or forgoing care due to cost more frequently than respondents with higher incomes (see Figure 1).

Employment also plays a critical role in health care affordability—not only by providing income but also by providing access to employer-sponsored insurance, which remains the main source of coverage for non-elderly adults in the U.S..⁴ Survey data indicate that part-time workers in Tennessee may face heightened affordability challenges (see Figure 2).

Insurance Coverage and Type

People with different types of insurance navigate the health care system in different ways. For example, people with private insurance may face higher premiums and out-of-pocket costs, while individuals enrolled in Medicaid typically encounter lower direct costs but may face other obstacles, including limited provider networks, restrictions on covered services, and longer wait times for appointments.

Approximately a fifth of Tennessee population (20%) is covered by Medicaid or the Children’s Health Insurance Program (CHIP), which provides subsidized health insurance to people who are low-income or have a disability.⁵ Given its reach, it is not surprising that many respondents expressed support for the program (see Table 1).

However, respondents enrolled in TennCare, the state Medicaid program, reported forgoing care more frequently than respondents with other forms of coverage. Respondents with coverage they purchased on their own, such as through the health insurance Marketplace, reported rationing their medication the most. Respondents enrolled in Medicare, coverage for seniors and people with certain disabilities, reported the lowest incidence of rationing medication or going without care due to cost (see Table 2).

When asked, some survey participants also shared personal accounts of being unable to access necessary health care because of the cost. The anecdotes illuminate a common theme: that challenges finding affordable health care exist across all coverage types. Although individuals without health insurance coverage often face the most acute affordability issues, respondents with commercial insurance, Medicare, and Medicaid also shared narratives revealing difficulties accessing care due to cost:

Race and Ethnicity

Overall, respondents of color in Tennessee reported going without care and rationing medication due to cost more frequently than white, alone non-Hispanic respondents. Eighty-one percent (81%) of respondents of color reported forgoing care due to cost in the past twelve months, compared to 68% of white alone, non-Hispanic/Latino respondents (see Table 3). White, non-Hispanic respondents reported slightly higher rates of skipping dental services. However, respondents of color reported other health care affordability burdens, like forgoing needed health services entirely due to cost, at the same or at an elevated rate relative to white respondents (see Figure 3).

Age and Disability

While anyone can be affected by a serious illness or injury, some groups face greater financial obstacles to accessing care. In Tennessee, young adults aged 25-34 reported the highest rates of forgoing care due to cost. However, affordability concerns extend across age groups—more than half of all respondents under age 65 reported skipping care in the past year due to financial constraints (see Table 4). Most adults over the age of 65 will be insured under Medicare, which provides affordable coverage for basic health services. However, affordability may remain a concern for this group, particularly for older adults with complex or chronic conditions.

Young adults also reported the highest rates of medication rationing due to cost. This finding has important implications for policymakers interested in improving prescription drug affordability in their state. For example, although the Inflation Reduction Act (IRA) capped insulin costs for Medicare beneficiaries at $35 per month, these protections do not apply to younger populations.⁶ While the survey does not specify which medications were rationed, a non-negligible number of respondents who reported rationing medication due to cost were under the age of 65, highlighting the need for broader efforts to lower out-of-pocket drug costs across all age groups.

Respondents with a disability, or who live with someone with a disability, also reported higher rates of health care affordability burdens. Of those included in this group, 83% reported going without some form of care and 44% 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 (66%) and rationing medication (25%) due to cost (see Table 5).

People with disabilities also face affordability burdens specific to their health needs. For example, 13% of respondents with a disability or with a disabled household member reported delaying the purchase of a medical assistive device (like a wheelchair, cane/walker, hearing aid, or prosthetic limb) due to cost, compared to only 4% of respondents in households without a disabled member. Overall, individuals living with or alongside someone with a disability were more likely to experience at least one health care affordability burden (see Figure 4).

Given that 29% of U.S. adults live with some form of disability, more than a quarter of the population often face elevated health care affordability burdens.⁷ People with a disability pay an average $13,492 annually for health care, while a person without a disability pays $2,853.⁸ Out-of-pocket costs are also more than twice as high for an individual with a disability versus an individual without ($1053 v. $486).⁹

Encountering Medical Debt

Although many respondents reported delaying, forgoing, or rationing care due to cost, others did receive care but faced financial hardship from the resulting medical bills. More than a third of respondents (45%) reported experiencing at least one significant financial burden related to medical debt, including:

• 16%—Used up all or most of their savings to pay off medical bills;
• 16%—Were contacted by a collection agency;
• 15%—Were unable to pay for basic necessities like food, heat or housing due to medical bills;
• 11%—Borrowed money, took out a loan, or another mortgage on their home to pay off medical bills;
• 9%—Accumulated large amounts of credit card debt to pay off medical bills;
• 9%—Were placed on a long-term payment plan to pay off medical bills; and
• 7%—Asked for donations (GoFundMe campaigns) to pay off medical bills.

Respondents of color reported experiencing at least one of the previous financial burden related to medical debt more frequently than white, alone non-Hispanic respondents. Likewise, respondents with a disability or who live with a person with a disability also reported navigating medical cost burdens more frequently than respondents without a disabled household member. Respondents that purchased coverage on their own, such as through the marketplace, reported the highest rates of the above burdens due to medical bills (57%) compared to respondents with all other insurance types (see Table 6).

These findings reflect broader societal challenges. In 2024, nearly 100 million Americans collectively owed more than $220 billion in medical debt.¹⁰ Even with insurance, many Americans struggle to afford medical bills—with the average cost of a one-night hospital stay in the U.S. exceeding $3,000, most consumers are unable to afford the cost of a sudden illness or injury.¹¹ Over one quarter (27%) of respondents reported that they or a family member currently has medical bills that are over dure. The majority of respondents (67%) reported that they were insured at the time they incurred their medical debt. When asked to describe why they still incurred medical debt despite having health insurance coverage, the most common responses were:

• 39%—My insurance only covered a portion of the service, and the remaining bill is too high;
• 17%—My insurance didn’t cover the service at all;
• 8%—My deductible was too high, and I was not able meet it;
• 3%—My coinsurance was too high, and I could not afford to pay it; and
• 3%—The interest rate on the debt is too high

Navigating Health System Consolidation*

In addition to the above health care affordability burdens, a small share of Tennessee respondents reported being impacted by health system consolidation.¹² Between 2017 and 2024, there were six changes in ownership (CHOW) involving Tennessee hospitals through mergers, acquisitions, and other transactions involving health care organizations.^13,14 In the past year, 27% of respondents reported that they were aware of a merger or acquisition in their community. Of those, nearly two out of five (39%) said that they or a family member lost access to a preferred health care organization due to changes arising from the merger.

Among those who reported losing access their preferred health care provider due to a merger:

• 46%—skipped one or more recommended follow-up appointment(s) 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; and
• 40%—changed their preferred doctor or hospital to one that is in-network;
• 36%—skipped filling a prescription medication;
• 28%—changed their health plan coverage to include their preferred doctor hospital.

Some respondents reported that the merger caused an additional burden for them or their families. Among those, the three most frequently cited issues include:

• 30%—reported that the merger created an added financial burden;
• 24% – reported that the merger created an added transportation burden;
• 21%—reported that the merger created an added wait time when searching for a new provider;
• 17%—reported that the merger created a gap in the continuity of my care.

While a smaller portion of respondents reported being unable to access their preferred health care organization because of a merger, far more respondents (61%) 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:

• 27%—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;
• 21%—I’m concerned I will have to pay more to see my doctor;
• 12%—I’m concerned I will have to travel farther to see my doctor; and
• 11%—I’m concerned I will have a lower quality of care.

The Tennessee Attorney General must be notified of nonprofit hospital transactions however, the state does require nonprofit hospitals to provide annual reports on whether the change in ownership has negatively impacted health services in the affected communities.¹⁵

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

High Levels of Worry about Affording Care and Coverage

The majority of Tennessee respondents are concerned about their ability to afford care. In total, 76% of respondents reported being either “worried” or “very worried” about affording some aspect of care in the future. The most commonly cited concerns include:

• 62%—Being unable to afford nursing home or home care services;
• 59%—Being unable to afford medical costs when elderly;
• 57%—Affording care in the event of a serious illness or accident;
• 51%—Cost of prescription drugs;
• 50%—Cost of needed dental care; and
• 31%—Cost of maternity and reproductive care

While two of the most frequently cited concerns, affording the cost of nursing home or home care services and affording medical costs when elderly, are typically associated with older adults, these worries were more frequently reported by younger respondents. For example, 70% of respondents aged 34–44 and 65% of those aged 45–54 expressed concern about being able to afford medical costs when they are older. More than half of all respondents under age 65 (57% or higher) reported being worried about paying for some form of long-term care services (see Figure 5).

The annual cost of long-term care in the U.S. ranges from $70,800 for assisted living to over $127,000 for a private room in a nursing facility.¹⁶ Although insurance can offset some of these costs, many plans—including Medicare—only cover long-term care in specific circumstances.¹⁷ As a result, paying out-of-pocket for care may be financially unfeasible for most families, and Medicaid remains the primary payer for nursing home and intermediate care facility services in the absence of a better option.^18,19

In addition to age, concerns about affordability were also cited across all other demographic groups. However, certain groups expressed concern more frequently than others, including respondents living in a household that earns less than $50,000 a year, those with a disability or who live with a person with a disability, and residents living in Southern Tennessee (see Table 7). Overall, 81% of respondents with an annual household income of less than $50,000 reported worrying about affording some aspect of coverage or care in the past year. However, 72% of those earning over $100,000 per year also reported concerns (see Table 7).²⁰

In addition to concerns about paying for specific types of care, many respondents also worried about affording and maintaining health insurance coverage. Overall, 37% of all respondents reported that they were concerned about losing their health insurance coverage, and 54% reported that they were concerned about affording their health insurance coverage. Worry about the cost of insurance was more common than concern about losing coverage, and this pattern held true across all income levels, geographic regions, racial and ethnic groups, and types of coverage (see Table 7).

Respondent Perceptions of the Health System, Policy Solutions

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

• Just 38% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
• While 72% 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

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

• 64% 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: 

• 69%—Take better care of my personal health; 
• 41%—Research treatments myself before going to the doctor; and
• 32%—Do more to compare provider cost and quality before getting services 

Government Actions

Tennessee 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:

• 54%—Health care
• 44%—Economy/Joblessness
• 37%—Affordable Housing

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

• 42%—Address high health care costs, including prescription drugs;
• 33%—Getting health insurance to those who cannot afford coverage; and
• 31%—Improve Medicare, coverage for seniors and those with serious disabilities.

Out of fifteen possible options, Tennesseerespondents most frequently reported believing that the reason for high health care costs lies with industry stakeholders, such as:

• 73%—Drug companies charging too much money;
• 70%—Hospitals charging too much money; and
• 69%—Insurance companies charging too much money.

Support for Policy Solutions

There is support for change regardless of respondents’ political affiliation (see Table 8). 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. When it comes to tackling costs, respondents endorsed a number of strategies, including:  

• 93%—The government should show what a fair price would be for specific procedures
• 92%—Require drug companies to provide notice of price increases and to justify those increases
• 92%—Require insurers to provide up-front cost estimates to consumers 
• 91%—Make it easier to switch insurers if your health plan stops covering your provider
• 91%—Require hospitals and doctors to provide upfront patient cost estimates
• 91%—Cap out-of-pocket costs for life-saving medications, such as insulin
• 90%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription drug price hikes