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THE STATE OF HEALTH INSURANCE COVERAGE IN THE U.S.  
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Sara R. Collins, Avni Gupta
November 21, 2024
The Commonwealth Fund
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_ Nearly a quarter of working-age adults have insurance that leaves
them underinsured. _

, Commonwealth Fund

 

Introduction

An estimated 26 million Americans, or 8 percent of the U.S.
population, lacked health insurance in 2023.1
[[link removed]] While
the United States still lags countries that have universal coverage,
today’s uninsured rate represents a sea change from the years prior
to the Affordable Care Act (ACA), when twice as many people — 49
million, or 16 percent of the population — lacked health coverage.2
[[link removed]] This
was also a time when people with preexisting conditions were out of
luck when they sought to buy insurance on their own, when millions of
young adults became uninsured when they graduated from high school or
college, and when insurance companies in the individual market charged
young women much higher premiums than young men and rarely covered
maternity care.

Congress and the Biden-Harris administration significantly
strengthened the ACA with a temporary boost in premium subsidies for
marketplace plans during the pandemic and then extended them in 2022.
These subsidies, along with restored funding for outreach and
enrollment following cutbacks during the Trump administration, led to
a record 21 million people enrolling in marketplace plans in 2024.3
[[link removed]] For
households with low or moderate incomes, zero-premium or otherwise
low-cost marketplace plans have been a source of affordable coverage
for people who lost Medicaid when the pandemic-era continuous coverage
protections ended. The extra subsidies also have allowed people in
high-cost employer plans to access a more affordable coverage option.

Policymakers have more to do to protect the sweeping coverage gains of
the past decade and build on these gains to bring comprehensive
coverage to more people. The extended premium tax credits are set to
expire at the end of 2025. If Congress fails to extend the enhanced
tax credits, marketplace enrollees will experience an average premium
increase of $705; 4 million more people are projected to become
uninsured.4
[[link removed]] Ten
states still have not adopted the ACA’s Medicaid eligibility
expansion, leaving 1.5 million of some of the poorest people in the
country uninsured. And many Americans with insurance are still
burdened by medical debt, medical billing errors, or denials of
coverage.5
[[link removed]]

In the wake of an election that could fundamentally alter health care
priorities, we present findings from the Commonwealth Fund Biennial
Health Insurance Survey to describe the state of Americans’ health
insurance coverage in 2024.6
[[link removed]] We
answer the following questions:

* How many people experience gaps in their coverage?
* How many people have insurance but are underinsured?
* Are health care costs affecting people’s decision to get needed
care and is their health suffering as a result?
* How widespread is medical debt, and how much do people owe?

For the survey, SSRS interviewed a nationally representative sample of
8,201 adults age 19 and older between March 18 and June 24, 2024. This
analysis focuses on 6,480 respondents ages 19–64; analysis of the
65-and-older population, most of whom have Medicare, will be published
separately. Because of a new sampling method and online questionnaire
introduced in 2022, in addition to changes to some key measures in
2024, we are unable to present data on trends in responses over the
years. To learn more about our survey, including the revised sampling
method, see “How We Conducted This Survey
[[link removed]].”

Survey Highlights

* More than half (56%) of U.S. working-age adults were insured all
year with coverage adequate to ensure affordable access to care. But
there are soft spots requiring policy attention: 9 percent of adults
were uninsured, 12 percent had a gap in coverage over the past year,
and 23 percent were underinsured, meaning they had coverage for a full
year that didn’t provide them with affordable access to heath care.
* Among adults who were insured all year but underinsured, 66
percent had coverage through an employer, 16 percent were enrolled in
Medicaid or Medicare, and 14 percent had a plan purchased in the
marketplaces or the individual market.
* Nearly three of five (57%) underinsured adults said they avoided
getting needed health care because of its cost; 44 percent said they
had medical or dental debt they were paying off over time.
* Delaying care has health consequences: two of five (41%)
working-age adults who reported a cost-related delay in their care
said a health problem had worsened because of it.
* Nearly half of adults (48%) with medical debt are paying off
$2,000 or more; half of those with debt said it stemmed from a
hospital stay.

Survey Findings

In 2024, a majority of American adults had the coverage necessary to
enable access to timely and affordable care. But there remain clear
areas for policy action. Nine percent of adults were uninsured at the
time of the survey, 12 percent were insured but said they had been
without coverage for a time during the year, and 23 percent had
coverage all year but were underinsured.7
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Who Is Underinsured?

For our analysis, people who are insured all year are considered to be
underinsured if their coverage doesn’t enable affordable access to
health care. That means at least one of the following statements
applies:

* Out-of-pocket costs over the prior 12 months, excluding premiums,
were equal to 10 percent or more of household income.
* Out-of-pocket costs over the prior 12 months, excluding premiums,
were equal to 5 percent or more of household income for individuals
living under 200 percent of the federal poverty level ($29,160 for an
individual or $60,000 for a family of four in 2023).
* The individual or family deductible constituted 5 percent or more
of household income.

Because out-of-pocket costs occur only if a person uses their
insurance to obtain health care, we also consider the deductible when
determining whether someone is underinsured. The deductible is an
indicator of the financial protection that a health plan offers as
well as the risk of incurring costs before a person gets health care.
We do not, however, consider the risk of incurring high costs owing to
an insurance plan’s other design features, such as out-of-pocket
maximums, copayments, or uncovered services, since we do not ask about
these features in the survey.

Among the insured working-age adults in the U.S. who had such high
out-of-pocket costs or deductibles relative to their income in 2024
that they were effectively underinsured, the vast majority were in
employer plans. About 14 percent had plans purchased in the individual
market or the marketplaces, and 17 percent were enrolled in Medicaid
or Medicare.

This distribution of underinsured adults reflects the predominance of
employer coverage in the U.S. health insurance system and the growth
of deductibles and cost sharing in those plans over time. It also
shows that many people across the insurance system, both public and
private, have plans that don't provide them with the cost protection
needed to get timely care.

The high cost sharing in many employer, individual-market, and
marketplace plans is primarily driven by growth in overall health care
spending. One of the biggest drivers of this growth is the prices that
health care providers charge commercial insurers and employers. These
prices are the highest in the world.8
[[link removed]] Bearing
the burden of high costs are consumers, who end up paying more for
their insurance and facing higher deductibles, out-of-pocket maximums,
and copayments.

 
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Being uninsured or underinsured are barriers to getting timely health
care. Fifty-seven percent of working-age adults who were underinsured
and 70 percent of those who lacked continuous coverage said they did
not get needed care because of the cost. This included not going to
the doctor when sick, skipping a recommended follow-up visit or test,
not seeing a specialist when recommended, or not filling a
prescription.

Forty-two percent of adults who didn’t get care because of cost said
it was for an ongoing health condition, 29 percent said it was for a
new health problem, and 28 percent said it was for both (data not
shown).

As many as three in 10 people with a chronic health problem, such as
diabetes, said that the costs for prescription drugs to treat the
problem had caused them to skip doses or not fill the prescription at
all. This includes about one-quarter of adults who had health
insurance for the full year.

Many Americans lack comprehensive dental coverage. Many employers that
offer dental coverage provide it as a supplemental benefit, which can
be limited to routine preventive care. In our survey, 41 percent of
adults reported delaying or not getting dental care because of the
cost.

Three-quarters of insured adults said they had dental coverage (data
not shown), and the survey’s findings show that it made a big
difference in their ability to get care. Insured adults who did not
have dental coverage reported cost-related delays in getting care at
nearly the same rate as those who lacked any health insurance.

One in five respondents said they had delayed getting mental health
care because of cost, with higher rates of delayed care reported by
those with inadequate coverage. The ACA requires health plans offered
in the individual and small-group markets and the marketplaces to
cover behavioral health care, and most employers cover it.9
[[link removed]] The
Mental Health Parity and Addiction Equity Act requires health plans
that include these services to cover them on par with their coverage
of other health services. Enforcement, however, is uneven, and
behavioral health provider shortages have made it difficult for many
people to get timely access to care.

Fear of incurring expenses for care they can’t afford is endangering
the health of many Americans, even those who have insurance. Two of
five adults who reported they had delayed or skipped getting needed
care because of costs said a health problem had gotten worse as a
result. People in poor health or dealing with a chronic health
condition reported at among the highest rates that a health problem
had worsened because of delayed care.

Costs prevent many Americans from seeking health care, and those who
do get care often leave the hospital or doctor’s office with bills
they cannot pay. We asked people whether they had medical bills or
debt of any kind that they were paying off over time, including
dental, home health, or long-term care. Three in 10 reported they were
paying off medical debt, with underinsured adults reporting this at
the highest rate.

Of survey respondents with employer coverage, those with low and
moderate income reported paying off medical debt at higher rates than
those with higher income. People in employer plans and the individual
market and marketplaces reported significantly higher rates of medical
debt than people who had Medicaid.

Medical debt can harm the health and well-being of entire households.
More than one-third of those reporting medical debt within their
household said it had caused a member to delay or avoid getting needed
health care or prescription medications. A similar share said they
were forced to cut back on basic necessities like food, heat, or rent,
while a quarter said they took on another job or worked more hours.
More than three-quarters of people with medical debt said it made them
anxious or worried.

Medical debt can have lasting financial consequences. Two of five
adults reporting debt said they had used up all or part of their
savings to pay it off, and 28 percent said they received a lower
credit rating because of it.

Most people who have medical debt carry a lot of it: 83 percent
reported total debt loads of $500 or more, and nearly half said they
were paying off $2,000 or more. This means an estimated 24 percent of
all U.S. working-age adults are carrying medical debt of more than
$500, and 14 percent are saddled with $2,000 or more.

While media reports frequently highlight unexpected health care events
and emergency room visits that leave people with lots of medical
bills, our survey findings suggest that the source of much debt is
simply care for chronic health problems. About half of adults with
debt said it stemmed from treatment they received for an ongoing
condition. Hospital care is the most frequently cited source of
medical debt.

National estimates of the medical debt that Americans owe are based
mainly on debt that goes to collection agencies who then report the
debt to a consumer reporting agency. In 2023, an estimated 15 million
people had $47 billion of medical debt on consumer credit reports.10
[[link removed]] This
is despite changes that the three largest nationwide credit reporting
agencies implemented in July 2022, including the removal of initial
medical debt balances of less than $500. Our survey shows these
estimates understate the medical expenses people are paying off over
time: three-quarters of respondents with medical or dental debt said
that they were making some or all of their payments directly to health
care providers.

More than a third of people with medical debt said the institutions
they owe money to had reported their bill to a credit rating agency.
Only small percentages of people said they had been threatened with a
lawsuit, had their wages garnished, or had a lien placed on their
property.

How to Bring Better Coverage to More Americans

The United States has made considerable gains in health insurance
coverage since the Affordable Care Act’s passage, but more work is
needed to cover the remaining uninsured, eliminate gaps in coverage,
and ensure that all health insurance does what it’s supposed to:
enable people to get health care when it’s needed, without fear of
incurring debt.

The findings of this survey point to two areas of policy change needed
to cover more people with good insurance. Below are some options for
policymakers to consider.

Covering All Americans, and Keeping Them Covered

_Permanently extend the enhanced marketplace premium tax credits set
to expire in 2025_. These larger tax credits, first passed by Congress
in 2021 and then extended in 2022, have dramatically lowered household
premiums and led to a record 21 million people enrolled in the
marketplaces in 2024. If Congress fails to make these enhanced
subsidies permanent, marketplace premiums will spike and enrollment
will fall, increasing the number of uninsured. For example, the Urban
Institute estimates that without the enhanced tax credits, annual
premiums in 2025 would be $387 more for the lowest-income enrollees,
who now pay nothing for their premiums, and nearly $3,000 more for
individuals with incomes of $60,240 or more.11
[[link removed]] They
estimate 4 million more people will become uninsured without these
enhanced tax credits.12
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_Fill the Medicaid coverage gap_. Congress could create a federal
fallback option for Medicaid-eligible people in the 10 states that
have yet to expand their program. One option is to expand marketplace
eligibility to include people in the coverage gap coupled with an
extension of the enhanced premium tax credits to ensure zero-premium
plans and no cost sharing.13
[[link removed]] Such
an approach could cover the estimated 1.5 million uninsured people in
the coverage gap in those states.14
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_Create a longer period of continuous Medicaid eligibility_.
Disruption in Medicaid coverage because of eligibility changes,
administrative errors, and other factors can leave people uninsured
and unable to get care. Congress could apply the lessons of the
pandemic and give states the option to maintain continuous enrollment
eligibility for adults for 12 months without the need to apply for a
waiver — just as has been done for children in Medicaid and the
Children’s Health Insurance Program.15
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_Create an autoenrollment mechanism_. Research shows that many
uninsured people are eligible for Medicaid or subsidized marketplace
coverage. By allowing autoenrollment in comprehensive health coverage,
Congress could move the nation closer to universal coverage.16
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Improving Insurance Design and Protecting Consumers from Medical Debt

_Lower deductibles and out-of-pocket costs in marketplace plans_.
Congress could extend cost-sharing reduction subsidies to
middle-income people and change the benchmark plan in the ACA
marketplaces from silver to gold, which offers better financial
protection.17
[[link removed]] These
policies would save households $4.8 billion and decrease the number of
uninsured by an estimated 1.5 million.18
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_Adjust premiums and cost sharing based on employee income_. In 2022,
just 10 percent of employers with 200 or more employees had programs
to reduce premium contributions for lower-wage workers; only 5 percent
had similar programs to reduce cost sharing.19
[[link removed]]

_Protect consumers from being financially ruined by medical debt_. In
June 2024, the Biden-Harris administration released a new proposed
rule to prohibit medical debt information from appearing on consumer
credit reports. Earlier, it had taken steps to ensure greater scrutiny
of providers’ bill collection tactics, among other actions. Many
states have passed legislation to relieve medical debt, such as
strengthening standards to ensure patients have access to hospital
financial assistance programs, banning aggressive collection
activities by hospitals, and prohibiting or capping interest on
medical debt.20
[[link removed]] North
Carolina has implemented an innovative debt relief program that
provides enhanced Medicaid reimbursements to participating
hospitals.21
[[link removed]] All
eligible hospitals in the state are participating and agree to relieve
outstanding debt dating back to 2014 for Medicaid beneficiaries and
other low-income patients, among other measures.

_Lower health care cost growth_. The relentless growth in the cost of
health care, driven primarily by the prices that commercial insurers
and employers pay to providers and for pharmaceuticals, is at the root
of the nation’s medical debt and affordability crisis in commercial
insurance. Ultimately, private payers will need to do a better job of
leveraging their purchasing power to slow cost growth in commercial
markets. Federal and state policymakers could help, for example, by
creating new public plan options.22
[[link removed]]

HOW WE CONDUCTED THIS SURVEY

The Commonwealth Fund 2024 Biennial Health Insurance Survey was based
on an integration of stratified address-based sample (ABS) with SSRS
Opinion Panel, and prepaid cell sample. This sampling design was first
introduced for the 2022 Biennial Health Insurance Survey and was a
shift from our historically exclusive use of phone administration via
stratified random-digit dial (RDD) phone sample. Similar to the 2022
survey, we included all adults age 19 and older and made refinements
to how we calculate poverty status and measure underinsurance.
Collectively, these changes affect year-to-year differences in our
trend questions. For that reason, similar to 2022, this year’s brief
does not report trends.

The 2024 Biennial Health Insurance Survey was conducted by SSRS from
March 18 through June 24, 2024. The survey consisted of telephone and
online interviews in English and Spanish and was conducted among a
random, nationally representative sample of 8,201 adults age 19 and
older living in the continental United States. A combination of
address-based, SSRS Opinion Panel, and prepaid cell samples was used
to reach people. In all, 4,742 interviews were conducted online or on
the phone via ABS, 2,706 were conducted online via the SSRS Opinion
Panel, and 753 were conducted on prepaid cell phones.

The sample was designed to generalize to the U.S. adult population and
to allow separate analyses of responses from low-income households.
Statistical results were weighted in stages to compensate for sample
designs and patterns of nonresponse that might bias results. The first
stage involved applying a base weight to account for different
selection probabilities and response rates across sample strata. In
the second stage, sample demographics were poststratified to match
population parameters. The data are weighted to the U.S. adult
population by sex, age, education, geographic region, family size,
race/ethnicity, county population density, civic engagement, and
frequency of internet use, using the 2023 Current Population Survey
(CPS), the 2022 Census Planning Database, the 2021 CPS Volunteering
and Civic Life Supplement, and Pew Research Center’s 2023 National
Public Opinion Reference Survey (NPORS) as benchmarks.23
[[link removed]]

The resulting weighted sample is representative of the approximately
253.5 million U.S. adults age 19 and older. The survey has an overall
maximum margin of sampling error of +/– 1.5 percentage points at the
95 percent confidence level. As estimates get further from 50 percent,
the margin of sampling error decreases. The ABS portion of the survey
achieved a 10.5 percent response rate, the SSRS Opinion Panel portion
achieved a 3.4 percent response rate, and the prepaid cell portion
achieved a 2.3 percent response rate.

This brief focuses on 6,480 adults ages 19–64. The resulting
weighted sample is representative of approximately 196.4 million U.S.
adults ages 19–64. The survey has a margin of sampling error of
+/– 1.7 percentage points at the 95 percent confidence level for
this age group.

Refinements to Poverty Status

A respondent’s household size and income are used to determine
poverty status.

Beginning with the 2022 Biennial Health Insurance Survey, we use a
survey question where respondents provide their household size via an
open-ended numeric response. This allows us to use the full U.S.
Federal Poverty Guidelines up to 14 household members. Previously,
household size was determined by combining information about marital
status and the presence of dependents under age 25 in the household,
which resulted in a maximum possible household size of four persons.

Starting this year, we asked respondents to indicate their exact
annual household income ranging from $0 to $999,997. For people who
could not or refused to provide their exact income, we asked them to
select an income range. We then generated random exact incomes for
each respondent who did not provide an exact income themselves but did
provide a range. Respondent incomes within each income range were
assumed to be uniformly distributed and were assigned using a standard
increment between each income based on the size of the income range
and the number of respondents with incomes in the range. To create a
fully populated income variable, we used hot deck imputation to
populate exact incomes for respondents who did not answer the income
range questions.

The more precise household size and exact incomes were used to
determine poverty status for all respondents according to the 2023
U.S. Federal Poverty Guidelines.

Underinsured adults are individuals who are insured all year but
report at least one of three indicators of financial exposure relative
to their household income: out-of-pocket costs, excluding premiums,
are equal to 10 percent or more of household income; out-pocket-costs,
excluding premiums, are equal to 5 percent or more of household income
if low income (less than 200% of the federal poverty level); or their
deductible is 5 percent or more of household income. This year we
asked and reported family-level deductible for those who indicated
family-level coverage in their health plan. Historically, we asked and
used only per-person deductible for all respondents.

For each of the three underinsurance component measures, there are
borderline cases for which the income or deductible ranges provided
were too imprecise to categorize the respondent into “less than”
or “more than” the stated underinsurance component. Previously,
the Fund redistributed borderline cases for each component by
conducting a 50/50 split into the “less than” and “more than”
categories. We refined our approach in 2022. We leveraged the imputed
exact incomes generated to determine poverty status to categorize
borderline cases. In 2024, as mentioned above, we also collected exact
income data directly from respondents, so we used either the reported
exact income or the imputed exact income to generate the
underinsurance component variables.

Additionally, for those respondents who provided deductibles, we
duplicated the methodology used to determine random exact incomes to
compute random exact deductibles. These exact deductibles were
compared to exact incomes to categorize borderline cases for the
component of underinsurance that relates deductible to income.

Estimates of U.S. Uninsured Rates

 

ACKNOWLEDGMENTS

The authors thank Robyn Rapoport, Rob Manley, and Paula Armendariz of
SSRS; and Tony Shih, Corinne Lewis, Arnav Shah, Chris Hollander, Paul
Frame, Jen Wilson, Kristen Kolb, Carson Richards, and Evan Gumas, all
of the Commonwealth Fund.

NOTES

* Katherine Keisler-Starkey and Lisa N. Bunch, _Health Insurance
Coverage in the United States: 2023_
[[link removed]],
Current Population Reports (U.S. Census Bureau, Sept. 2024). ↩
[[link removed]]
* Robin A. Cohen, Brian W. Ward, and Jeannine S. Schiller, _Health
Insurance Coverage: Early Release of Estimates from the National
Health Interview Survey, 2010_
[[link removed]] (Centers
for Disease Control and Prevention, National Center for Health
Statistics, June 2011). ↩
[[link removed]]
* Jeanne Lambrew, _Enhanced ACA Marketplace Tax Credits Worked —
And Shouldn’t Be Eliminated_
[[link removed]] (The
Century Foundation, Aug. 2024). ↩
[[link removed]]
* Jameson Carter et al., “Four Million People Will Lose Health
Insurance if Premium Tax Credit Enhancements Expire in 2025
[[link removed]],” _Urban
Wire_ (blog), Urban Institute, Nov. 14, 2024; and Jared Ortaliza et
al., _Inflation Reduction Act Health Insurance Subsidies: What Is
Their Impact and What Would Happen if They Expire?_
[[link removed]] (KFF,
July 2024). ↩
[[link removed]]
* Sara R. Collins, Shreya Roy, and Relebohile Masitha, _Paying for
It: How Health Care Costs and Medical Debt Are Making Americans Sicker
and Poorer — Findings from the Commonwealth Fund 2023 Health Care
Affordability Survey_
[[link removed]] (Commonwealth
Fund, Oct. 2023); and Avni Gupta et al., _Unforeseen Health Care
Bills and Coverage Denials by Health Insurers in the U.S._
[[link removed]] (Commonwealth
Fund, Aug. 2024). ↩
[[link removed]]
* Sara R. Collins and Christina Ramsay, "What’s at Stake in the
2024 Election for Health Insurance Coverage
[[link removed]]"
(explainer), Commonwealth Fund, Sept. 30, 2024. ↩
[[link removed]]
* Our uninsured estimate is lower than the rate reported by the
Centers for Disease Control and Prevention for this age group in the
second quarter of 2024 (10.8%, with a confidence interval of 9.7% to
11.9%) and recently by the U.S. Census Bureau for January–December
2023 (10.9%, with a 90% confidence interval of 10.6% to 11.2%). (See
“Estimates of U.S. Uninsured Rates
[[link removed]]”
for detail.) Smaller surveys like ours can provide leading indications
of the overall direction of U.S. uninsured rates; federal surveys,
given their large sample sizes, will always provide the most reliable
point estimates. It’s important to note that because our estimated
uninsured rate has a margin of error of +/− 0.95 percentage point,
the true estimate falls between 7.9 percent and 9.9 percent. ↩
[[link removed]]
* Gerard F. Anderson, Peter Hussey, and Varduhi Petrosyan, “It’s
Still the Prices, Stupid: Why the U.S. Spends So Much on Health Care,
and a Tribute to Uwe Reinhardt
[[link removed]],” _Health
Affairs_ 38, no. 1, (Jan. 2019): 87–95. ↩
[[link removed]]
* JoAnn Volk, Emma Walsh-Alker, and Christina L. Goe, _Enforcing
Mental Health Parity: State Options to Improve Access to Care_
[[link removed]] (Commonwealth
Fund, Aug. 2024). ↩
[[link removed]]
* Consumer Financial Protection Bureau, “Prohibition on Creditors
and Consumer Reporting Agencies Concerning Medical Information
(Regulation V)
[[link removed]],”
Proposed Rule, June 11, 2024; and Ryan Sandler and Zachary
Blizard, _Recent Changes in Medical Collections on Consumer Credit
Records: Data Point_
[[link removed]],
(Consumer Financial Protection Bureau, Mar. 2024). ↩
[[link removed]]
* Jessica Banthin et al., _Who Benefits from Enhanced Premium Tax
Credits in the Marketplace?_
[[link removed]] (Urban
Institute, June 2024). ↩
[[link removed]]
* Jameson Carter et al., “Four Million People Will Lose Health
Insurance if Premium Tax Credit Enhancements Expire in 2025
[[link removed]],” _Urban
Wire_ (blog), Urban Institute, Nov. 14, 2024. ↩
[[link removed]]
* Sherry A. Glied and Richard G. Frank, “Extend Marketplace
Coverage to Insure More People in States That Have Not Expanded
Medicaid
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, June 10, 2021. ↩
[[link removed]]
* Patrick Drake et al., _How Many Uninsured Are in the Coverage Gap
and How Many Could Be Eligible if All States Adopted the Medicaid
Expansion?_
[[link removed]] (KFF,
Feb. 2024). ↩
[[link removed]]
* Sara R. Collins and Lauren A. Haynes, “Congress Can Give States
the Option to Keep Adults Covered in Medicaid
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, Nov. 14, 2022. ↩
[[link removed]]
* The approach would treat all legal residents as insured 12 months
a year regardless of whether they actively enrolled in a health plan.
Income-related premiums would be collected through the tax system. See
Linda J. Blumberg, John Holahan, and Jason Levitis, _How
Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and
Implementation Issues_
[[link removed]] (Commonwealth
Fund, June 2021). ↩
[[link removed]]
* A bill introduced by Senator Jeanne Shaheen (D–N.H.) would raise
the cost protection of the marketplace benchmark plan and make more
people eligible for cost-sharing subsidies (Improving Health Insurance
Affordability Act of 2021
[[link removed]], S. 499,
117th Cong. (2021), S. Doc. 1–6). This could eliminate deductibles
for some people and reduce them for others by as much as $1,650 a
year. See Linda J. Blumberg et al., _From Incremental to
Comprehensive Health Insurance Reform: How Various Reform Options
Compare on Coverage and Costs_
[[link removed]] (Urban
Institute, Oct. 2019); and Jesse C. Baumgartner, Munira Z. Gunja, and
Sara R. Collins, _The New Gold Standard: How Changing the Marketplace
Coverage Benchmark Could Impact Affordability_
[[link removed]] (Commonwealth
Fund, Sept. 2022). ↩
[[link removed]]
* John Holahan and Michael Simpson, _Next Steps in Expanding Health
Coverage and Affordability: What Policymakers Can Do Beyond the
Inflation Reduction Act_
[[link removed]] (Commonwealth
Fund, Sept. 2022). ↩
[[link removed]]
* KFF, “Section 13: Employer Practices, Telehealth, Provider
Networks and Coverage for Mental Health Services
[[link removed]],”
in _2022 Employer Health Benefits Survey_ (KFF, Oct. 2022). ↩
[[link removed]]
* Maanasa Kona, “States Continue to Enact Protections for Patients
with Medical Debt
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, Aug. 8, 2024; Maanasa Kona,
“State Options for Making Hospital Financial Assistance Programs
More Accessible
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, Jan. 11, 2024; and Maanasa Kona
and Vrudhi Raimugia, _State Protections Against Medical Debt: A Look
at Policies Across the U.S._
[[link removed]] (Commonwealth
Fund, Sept. 2023). ↩
[[link removed]]
* North Carolina Department of Health and Human Services, “North
Carolina Hospitals Sign On to Relieve Medical Debt
[[link removed]],”
press release, Aug. 12, 2024. ↩
[[link removed]]
* Richard M. Scheffler and Stephen M. Shortell, _A Proposed Public
Option Plan to Increase Competition and Lower Health Insurance
Premiums in California_
[[link removed]] (Commonwealth
Fund, Apr. 2023); Christine H. Monahan, Justin Giovannelli, and Kevin
Lucia, “HHS Approves Nation’s First Section 1332 Waiver for a
Public Option Plan in Colorado
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, July 13, 2022; Christine H.
Monahan, Justin Giovannelli, and Kevin Lucia, “Update on State
Public Option-Style Laws: Getting to More Affordable Coverage
[[link removed]],” _To
the Point_ (blog), Commonwealth Fund, Mar. 29, 2022; Ann Hwang et
al., _State Strategies for Slowing Health Care Cost Growth in the
Commercial Market_
[[link removed]] (Commonwealth
Fund, Feb. 2022); Choose Medicare Act
[[link removed]],
H.R. 5011, 117th Cong. (2021), H.R. Doc. 1–32; Medicare-X Choice
Act of 2021
[[link removed]],
H.R. 1227, 117th Cong. (2021), H.R. Doc. 1–24; Medicare-X Choice
Act of 2021
[[link removed]], S. 386,
117th Cong. (2021), S. Doc. 1–25; State Public Option Act
[[link removed]],
H.R. 4974, 117th Cong. (2021), H.R. Doc. 1–27; State Public Option
Act [[link removed]],
S. 2639, 117th Cong. (2021), S. Doc. 1–27; Public Option Deficit
Reduction Act
[[link removed]],
H.R. 2010, 117th Cong. (2021), H.R. Doc. 1–17; CHOICE Act
[[link removed]], S. 983,
117th Cong. (2021), S. Doc. 1–12; Health Care Improvement Act of
2021 [[link removed]], S.
352, 117th Cong. (2021), S. Doc. 1–75; and State-Based Universal
Health Care Act of 2021
[[link removed]],
H.R. 3775, 117th Cong. (2021), H.R. Doc. 1–30. ↩
[[link removed]]
* Weights for sex, age, education, geographic region, family size,
and race/ethnicity were determined using the 2023 Current Population
Survey Data for Social, Economic and Health Research; population
density using the 2022 Census Planning Database; civic engagement
using the 2021 Volunteering and Civic Life Supplement of the CPS; and
frequency of internet use using the Pew Research Center’s 2023
National Public Opinion Reference Survey (NPORS). ↩
[[link removed]]
* Robin A. Cohen and Elizabeth M. Briones, _Health Insurance
Coverage: Early Release of Quarterly Estimates from the National
Health Interview Survey, 2023–June 2024_
[[link removed]] (Centers
for Disease Control and Prevention, National Center for Health
Statistics, Nov. 2024). ↩
[[link removed]]
* Centers for Disease Control and Prevention, National Center for
Health Statistics, “About the National Health Interview Survey
[[link removed]],” last reviewed Nov.
22, 2023. ↩
[[link removed]]
* Katherine Keisler-Starkey and Lisa N. Bunch, _Health Insurance
Coverage in the United States: 2023_
[[link removed]],
Current Population Reports (U.S. Census Bureau, Sept. 2024). ↩
[[link removed]]
* United States Census Bureau, _Design and Methodology: Current
Population Survey — America’s Source for Labor Force Data_
[[link removed]],
Technical Paper 77 (U.S. Census Bureau, Oct. 2019). ↩
[[link removed]]

SARA R. COLLINS, Ph.D., is senior scholar and vice president for
health care coverage and access and tracking health system performance
at The Commonwealth Fund. An economist, Dr. Collins directs the
Fund’s program on insurance coverage and access and the research
initiative on tracking health system performance which produces the
Fund’s annual scorecard on state health system performance. Since
joining the Fund in 2002, Dr. Collins has led several multi-year
national surveys on health insurance and authored numerous reports,
issue briefs, blog posts, and journal articles on health insurance
coverage, health reform, the Affordable Care Act, and state health
system performance.  She has provided invited testimony on 17
occasions before several Congressional committees and subcommittees.
Prior to joining the Fund, Dr. Collins was associate director/senior
research associate at the New York Academy of Medicine, Division of
Health and Science Policy. Earlier in her career, she was an associate
editor at _U.S. News & World Report,_ a senior economist at Health
Economics Research, and a senior health policy advisor in the New York
City Office of the Public Advocate. She holds an A.B. in economics
from Washington University and a Ph.D. in economics from George
Washington University.

AVNI GUPTA, Ph.D., is a researcher for the Health Care Coverage and
Access program at the Commonwealth Fund. As a health policy
researcher, Gupta is primarily responsible for the Fund’s national
surveys on health insurance and for publishing reports, issue briefs,
blog posts, and journal articles on health insurance coverage, access,
underinsurance, and health care reforms. Prior to joining the Fund,
she was a research scientist at Brigham and Women’s Hospital,
Boston, for nearly four years. There she led several research projects
on insurance, access, quality of care, and health outcomes. Her
clinical training is in dental surgery from India. Additionally, Gupta
earned an M.P.H. in epidemiology and biostatistics from Johns Hopkins
University and a Ph.D. in public health policy and management from New
York University.

THE COMMONWEALTH FUND [[link removed]] was
established in 1918 with the broad charge to enhance the common good.
Its founder, Anna M. Harkness, is among the first women to start a
private foundation. 

Today, the mission of the Commonwealth Fund is to promote a
high-performing, equitable health care system that achieves better
access, improved quality, and greater efficiency, particularly for
society’s most vulnerable, including people of color, people with
low income, and those who are uninsured. 

The Fund carries out this mandate by supporting independent research
on health care issues and making grants to improve health care
practice and policy. An international program in health policy is
designed to stimulate innovative policies and practices in the United
States and other industrialized countries. 

* Health Care
[[link removed]]
* health insurance
[[link removed]]
* medical debt
[[link removed]]
* Medially uninsured
[[link removed]]

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