Key Findings

A survey of more than 1,400 Texas adults, conducted from November 7 to November 13, 2023, found that:

• Over 3 in 5 (70%) experienced at least one health care affordability burden in the past year;
• Over 4 in 5 (84%) worry about affording health care in the future;
• Over 3 in 5 (62%) 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, Texas adults experience hardship due to high health care costs. Overall, well over half (70%) 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 (58%) 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, 56% of respondents without dental insurance cited cost as the main reason for not having coverage, and 50% those without vision insurance cited cost as the main reason for not having coverage.

2) Delaying or Going Without Healthcare Due to Cost 

Well over half (62%) of all respondents reported delaying or going without health care during the prior 12 months due to cost:

• 40%—Skipped needed dental care
• 38%—Delayed going to the doctor or having a procedure done
• 34%—Skipped a recommended medical test or treatment
• 32%—Cut pills in half, skipped doses of medicine or did not fill a prescription¹
• 32%—Avoided going to the doctor or having a procedure done altogether
• 29%—Skipped needed vision services
• 23%—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 most frequently cited cost as the reason for them or their family members not getting care in the last year, exceeding a host of other barriers like not being able to get 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. Nearly one-half (47%) of respondents reported experiencing one or more of these struggles to pay their medical bills:

• 20%—Were contacted by a collection agency
• 19%—Used up all or most of their savings
• 18%—Were unable to pay for basic necessities like food, heat or housing
• 15%—Borrowed money, got a loan or another mortgage on their home
• 14%—Racked up large amounts of credit card debt
• 10%—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 Texas respondents seek these services. Trouble paying for dental bills likely reflects lower rates of coverage for these services (42% said they were partially or completely without dental coverage in the past year).

High Levels of Worry About Affording Health Care in the Future 

Texas respondents also exhibit high levels of worry about affording health care in the future. Over four in five (84%) reported being “worried” or “very worried” about affording some aspect of health care in the future, including:

• 69%—Medical costs when elderly
• 69%—Health insurance will become unaffordable
• 66%—Medical costs in the event of a serious illness or accident
• 66%—Cost of nursing home or home care services
• 59%—Prescription drugs will become unaffordable
• 60%—Cost of dental care
• 53%—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 respondents ages 25-54. This finding suggests that Texas 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 Texas’ Public Health Service Region 11 (see Appendix), closely followed by service regions 2/3 and 4/5N (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.² Still, most Texas respondents of all incomes, races, ethnicities, geographic regions, and levels of ability were somewhat or very concerned.

Concern that health insurance will become unaffordable is also more prevalent among certain groups of Texas respondents. By insurance type, respondents with coverage through their employer most frequently reported worrying about affording coverage, followed by respondents with coverage that they have purchased on their own, not through an employer, 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, as well as the highest rates of worrying about not being able to afford coverage in the future (see Table 2). Respondents living in households with a person with a disability reported higher rates of being concerned about losing health insurance than those living in a household without a person with a disability. Respondents living in Texas’ Public Health Service Regions 6/5S and 11 reported the highest rate of worry about losing insurance compared to residents in other geographic areas.

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

Differences in Health Care Affordability Burdens 

The survey also revealed differences in how Texas 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 (79%) 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 Texas respondents ages 18-44 reported higher rates of going 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

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. Nearly eight in ten (79% of) respondents in this group reported going without some form of care and 45% reported rationing medication, compared to 55% 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 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—27% 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 9% 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.

Insurance Type 

Respondents with Texas Medicaid coverage reported the highest rates of going without care due to cost and rationing medication, followed by respondents with private insurance from an employer or purchased independently (see Table 4). Still, nearly half (49%) of respondents with Medicare coverage also 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 

Texas respondents of color reported higher rates of rationing medication and forgoing care than white alone, non-Hispanic/Latino respondents. Sixty-four percent of Black or African American respondents and 67% of Hispanic/Latino respondents reported going without care due to cost in the past twelve months, compared to 58% of white alone, non-Hispanic/Latino respondent (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-seven percent of Black or African American respondents and 57% of Hispanic/Latino respondents reported going into debt, depleting savings, or going without other needs due to medical bills, compared to 39% of white alone, non-Hispanic/Latino 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 two-thirds (63%) reporting going into debt or going without other needs due to medical bills, compared to 40% of respondents without a disabled household member. Geographically, respondents in Texas’ Public Health Service Regions 1 and 11 reported higher rates of going into debt or going without other needs due to medical bills, although all geographic groups reported somewhat similar levels. In addition, respondents with Medicaid coverage reported the highest rate of the above financial burdens due to medical bills (66%) compared to respondents with all other insurance types.

Impact and Worry Related to Hospital Consolidation*

In addition to the above healthcare affordability burdens, a small share of Texas respondents were negatively impacted by health system consolidation. From 2017 to 2022, there were 19 changes in ownership involving hospitals through mergers, acquisitions, or changes of ownership (CHOW) in Texas.^3,4 Texas does not require that the State Attorney General must be notified of nonprofit health care mergers and acquisitions, and there is no notice or approval process for such transactions.⁵

In the past year, 18% of respondents reported that they were aware of a merger or acquisition in their community—of those respondents, 29% 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:

• 41% 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,
• 44% changed their preferred doctor or hospital due to a merger,
• 35% changed their health plan coverage to include their preferred doctor or hospital,
• 33% skipped recommended follow-up visits due to a merger,
• 32% 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, the top three most frequently reported issues were:

• 34%—The merger created an added financial burden
• 32%—The merger created an added wait time when searching for a new provider
• 17%—The merger created an added transportation burden

While a small portion of respondents reported being unable to access their preferred health care organization because of a merger, far more respondents (57%) 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
• 26%—I’m concerned I will have fewer choices of where to receive care
• 22%—I’m concerned my doctor may no longer be covered by my insurance
• 12%—I’m concerned I will have to travel farther to see my doctor
• 12%—I’m concerned I will have a lower quality of care

*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.

Dissatisfaction with the Health System and Support for Change 

In light of Texas 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 72% 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  

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

• 61% of respondents reported researching the cost of a drug beforehand, and
• 77% 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:

• 73%—Take better care of my personal health
• 42%—Research treatments myself before going to the doctor
• 37%—Do more to compare doctors on cost and quality before getting services
• 20%—Write to or call my state representative asking them to take action on high healthcare prices and lack of affordable coverage options
• 25%—There is not anything I can do personally to make our health system better

Government Actions  

But far and away, Texas 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:

• 47%—Economy/Joblessness
• 46%—Health care
• 38%—Immigration

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

• 51%—Address high health care costs, including prescription drugs
• 36%—Get health insurance to those who cannot afford coverage
• 30%—Improve Medicare, coverage for seniors and those with serious disabilities
• 30%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition

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

• 74%—Hospitals charging too much money
• 73%—Drug companies charging too much money
• 69%—Insurance companies charging too much money

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

• 92%—Show what a fair price would be for specific procedures
• 92%—Require insurers to provide up-front cost estimates to consumers
• 92%—Make it easy to switch insurers if a health plan drops your doctor
• 92%—Set standard prices for drugs to make them affordable
• 92%—Require drug companies to provide advanced notice of price increases and information to justify those increases
• 91%—Cap out-of-pocket costs for life-saving medications, such as insulin
• 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%—Require hospitals and doctors to provide up-front cost estimates to consumers

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. Annual surveys can help assess whether progress is being made.

Notes 

1. Twenty-six percent (26%) did not fill a prescription and 20% cut pills in half or skipped doses of medicine due to cost.
2. Median household income in Texas was $73,035 (2017-2021). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts, U.S. Census Bureau QuickFacts: Texas.
3. Centers for Medicare and Medicaid Services. (2023). Hospital Change of Ownership. Retrieved January 11, 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, 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 January 11, 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 possible policy solutions.

This survey, conducted from November 7 to November 13, 2023, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,500 respondents who live in Texas. 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 1,405 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

The geographic regions used in this survey brief were identified from the Texas Department of State Health Services Public Health Service Regions and are divided by county.

Texas Counties and Corresponding Public Health Service Regions

County	Public Health Service Region	County	Public Health Service Region
Crockett	9/10	Grayson	2/3
Crosby	1	Gregg	4/5N
Culberson	9/10	Grimes	7
Dallam	1	Guadalupe	8
Dallas	2/3	Hale	1
Dawson	1	Hall	1
Deaf Smith	1	Hamilton	7
Delta	4/5N	Hansford	1
Denton	2/3	Hardeman	2/3
DeWitt	8	Hardin	6/5S
Dickens	1	Harris	6/5S
Dimmit	8	Harrison	4/5N
Donley	1	Hartley	1
Duval	11	Haskell	2/3
Eastland	2/3	Hays	7
Ector	9/10	Hemphill	1
Edwards	8	Henderson	4/5N
El Paso	9/10	Hidalgo	11
Ellis	2/3	Hill	7
Erath	2/3	Hockley	1
Falls	7	Hood	2/3
Fannin	2/3	Hopkins	4/5N
Fayette	7	Houston	4/5N
Fisher	2/3	Howard	9/10
Floyd	1	Hudspeth	9/10
Foard	2/3	Hunt	2/3
Fort Bend	6/5S	Hutchinson	1
Franklin	4/5N	Irion	9/10
Freestone	7	Jack	2/3
Frio	8	Jackson	8
Gaines	1	Jasper	4/5N
Galveston	6/5S	Jeff Davis	9/10
Garza	1	Jefferson	6/5S
Gillespie	8	Jim Hogg	11
Glasscock	9/10	Jim Wells	11
Goliad	8	Johnson	2/3
Gonzales	8	Jones	2/3
Gray	1	Karnes	8

Kaufman	2/3	Mills	7
Kendall	8	Mitchell	2/3
Kenedy	11	Montague	2/3
Kent	2/3	Montgomery	6/5S
Kerr	8	Moore	1
Kimble	9/10	Morris	4/5N
King	1	Motley	1
Kinney	8	Nacogdoches	4/5N
Kleberg	11	Navarro	2/3
Knox	2/3	Newton	4/5N
La Salle	8	Nolan	2/3
Lamar	4/5N	Nueces	11
Lamb	1	Ochiltree	1
Lampasas	7	Oldham	1
Lavaca	8	Orange	6/5S
Lee	7	Palo Pinto	2/3
Leon	7	Panola	4/5N
Liberty	6/5S	Parker	2/3
Limestone	7	Parmer	1
Lipscomb	1	Pecos	9/10
Live Oak	11	Polk	4/5N
Llano	7	Potter	1
Loving	9/10	Presidio	9/10
Lubbock	1	Rains	4/5N
Lynn	1	Randall	1
Madison	7	Reagan	9/10
Marion	4/5N	Real	8
Martin	9/10	Red River	4/5N
Mason	9/10	Reeves	9/10
Matagorda	6/5S	Refugio	11
Maverick	8	Roberts	1
McCulloch	9/10	Robertson	7
McLennan	7	Rockwall	2/3
McMullen	11	Runnels	2/3
Medina	8	Rusk	4/5N
Menard	9/10	Sabine	4/5N
Midland	9/10	San Augustine	4/5N
Milam	7	San Jacinto	4/5N

San Patricio	11	Wichita	2/3
San Saba	7	Wilbarger	2/3
Schleicher	9/10	Willacy	11
Scurry	2/3	Williamson	7
Shackelford	2/3	Wilson	8
Shelby	4/5N	Winkler	9/10
Sherman	1	Wise	2/3
Smith	4/5N	Wood	4/5N
Somervell	2/3	Yoakum	1
Starr	11	Young	2/3
Stephens	2/3	Zapata	11
Sterling	9/10	Zavala	8
Stonewall	2/3
Sutton	9/10
Swisher	1
Tarrant	2/3
Taylor	2/3
Terrell	9/10
Terry	1
Throckmorton	2/3
Titus	4/5N
Tom Green	9/10
Travis	7
Trinity	4/5N
Tyler	4/5N
Upshur	4/5N
Upton	9/10
Uvalde	8
Val Verde	8
Van Zandt	4/5N
Victoria	8
Walker	6/5S
Waller	6/5S
Ward	9/10
Washington	7
Webb	11
Wharton	6/5S
Wheeler	1