Maria DeNunzio, PhD, MS and Shelby Owen, MPH

Executive Summary

Background

The Health Care Value Hub conducted 45 Consumer Health Care Experience State Surveys (CHESS) across 36 states between 2018 and 2025, with some states participating multiple times. CHESS is designed to provide reliable, state-level estimates of respondents’ views on a wide range of health system issues: confidence in using the health system, the financial burden and tradeoffs that respondents have experienced, their worries about needing and affording health care now and in the future, and the policy fixes that might be needed to address these issues. The purpose of this report is to present key findings on core topics assessed by the CHESS from 2021 to 2025 and contextualize the results in relation to the social, political, and economic landscape of the U.S.

CHESS findings consistently reveal high levels of concern about health care affordability, insurance stability, and the overall performance of the U.S. health care system. These attitudes closely track the political, social, and economic context of each survey year, highlighting the value of CHESS as a tool for monitoring public sentiment in response to significant events.

Health Care Access and Affordability are Concerns for CHESS Respondents

Unexpected medical bills remained a key source of financial stress, with about half of U.S. adults nationally unable to cover a $500 bill without borrowing (Sparks, Lopes, et al., 2025). With Medicaid eligibility rules shifting in 2026 and Affordable Care Act premium subsidies expiring in late 2025 (Lo et al., 2025; Sullivan & Rapfogel, 2025), worry about affordability is expected to rise. CHESS data will play a critical role in tracking these changes.

From 2021–2025, a rising share of respondents across all income levels reported experiencing at least one affordability burden with Medicaid enrollees, lower‑income, and non-White respondents experiencing the highest burden levels.

From 2021–2025, CHESS respondents expressed strong concern about being able to obtain and afford needed health care. Younger adults, respondents with lower incomes, Medicaid enrollees, and non‑White respondents were consistently the most worried populations. A greater share of respondents feared their insurance becoming too expensive compared to losing it entirely.

CHESS Respondents Want the Government to Address Health Care Issues

When asked to select top health related issues for the government to address, CHESS respondents consistently selected:

• Addressing high health care and prescription drug costs;
• Preserving consumer protections, such as preexisting condition safeguards;
• Expanding access to affordable coverage; and
• Improving Medicare

Women’s issues were rarely selected as a top three government priority, but interest spiked in 2022 following the Dobbs v. Jackson decision (U.S. Supreme Court, 2022), which overturned Roe v. Wade and led to widespread changes in reproductive health care laws. Women, especially those with low income or from racial minority groups, face disproportionate challenges related to mental health and intimate partner violence, in addition to obstacles to reproductive health care, intensified by affordability and access obstacles (Ranji et al., 2019; Zivin & Courant, 2024). CHESS results show that U.S. adults are motivated by societal issues and seek government action to address health care concerns, including those affecting women.

Attitudes Toward the Health Care System and Policy Solutions

Across all states and years, most CHESS respondents believed the U.S. health care system needs meaningful change. Between 69% and 82% agreed that reforms are necessary, with the number of respondents who supported health care system change increasing each year. Respondents expressed exceptionally strong (greater than 80%) bipartisan support for policies that would:

• Improve price transparency for procedures and medications,
• Cap out of pocket costs for life saving drugs,
• Simplify insurer switching,
• Require upfront cost estimates from insurers and providers, and
• Expand affordable insurance options.

These findings demonstrate widespread alignment on core affordability and transparency reforms, regardless of political affiliation.

Conclusion

Across five years of data, CHESS findings consistently illustrate a health care system that is difficult for many Americans to afford, navigate, and trust. Respondents’ experiences reflect both longstanding structural, historical barriers and acute stresses brought on by policy changes, economic conditions, and shifting social dynamics. As the U.S. enters a period of major health policy transition, particularly related to Medicaid eligibility and marketplace subsidies, CHESS offers a crucial, real-time benchmark of public concern. The evidence underscores a clear call for policy action to improve health care affordability, strengthen social supports, and address persistent disparities.

CHESS Five Year Retrospective Report

Introduction

The adult population in the United States (U.S.) continues to have poorer overall health outcomes (Watson et al., 2025). Chronic diseases like cardiovascular disease, cancer, stroke, and diabetes are leading causes of death, disability, and reduced quality of life for U.S. adults (Mokdad et al., 2018). Many of the major chronic diseases in the U.S. have modifiable risk factors, yet, incidence rates, and by extension, health care costs, continue to increase (Hartman et al., 2024). Inadequate access, including affordability obstacles, to health care exacerbate the burden of poor health among the U.S. adult population.

Health outcomes are not fair across social and economic segments of the population. Individuals who identify with a race other than White are more likely to have a chronic disease, health care affordability burdens, and other poor health outcomes (Dwyer-Lindgren et al., 2024). Similarly, individuals with low incomes and Medicaid enrollees are more likely to experience poor health outcomes (Collins et al., 2023).People with a disability are more likely to experience obstacles to affordable health care and access to health resources, which can lead to poor health outcomes and a compounding effect if the individual is part of multiple disenfranchised groups (Mitra et al., 2022). Disparities in access to insurance coverage exist by race and income, compounding the disparity effects of these demographics in U.S. society (Lee et al., 2021; Sharer & Lukens, 2024).

In July 2025, the U.S. Congress passed a law that mandates substantial changes to Medicaid eligibility beginning in 2026 (H.R.1, 2025). Additionally, government subsidies on Affordable Care Act premiums expired in December 2025, which could cause out of pocket health care costs to rapidly increase for many U.S. adults (Lo et al., 2025; Sullivan & Rapfogel, 2025). Access to Medicare has been shown to reduce racial and ethnic disparities in health care access and self-reported perceptions of good health (Wallace et al., 2021). Given the large changes in health policy experienced by U.S. adults, it is imperative to document consumer’s perspectives on the health care system, including ease of access, affordability, and priorities for the government to address.

Background

The Healthcare Value Hub conducted 45 Consumer Health Care Experience State Surveys (CHESS) across 36 states between 2018 and 2025, with some states participating multiple times.

CHESS is designed to provide reliable, state-level estimates of respondents’ views on a wide range of health system issues: confidence in using the health system, the financial burden and tradeoffs that respondents have experienced, their worries about needing and affording health care now and in the future and the policy fixes that might be needed to address these issues. The purpose of this report is to present key findings on core topics assessed by the CHESS from 2021 to 2025 and contextualize the results in relation to the social, political, and economic landscape of the U.S.

Research Questions

From 2021 to 2025, the CHESS surveys looked at key topics related to people’s experiences with the U.S. health care system. In this report, we used CHESS survey data to answer the following questions:

• Do people’s opinions about government priorities and the health care system reflect what’s happening in the U.S. socially and politically between 2021 and 2025?
  • What do people think are the most important problems that state and federal governments should work on, and have those opinions changed over time?
  • How do people view the U.S. health care system, and have their views shifted from year to year?
• How do people rate their own health, and has that changed over time?
• Has insurance coverage changed for people, and what are the financial effects of not having insurance or having medical debt?
• Has worry about health care changed over time for people, and are there certain worries that have gotten better or worse for groups based on income, race, or insurance status?

Methods

CHESS has been administered in 36 states and Washington DC since 2018 (See Exhibit 1). While the purpose of the survey remained consistent to measure U.S. adults’ perceptions of the health care system, the instrument was edited each year based on funding priorities and national context. As a result, and due to additional methodological limitations related to population weighting, data was not aggregated for this report. Rather, findings are presented individually by state and year. This report presents a core set of variables that were measured consistently from 2021-2025 in most states surveyed. See Exhibit 2 for a list of states surveyed by year. Affordability burden is a foundational variable discussed in each CHESS brief. It is defined as an aggregate measure of multiple survey questions. Respondents were classified as having a health care affordability burden if they reported being without health insurance for all or part of the past 12 months or if due to cost, they skipped a recommended medical test or treatment, did not fill a prescription or cut pills in half or skipped medication doses.

Result Trends and Contextualization from CHESS Surveys from 2021 to 2025

Data is presented by medians and ranges for states surveyed on a core set of CHESS items. Core topics include respondent perceptions of their own health, insurance coverage, health care affordability burdens, preferred government priorities, and worry regarding health care.

Respondents Perceptions of their own Health

Less than one quarter (25%) of respondents rated their overall health as ‘excellent’ across all states and survey years, except for Washington in 2024 (31%). The low self-rating of excellent overall health aligns with the actual overall health of adults in the United States. Most U.S. adults have one or more chronic diseases with onset influenced by modifiable social determinants of health (Jilani et al., 2021; Watson et al., 2025). Previous survey research substantiates the CHESS findings that U.S. adults do not perceive their health to be excellent or very good, with only 13% of respondents to an International Food Information Council survey rating their health as excellent (International Food Information Council, 2025).

Few respondents rated their overall health poorly, with each state and survey year having six percent or less of respondents selecting poor overall health. The largest proportions of respondents rated their health as ‘very good’ or ‘good’ across states and survey years, with a non-outlier range from 40% (Idaho, 2024) to 28% (Indiana, 2022) for very good and 38% (Mississippi, 2023 and Kansas, 2025) to 28% (Connecticut, 2022 and Idaho, 2024) for good. One outlier in the health ratings was Florida in 2023, in which 21% of respondents rated their overall health as ‘very good.’ For ‘good’ health ratings, low outliers were Florida in 2023 (20%) and Washington in 2024 (24%). While there were fluctuations in how respondents rated their health, proportions of individuals who rated ‘excellent,’ ‘very good’, ‘good’, ‘fair’, and ‘poor’ did not change by large practical amounts over time. See Exhibit 3.

Insurance Coverage

Across all states from 2021 to 2025, the majority of respondents were insured for the past 12 months. See Exhibit 4. Additionally, over one-third of respondents reported that their primary health insurance coverage was obtained through their employer or a family member’s employer. See Exhibit 5.

Across all survey years, the most common reason that respondents did not have health insurance at some point in the previous year was that health insurance was too expensive. One third or more of respondents reported that the cost of health insurance was the reason they were uninsured part or all of the past year in all states and survey years. The median percentage of respondents who reported that they were uninsured because they were not eligible for Medicaid was between 6% and 9% from 2021 to 2025 in all states surveyed. See Exhibit 6.

The median percentage of CHESS respondents who were uninsured for all or part of the past 12 months was 16% or less in each of the survey years. Medicaid expansion had been implemented in most states during the survey period and federal subsidies on premium costs for insurance purchased on the marketplace were available for many marketplace shoppers (KFF, 2025). While the rates of under- and uninsured CHESS respondents were stable from 2021 to 2025, future research should closely examine uninsured rates among subpopulations who are more likely to purchase marketplace insurance and use Medicaid (Lo et al., 2025; Sullivan & Rapfogel, 2025).  

CHESS data from 2021 to 2025 showed that the most common reason respondents did not have health insurance for all or some of the previous year was the cost. 2025 CHESS data does not capture the impact of the forthcoming health care policy changes. However, the results described in this report may serve as a baseline against which future research can describe reasons for underinsurance status among U.S. adults. Major changes to Medicaid structure and eligibility, as mandated in HR1, will start to be implemented in 2026 (H.R.1, 2025). Affordable Care Act marketplace health care premiums expired on December 31, 2025 (Sullivan & Rapfogel, 2025). At the time of this writing, there were several pending legislation packages to address the expired subsidies.

Health Care Affordability Burdens

The median percentage of respondents who reported that they or a family member who lived with them had overdue medical bills was 25% in 2021, 24% in 2022, 29% in 2023, 24% in 2024, and 24% in 2025. The lowest percentage of respondents with overdue medical bills was 16% in Massachusetts in 2021 and the highest percentage was 38% in Mississippi in 2023.

While a large percentage of respondents reported that they did not have any major financial burdens due to medical bills, 12% or more of respondents in 39 of 43 states surveyed across five years reported that they used up all or most of their savings due to medical bills in the past 12 months. In 27 of 44 states surveyed, 12% or more of respondents reported that were unable to pay for basic necessities like food, heat, or housing due to medical bills and 12% or more of respondents in 36 of 44 states surveyed had been contacted by collections agencies regarding medical bills in the year preceding the survey. In decreasing order of frequency across survey years, respondents also reported borrowing money, taking out loans, remortgaging their home, racking up credit card debt, getting placed on long term payment plans, and declaring bankruptcy from high medical bills.

Across each income category, the number of respondents who reported experiencing a health care affordability burden had an increasing trend from 2021 to 2025. Those who reported an income of less than $50,000 reported the highest median percentage of experiencing a health care affordability burden across each year with a median of 72% in 2021 and a median of 81% in 2025. See Exhibit 7.

While most states followed a similar pattern to the median percentages, outliers in the higher income categories were present in 2024. CHESS respondents from Idaho (81%), Oregon (73%), and Washington DC (73%) who reported an income of $100,000 or more were found to have higher rates of experiencing a health care affordability burden when compared to the 2024 median (61%) of all states surveyed. Those using Medicaid reported the highest median percentage of experiencing a health care affordability burden across each year with a median of 70% in 2021 and a median of 82% in 2025. See Exhibit 8.

Like income status, most states followed a similar pattern of experiencing a health care affordability burden by race and insurance coverage type, but some outliers were present. The lowest percentage of White respondents who reported experiencing a health care affordability burden was 41% in California in 2021 while the highest percentage of White respondents who reported a health care affordability burden was 82% in Idaho in 2024. Non-White respondents reported similar percentages of experiencing a health care affordability burden, but the highest percentage occurred in Maryland in 2022 (86%).    

CHESS respondents who identified as non-White reported a higher median percentage of experiencing a healthcare affordability burden across each year with a median of 67% in 2022 and a median of 80% in 2025. See Exhibit 9. It has been documented in the literature that communities of color experience disparities in all areas of life, including the health care system which negatively impacts the health and wellness of these communities. Non‑White communities face greater health care burdens linked to system-wide disparities and an imbalance to access to high‑quality care. The COVID-19 pandemic magnified health disparities between White and non-White patients (Miller, 2021); non‑White adults experienced higher infection rates and worse clinical outcomes when compared to White adults (Robertson et al., 2022). Non-White communities still face disproportionate care and have reported higher levels of unfair treatment when seeking health care when compared to White adults (Artiga et al., 2023).

Worry about Health Care Access and Affordability

CHESS respondents were asked to rate their level of worry for a range of healthcare concerns. Across each survey year, CHESS respondents were worried about health care access and affordability, regardless of age, income, race, and insurance coverage. Those who identified as younger, low-income, non-White, and those who utilize Medicaid, generally reported being more worried when compared to other groups.

While many respondents reported being worried about losing their health insurance, a greater proportion of respondents indicated that they were worried about their health insurance becoming too expensive regardless of income, age or race.

Given the substantial changes to Medicaid eligibility beginning in 2026 and the December 2025 expiration of government subsidies on Affordable Care Act premiums. worry around health insurance affordability is likely to increase. It will be imperative to continue to collect data around worry about health insurance affordability and access in 2026 and future CHESS surveys to identify trends that may correspond with 2026 changes to Medicaid eligibility and Affordable Care Act premium subsidies.  

Unexpected medical costs can prove to be difficult financially for households. A 2022 Kaiser Family Foundation survey found that about half of adults say they would be unable to pay a $500 unexpected medical bill without borrowing money (Sparks, Lopes, et al., 2025). The CHESS survey revealed that concerns about unexpected medical bills, healthcare costs in later life, and expenses for nursing home or home health care services are higher among younger age groups. This heightened level of worry among younger respondents likely reflects their anxieties about covering medical costs not only for themselves but also for aging family members.

Worry about Losing Health Insurance

In 2021, five of the eight states surveyed had 40% or more of all respondents report that they were worried or very worried about losing their health insurance. Less than 40% of respondents reported that they were worried or very worried that they would lose their health insurance for each state surveyed in 2022 to 2025. The level of worry about losing health insurance was analyzed by sub-groups of insurance coverage, income, race, and age, with details provided below.

Worry about Losing Health Insurance Coverage, by Insurance Coverage

CHESS respondents were asked to report their primary health insurance source: an employer- sponsored plan, coverage purchased on their own, Medicare, or Medicaid. The median range of ‘worried’ or ‘very worried” responses among Medicaid users was 45% to 55% across survey years and was the highest level of worry among all insurance users. Medicare users were the least worried about losing their health insurance, with a median percent reporting worry from 17% to 35% from 2021 to 2025. See Exhibit 10.

Worry about Losing Health Insurance, by Income

During the 2021 to 2025 CHESS, respondents at all income levels had a similar level of worry about losing their health insurance. However, those earning $75,000 or more had lower levels of worry than respondents with lower incomes. See Exhibit 10.

Worry about Losing Health Insurance, by Race

Data on the level of worry about losing health insurance and race was not available for 2021. Between 2022 and 2025, the median percentage of CHESS respondents who identified as White and reported that they were worried or very worried that they would lose their health insurance was 26% to 33%. The range of medians for respondents who identified as non-White and reported worry about losing their health insurance was 38% to 42%. See Exhibit 10. Michigan respondents reported levels of worry higher than general state trends in 2025, with 60% of non-White and 55% of White respondents reporting worry about losing their health insurance. The 2025 CHESS data collection occurred in Michigan from June 30 to July 29, a period in which news coverage of the HR1 legislative process was frequent (Gibbons, 2025; San Martin, 2025; Shamus, 2025). Respondents may have been more worried about losing their health insurance during this period of heightened public awareness on health policy.

Worry about Losing Health Insurance, by Age

Respondents who were older reported lower levels of worry about losing their health insurance, a finding that was true in each survey year. The proportion of respondents between 18 and 54 years old who were worried or very worried that they would lose their health insurance decreased from 2021 to 2025 while the proportion of respondents 55 years and older who were worried or very worried that they would lose their health insurance remained stable. See Exhibit 10. While most states followed a similar pattern, some exceptions were present among CHESS respondents:

• In 2021, 34% of Michigan respondents who were 18-24 years old reported they were worried or very worried that they would lose their health insurance.
• In 2022, 51% of West Virginia respondents who were 18-24 years old reported they were worried or very worried that they would lose their health insurance.
• In 2023, 59% of Louisiana respondents and 50% Florida respondents who were 18-24 years old reported they were worried or very worried that they would lose their health insurance.
• In 2024, 33% of Idaho respondents who were 65+ years old reported they were worried or very worried that they would lose their health insurance.

Worry that Health Insurance will Become too Expensive

The median proportion of respondents who were worried or very worried about their health insurance becoming too expensive was 62% in 2021, 2022, and 2024, 64% in 2023, 62% in 2024, and 53% in 2025. There were no high or low outliers in the proportion of respondents worried or very worried about their health insurance becoming too expensive across all states surveyed, suggesting this is a constant and stable concern. CHESS data corroborates other repeated studies that have reported that many U.S. adults are concerned about the cost of health insurance (Sparks, Lopes, et al., 2025).

Worry that Health Insurance will Become too Expensive, by Insurance Coverage

While there were slight fluctuations across survey years, respondents using Medicare had the lowest proportion of respondents who were worried or very worried about their health insurance becoming too expensive, with a range of medians from 42% to 53%. Those who had health insurance through their employers had the highest median proportion of respondents who were worried or very worried in 2021 at 72%, but this group reported the largest decrease from 2021 to 2025. A median percentage of 55% of respondents receiving health insurance through their employers in 2025 reported they were worried or very worried about their health insurance becoming too expensive. Respondents who use Medicaid or purchased private insurance on their own reported similar proportions of worry across 2021 to 2025. See Exhibit 11.

Worry that Health Insurance will Become too Expensive, by Income

Generally, respondents at all income levels had a similar level of worry about their health insurance becoming too expensive. The median percentage of those who were worried or very worried decreased across all income levels from 2021 to 2025. See Exhibit 11. Most states followed a similar pattern, with higher levels of worry about affording their health insurance at the lower income groups. However, even respondents indicating their households earn $100,000 or more annually reported being concerned about affording their health insurance.  

Worry that Health Insurance will Become too Expensive, by Race

Between 2022 and 2025, those who identified as White and non-White reported similar levels of worry about their health insurance becoming too expensive. Both groups reported a decrease in worry over time. Those who identified as White reported that they were worried or very worried that their health insurance would become too expensive had a range of medians from 49% to 63% while those who identified as non-White had a range of medians from 55% to 67%. See Exhibit 11. Respondents from every state reported similar proportions of worry.

Worry that Health Insurance will Become too Expensive, by Age

CHESS respondents reported less worry about affording their health insurance in older age groups. Younger adults tend to express greater concern about affording health insurance, likely because they depend on employer-sponsored plans or purchase coverage individually through the Marketplace. In contrast, individuals transitioning to Medicare report less worry about the cost of their health insurance. However, the proportion of respondents in all age groups who were worried or very worried that their health insurance would become too expensive decreased from 2021 to 2025. See Exhibit 11.

Health care experts warn that the current U.S. health care system is unprepared for the aging of the Baby Boomer generation and the anticipated health care costs that will accompany this demographic (Jones & Dolsten, 2024). Resource allocations to address the non-medical drivers of health and related disparities among aging populations are needed to limit a potential exacerbation of existing disparities among those who can access health care resources easily and those who cannot (Jones & Dolsten, 2024).

Worry about Unexpected Medical Costs

The median proportion of respondents who were worried or very worried that they would not be able to pay medical costs in the event of a serious illness or accident was consistently equal to or more than 53% from 2021-2025. The highest proportion of respondents who were worried or very worried that they would not be able to pay medical costs in the event of a serious illness or accident was 68% in Utah in 2023. Unexpected medical costs are expensive, with the U.S. Centers for Medicare and Medicaid Services estimating that care for a broken bone costs $30,000 and the average cost for a three-day hospital stay is $30,000. A 2018 survey conducted by KFF corroborated the findings of the CHESS survey in that that most U.S. adults worry about surprise medical bills (Rau, 2018).

Worry about Cost of Aging

When asked to rate how worried they were that they or a family member living with them would not be able to pay medical costs when they were an older adult, 55% or more of respondents reported they were worried or very worried in each state from 2021 to 2025. The highest proportion of respondents who were worried or very worried was 70% in Utah in 2023. Similarly, 55% or more of respondents reported they were worried or very worried about affording nursing home and home health care services in each state from 2021 to 2025.

Health care spending continues to grow; however, wages are not rising at the pace of the cost of health care and other essential resources (Hartman et al., 2024). CHESS respondents had high (consistently more than 60% of respondents) levels of worry about health insurance becoming too expensive and being unable to afford care when they are older such as nursing home and home care services. The high rates of worry about affordability of nursing home services were observed across all age groups and may reflect the worry of the Baby Boomer generation and that of their family members as the Boomers age into need for these types of services. 

Worry about the Cost of Aging, by Income

Respondents earning less than $100,000 were similarly worried about the medical costs associated with aging. Unsurprisingly, those with incomes of $100,000 or more were least worried, with only 49% to 59% expressing concern across all five years of data. See Exhibit 12. While most states followed a similar pattern, one exception was present among CHESS respondents. In 2023, 66% of Utah respondents who indicated that their income was $100,000 or more reported they were worried or very worried that they would not be able to pay for medical costs when they are an older adult. Results were similar for CHESS respondents who worried about affording nursing home and home care services as they age. See Exhibit 13.     

Worry about the Cost of Aging, by Age

Across all survey years, most respondents were generally worried about the costs of aging and nursing home and home care services. Those aged 35 to 54 years old had the highest proportion of respondents who were worried or very worried about the medical costs associated with aging, while those aged 45 to 54 years old had the highest proportion of respondents who were worried or very worried about the medical costs associated with nursing home and home care services. Median percentages can be seen in Exhibit 12 and 13. 

Worry about Affording Prescription Drugs

High prescription drug prices can cause patients to skip dosages, not fill prescriptions and not be compliant with medical guidance. The CHESS found that around 30% of CHESS respondents cut pills in half, skipped doses of medicine or did not fill a prescription from 2021 to 2025.

More than 45% of respondents in each state per year surveyed reported that they were worried or very worried that they or a member of their household would not be able to afford needed prescription drugs. The highest proportion of worried or very worried respondents was 59% in Texas in 2023 and the lowest proportion was 46% in Connecticut in 2025.

Worry about Affording Prescription Drugs, by Income

Generally, respondents in all income categories were worried about affording prescription drugs. The median proportion of respondents who were worried or very worried about affording prescription drugs decreased from 2021 to 2025 among respondents who earned more than $75,000. It is not surprising that those who earn more money are less worried about affording prescription drugs than those with lower incomes.

Worry about Affording Prescription Drugs, by Age

Across all survey years, respondents’ level of worry about being able to afford prescription drugs decreased with age. The proportion of respondents between 18 and 54 years old who were worried or very worried about being able to afford prescription drugs decreased from 2021 to 2025 while the proportion of respondents 55 to 64 years old who were worried or very worried that they would lose their health insurance remained stable. The proportion of respondents 65 years and older who were worried or very worried about being able to afford prescription drugs also decreased from 2021 to 2025. See Exhibit 14. Most states followed a similar pattern, with younger age groups reporting higher levels of worry of affording prescription drug medication which may likely reflect their insurance status as well.

Worry about Dental Care Costs

The proportion of respondents who were worried or very worried that they would not be able to pay for needed dental care was consistent across states from 2021-2024, with a median of 55% (2021), 54% (2022), 56% (2023), and 54% (2023). The lowest proportion of respondents who were worried or very worried about affording dental care was 45% in Washington in 2024, and the highest proportion was 60%– reported in Texas (2023), New Mexico (2021), and Maine (2021). The median for 2025 was 48%, with a range of 28% (Oklahoma) to 51% (Kansas). When CHESS respondents were asked to describe a time when they went without care due to cost, most consistently they report needing and skipping dental care services.

Worry about Maternity or Reproductive Health Care Costs

In 2025, CHESS respondents in Kansas, Michigan, and Tennessee were asked to report their level of worry about the cost of maternity or reproductive care. The median percentage of respondents who reported they were worried or very worried was generally higher among respondents of reproductive age, from 18 to 24 and 25 to 35. Worry about maternity or reproductive care costs was still reported by respondents 65 years of age or older at a median percent of 16% or more. Previous research has reported that cost is a common obstacle to accessing maternity and reproductive health care, with exacerbated difficulties for adults with low income and those who identify as non-White (Aleshire et al., 2021; Ranji et al., 2019; VandeVusse et al., 2023).

Perceptions of the Health Care System and the Top Three Health-Related Priorities for the Government to Address

From 2021 to 2025 across all states surveyed, 59% or more of respondents agreed or strongly agreed that the U.S. health care system needs to change. The highest percentage of respondents who agreed or strongly agreed to this statement was 82% (Washington, 2025). The median percent agreement among states surveyed increased each year, from 69% in 2021 (New Mexico and Massachusetts) to 77% in 2025 (Kansas). To gain some insight into how CHESS respondents would like the health care system in the United States to change, they were provided a list of priorities and asked to rank the top three health priorities that the federal or state government should work towards fixing. See Exhibit 15.

CHESS respondents most often selected “address high health care costs including prescription drug costs” as one of their top three preferred government priorities.

Across nearly all states and survey years, more than 37% of respondents reported that addressing high health care costs, including prescription drug costs, should be a top three priority for the government. The range of the percentage of respondents who selected high health care costs as a top three government priority was between 37% and 56% from 2021 to 2025. See Exhibit 16.

Although respondents consistently selected high health care costs as a top three government priority, they did not fully endorse single payer coverage. The median percentage of respondents who ranked implementation of Medicare-for-All/ single payer health coverage to be a top three government priority was consistent across survey years: 21% in 2021 (Massachusetts and Michigan), 20% in 2022 (California, Missouri, and New Jersey), 16% in 2023 (Florida), 20% in 2024 (New Hampshire, New Mexico), and 18% in 2025 (Tennessee and Virginia). The highest percentage of respondents who selected this option was 26% in Oregon in 2024 and the lowest percentage was 13% in Mississippi in 2022. The implementation of Medicare-for-All/single payer health coverage was selected as a top three government priority consistently less frequently than other priorities.

Other priorities that had the second or third highest median percentage of respondents who selected that option in each year were: 1) preserve consumer protections like you can’t be denied coverage or charged more if you have a pre-existing medical condition; 2) get health insurance to those who cannot afford coverage; 3) improve Medicare. 

The health-related government priority that was second most frequently selected by CHESS respondents was “preserve consumer protections like you can’t be denied coverage or charged more if you have a pre-existing condition,” with a range of 27% to 38% of respondents selecting this option as a government priority in all states and survey years.

The third most frequently selected health- related government priority was to get health insurance to those who cannot afford coverage, with forty percent or less of respondents selecting this option as a top three government priority in all states and survey years. The median percentage of respondents who selected getting health insurance to those who cannot afford it as top government priority was 33% in 2021 (New Mexico), 33% in 2022 (Indiana and New Jersey), 35% in 2023 (Minnesota), 31% in 2024 (Washington) and 32% in 2025 (with four states reporting). The lowest percentage of respondents who selected this government priority was Colorado in 2024, at 27%.

About one third of respondents across all states and survey years ranked improving Medicare as one of their top three government priorities. The lowest percentage of respondents who selected this option were those in Colorado and Idaho in 2024 (27%) and the highest percentage was West Virginia in 2022 (37%). Improving Medicare had one of the three highest median percentages of respondents selecting it as a top three government priority in 2023, 2024, and 2025. In 2023, several Medicare-relevant components of the Inflation Reduction Act, a large spending bill passed by the U.S. Congress, were implemented. The provisions included a $35 per month cap on insulin costs and access to a range of vaccines for free for Medicare users (Schwarz, 2022).

CHESS respondents did not select health policy repeal or refinement, women’s health, research funding, improvements to Medicaid, preservation of consumer protections, single-payer health coverage, and more transparency about the quality of doctors and hospitals as a top three government priority very often.

Of the less frequently selected top three government priorities, improving Medicaid had the highest median percentages of respondents across survey years, followed by refining federal health care legislation such as the Affordable Care Act, coronavirus aid packages, or the Inflation Reduction Act. One third or less of respondents in all states surveyed from 2021 to 2025 ranked improving Medicaid as a government priority. The range of respondents who selected this option was within eleven percentage points across all states and survey years, from 19% in Idaho in 2024 to 30% in Mississippi in 2023 and New Mexico in 2024. The range of respondents who selected refining health care reform legislation as a top three government priority was 10% in Idaho in 2024 to 23% in Colorado in 2024.

Less than 19% of respondents ranked the securement of funding for research into causes of and cures for specific diseases as a top three government priority in 2021, 2022, 2023, 2024 and 2025. The median percentage of respondents who ranked health research funding as a top three government priority was 15% in 2021 and 2022, 16% in 2023 and 2024, and 17% in 2025. The lowest percentage of respondents who ranked health research funding as a government priority was 12% in West Virginia in 2022 and the highest percentage was 18% in Washington in 2024 and Georgia in 2021. Significant changes occurred to scientific research infrastructure in the U.S. in 2025(Langin, 2025; Mastej et al., 2025), and future examinations of CHESS data should be designed to assess if science policy decisions made in 2025 are reflected in CHESS responses. A rapid response poll conducted by KFF found mixed levels of support for federal funding cuts from January to April 2025; however, six in 10 respondents opposed major staff and funding cuts at federal health agencies (Sparks, Montero, et al., 2025). As additional information on public perceptions of federal health spending and budget cuts become available, the CHESS results can serve as a valuable baseline measurement for comparison.

CHESS respondents were less likely to rank specific health issues as one of their top three government health-related priorities compared to other topics. However, 2022 saw a shift in some level of preference for women’s health and research funding, likely due to the reversal of Roe v Wade by the Supreme Court (see discussion on government priorities for more details). Exhibit 17 displays for the range of the percent of respondents who ranked addressing women’s health as a top three government priority.

Preferred Government Priorities

In addition to selecting their top three health-related priorities for the government to address, CHESS respondents were asked to select the top three issues that they believed the government should address in the coming year. In 2021 through 2025, nine options were provided, as listed below:

• Economy/Joblessness
• Cost of Higher Education/Student Loans
• Health Care
• Foreign Policy
• Women’s issues
• Environment/Energy
• Taxes
• Immigration
• Affordable Housing

Two options were added to the surveys in 2022-2025: 1) police reform and police violence against Black people and 2) racism in America.

CHESS respondents most often selected the economy/joblessness, health care, taxes, and affordable housing as a top three preferred government priority, as measured by the median percentage of respondents who selected this option. Health care was the most selected priority for the government to address among CHESS respondents across survey years and states. See Exhibit 18.

Between 2021 and 2025, CHESS respondents consistently wanted the government to prioritize the economy/joblessness and health care.

More than 40% of respondents in most states and survey years selected the economy and joblessness as a government priority, with an exception of 38% selecting this option in Minnesota in 2023 and Washington DC in 2024. The highest percentage of respondents who selected the economy and joblessness as a government priority was 57% in Massachusetts and Michigan in 2021.

While the economy/joblessness often had a higher median percentage of respondents who selected it as a government priority than health care, consistently more than 40% of CHESS respondents wanted the government to prioritize health care. Health care was selected by a higher percentage of respondents in 2021 and 2025 than in 2022, 2023, and 2024. In 2021, death rates from COVID-19 among U.S. adults were high (Centers for Disease Control and Prevention, 2025), and the Delta variant was causing rapid spread of infection (Berg, 2021). The distribution of vaccines increased as eligibility policies expanded (AJMC Staff, 2021). A once in a lifetime catastrophic health care event like COVID-19 and its variants brought the health care system to the forefront of everyone’s mind, not just those that needed it (Blumenthal et al., 2020), thus likely contributing to the higher rate of respondents who selected health care as a government priority in 2021 than 2022 to 2024.

Again in 2025, health care became a hyper focused topic in the U.S. CHESS surveys were fielded between June and October, a period of substantial federal health care policy change. The U.S. Congress passed a federal spending package in July 2025 (HR1) that reduced federal funding for Medicaid (H.R.1 – An Act to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14., 2025). Health care spending was also a prevalent policy topic following passage of HR1, as the longest government shutdown in U.S. history centered on a political disagreement over extension of Affordable Care Act health care premium subsidies expiration.

Political control of the federal executive branch changed power in 2021 and 2025, from Republican to Democrat in 2021 and Democrat to Republican in 2025. While most health care policy changes must be codified by Congress, the presidential election cycles in 2020 and 2024 may have influenced the CHESS respondents to select preferred government priorities that were discussed by political candidates. The 2020 campaign and election occurred during the start of the COVID-19 pandemic, an event that exposed vulnerabilities in the health care and social safety net system to U.S. adults (Blumenthal et al., 2020). Medicaid and health care subsidies were often referenced by leading candidates during the 2024 election cycle, and heightened coverage of these issues in the news media may have influenced CHESS respondents to more often select health care as a preferred government priority in 2025. 

Other financial and economic topics were less often selected as a top three government priority. The median percentage of respondents who selected the cost of higher education and student loans as a top three government priority was highest in 2021, at 19% in Georgia. The median percentage was lower in 2022 to 2025: 15% in 2022 (n=5 states), 16% in 2023 (Texas), 14% in 2024 (n=3 states), and 14% in 2025 (Michigan, Tennessee).

Most states had between 30% and 40% of respondents select taxes as a government priority in each survey year, with medians being 36% in 2021, 34% in 2022, 34% in 2023, 30% in 2024, and 35% in 2025. States that were outside of the range of 30% to 40% of respondents selecting taxes as a government priority were Nevada in 2022 (29%); four states in 2024: Idaho at 20%, New Mexico at 27%, and Oregon at 25%, and Washington DC at 22%; and Kansas in 2025 (41%).

Women’s issues were not selected as a top three priority, however, they were of high interest in 2022 in coincidence with major federal and state policy changes regarding reproductive health care.

The percentage of CHESS respondents who selected women’s issues as a top government priority was higher in 2022 than any other survey year. The CHESS did not specify women’s health issues, however, 2022 marked a monumental shift in women’s health policy, with media coverage and implications that may have influenced CHESS respondents’ selection of top government priorities. In June 2022, the U.S. Supreme Court ruled in Dobbs. V Jackson Women’s Health Organization that states had autonomy to regulate abortion, a ruling that overturned the 1973 Roe v Wade decision that had federally protected a pregnant woman’s choice to seek an abortion (U.S Supreme Court, 2022). A draft Supreme Court ruling in Dobbs leaked to Politico in May 2022 (Gerstein & Ward, 2022), and the contents of the draft ruling were widely reported, thus increasing the likelihood that CHESS respondents in 2022 had some knowledge of the impeding change to the women’s health policy landscape. Following the Dobbs decision, several states implemented ‘trigger laws’ that outlawed abortion immediately, while other states adopted additional restrictions (Guttmacher Institute, 2025). In the three years since the Dobbs decision, access to abortion has become overall more restricted across the U.S. (Guttmacher Institute, 2025), and a patchwork of protective and restrictive reproductive health care policies mean geography substantially influences a woman’s access to reproductive care.

In 2024, Idaho respondents reported the highest proportion of individuals who identified women’s issues as a government priority, with 20% selecting this option—noticeably more than the 13% to 17% range observed in other surveyed states. Idaho’s reproductive health care policies are among the most restrictive nationally, and the state experienced several notable legal cases regarding these policies between 2024 and 2025. During this period, repeated surveys of OB/GYN physicians practicing obstetrics in Idaho found that 94 out of 268 doctors either retired, relocated, or stopped providing obstetric care. These changes in access to women’s health care in Idaho may have influenced the greater emphasis placed on women’s issues by CHESS respondents in 2024. Further research is needed to better understand these findings and to compare Idaho’s results with those from states where women’s issues were less frequently prioritized.

Beyond reproductive health care, additional major women’s health issues include mental health and intimate partner violence (Ranji et al., 2025). Women with additional characteristics, like having low income or identifying as a racial minority, are disproportionately more likely to experience poor outcomes related to these issues (Ranji et al., 2025).Obstacles to robust health care, like affordable health insurance and lack of quality access reported by CHESS respondents as high burdens, exacerbate health concerns like maternal mental health (Zivin & Courant, 2024).

Less than 30 percent of respondents selected women’s issues as one of their top three government priorities across states and survey years. However, a greater percentage (median of 22%) of respondents selected women’s issues as a government priority in 2022 than in other survey years, after Supreme Court decision in Dobbs v Jackson Women’s Health Organization.

Preferred prioritization of social issues like racism and immigration reflect the disparities in public opinion on these topics.

In the CHESS, “Racism in America” was not commonly selected as a top government priority. Notably CHESS respondents’ prioritization of this issue has declined over this period of time despite non-White respondents reported having greater health care burdens and worries from 2021 to 2025. The impact of the health disparities experienced by non-White groups is well documented, additionally, research has shown that patients who do not feel respected by their providers are three times more likely to not believe their doctors and are twice as likely not to adhere to medical guidance (Duke et al., 2017). Between 2022 and 2024, the CHESS survey asked respondents in general, how often they thought our health care system treats people unfairly based on their race, and across states around 60% of respondents indicated this happened ‘Somewhat’ or ‘Very Often’. Furthermore, the CHESS asked respondents between 2021 and 2025 how often they felt health care providers treated them with respect, and across all states around 40% of non-White respondents indicated that they ‘Never’, ‘Rarely’, or ‘Sometimes’ felt their health care providers treated them with respect.

Also, while the environment/energy has not been selected by respondents overall as a top three priority, there have been some respondents who have selected it, and the median percentage of respondents who selected this option decreased over time. In 2021, the median was 33% (Massachusetts), 26% in 2022 (n=5 states), 23% in 2023 (Louisiana, North Carolina), 21% in 2024 (Idaho, Rhode Island), and 20% in 2025 (Virginia). See Exhibit 19.

There was a large range of the percentage of respondents who selected immigration as a top three government priority, from 18% in Washington DC in 2024 to 40% in Colorado in 2024. The largest disparity between the percentage of respondents who ranked immigration as a top three government priority was in 2024 and the smallest disparity was in 2025. Intersecting policy changes regarding health care and immigration were led by the federal government in 2025 and early 2026 (Pillai et al., 2026), and public opinion on government prioritization of these topics should continue to be tracked. To the extent possible with careful consideration to respect and ethics, conducting research to understand the worries of immigrants regarding the U.S. health care system is essential to inform policy to promote health across social segments of the population.

Policy

Results of the CHESS support a body of evidence that calls for change in the U.S. health care system, especially regarding affordability (Jones & Dolsten, 2024; Sara R Collins et al., 2023; Sparks, Lopes, et al., 2025). While systems change is not easy, state or federal government could enact policies to influence health care costs and efficiency and make health care more affordable. Between 2021 and 2025, CHESS respondents were asked to rate their level of agreement with the government enacting certain policies that would influence health care. Results can be found in Exhibit 20. Most respondents agreed that state or federal government should enact policies that:

• Show what a fair price would be for specific procedures,
• Make it easy to switch insurers if a health plan drops your doctor,
• Require insurers to provide upfront cost estimates to consumers,
• Require hospitals and doctors to provide up front patient cost estimates, and
• Cap out-of-pocket costs for life-saving medications, such as insulin.  

CHESS respondents were also asked to provide their political party affiliation and rates of policy agreement were consistent across political party affiliations, indicating broad agreement that policies promoting affordable and accessible health care are important regardless of political affiliation.

Conclusion

CHESS respondents reported high levels of worry about access to affordable health care. CHESS data reflects some aspects of the political and social environment of the U.S. at the time and state in which survey data was collected. Social and economic segments of the population that have been disenfranchised from fair access to resources had higher levels of worry regarding a range of health care topics. Without policy intervention, the burden of disease in the United States will increase and quality of life will decrease (Mokdad et al., 2024).Expert recommendations for policy intervention include  investment in disease and injury prevention, addressing mental health, and installation of universal health coverage (Mokdad et al., 2024).

Although data was not aggregated across states surveyed, this retrospective analysis of five years of CHESS data provided documentation of inflections in health care perceptions that can be further explored in future analysis of policy decisions and societal moments.  

Results of the CHESS survey have reflected the evolving concerns, lived realities, and challenges faced by Americans across the years. Findings reveal a clear alignment with the public’s most pressing issues, reflecting not only broad economic and health care anxieties but also the shifting priorities brought on by current events. Whether it is the heightened focus on health care during the COVID-19 pandemic, increased attention to women’s issues following federal policy changes, or the persistent worries around racism and police reform, the survey’s results reliably capture the pulse of the nation. This consistency underscores the value of surveys like CHESS in revealing how the collective worries of Americans are shaped by—and respond to—real-time developments, policy shifts, and social challenges. Through its repeated findings, CHESS stands as a testament to the ongoing health care affordability burdens that many individuals and communities face, offering crucial insight into how public sentiment is both influenced by and reflective of the historical moments we live through.

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