Tracking trends in health insurance coverage is another mission of the Task Force. In late 2003, it conducted the latest Commonwealth Fund Biennial Health Insurance Survey, a nationally representative study of more than 4,000 adults that assesses trends in the extent of insurance coverage, the quality of insurance, and public sentiment regarding policies to expand coverage. Findings from the survey—which the Task Force is continuing to analyze—provide ample evidence of an "affordability crisis" in American health care.⁽⁹⁾ Instability in insurance coverage appears to be growing, particularly among people with low incomes and minorities, while the quality of benefits for those with coverage is eroding. Large shares of uninsured and insured Americans alike reported not getting needed health care because of costs.

Paying medical bills is a problem as well. According to the biennial survey, two of five adults ages 19 to 64—more than 70 million people—had problems with medical bills in the past 12 months or were paying off medical debt accrued over the past three years. Medical bill problems were most common among those who experienced a period without coverage, with around 60 percent reporting that they had problems with bills or were currently paying off debt. But even those who were continuously insured cited difficulties, particularly those with annual incomes less than $35,000. Given these results, it is perhaps unsurprising that most of those surveyed are in favor of federal efforts to extend health insurance coverage, and believe that the financing of care should continue to be a responsibility shared among individuals, employers, and the government.

Medical bill problems and medical debt are of increasing concern to policymakers. Newspaper reports have documented how some hospitals charge uninsured patients at rates higher than those negotiated with insurance companies. Other hospitals also charge high interest rates on debts owed by patients, have collection agencies harass them, or place liens on their homes.

Spurred in part by Fund-supported work by the Access Project, the U.S. Department of Health and Human Services in February 2004 issued a clarification of its rules regarding hospital billing and collection practices, stating unambiguously that hospitals are free to waive the collection of fees to any patient or provide discounted care to uninsured patients who cannot afford to pay their bills.^(10),(11) Later, in June, Karen Davis and Sara Collins were invited to testify in two separate congressional hearings on pricing and debt collection practices of hospitals.⁽¹²⁾ New Fund-supported work by Jeffrey Prottas of Brandeis University will further examine hospital billing practices and insurance coverage characteristics that may also contribute to medical debt.

The hospital pricing and collection practices described above are symptoms of a safety net system under tremendous strain. Task Force-supported research by Gerry Fairbrother and colleagues at the New York Academy of Medicine shows that community health centers find it difficult or impossible to arrange off-site care for their uninsured patients. The researchers also found that internists report difficulties referring their uninsured patients for laboratory tests, diagnostic procedures such as mammograms and colonoscopies, and prescription drugs.⁽¹³⁾ Sherry Glied documented that patients without health insurance do not have the same access to innovative treatments that insured patients do for three medical conditions—heart attack, cataracts, and depression. This omission costs the U.S. health system and the economy an estimated $1.1 billion in higher morbidity and mortality.⁽¹⁴⁾