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Press Release


Apr 10, 2015

New Commonwealth Fund Report: Disparities in Medical Bill Problems, Medical Debt, and Ability to Afford Health Care Among Adults in Four Largest U.S. States

Health Insurance Survey Highlights Connection Between State Policies and Access to Health Care in California, Florida, New York, and Texas

New York, NY, April, 10, 2015—Four of 10 adults in Florida and Texas reported they had trouble paying their medical bills or were paying off medical debt over time in 2014, compared to one of four in California and three of 10 in New York, according to a new Commonwealth Fund report comparing health care coverage in the nation’s four largest states.

The study, based on findings from the Commonwealth Fund 2014 Biennial Health Insurance Survey of working-age adults, also found higher proportions of people in Florida and Texas had trouble getting needed health care because of the cost than in California and New York. More than four of 10 in Florida (43%) and Texas (43%) said they did not see a doctor when sick, did not fill a prescription, skipped a test, treatment, or follow-up visit, or did not get needed specialist care in the past 12 months for cost reasons, compared to three of 10 in California (31%) and New York (30%). The differences in bill problems, debt, and cost-related access problems remained even when taking into account demographic variations across the states.

According to Health Care Coverage and Access in the Nation’s Four Largest States—Results from the Commonwealth Fund Biennial Health Insurance Survey, 2014, by Commonwealth Fund researchers Petra Rasmussen, Sara Collins, Michelle Doty, and Sophie Beutel, the differences among the states may be attributable to state health insurance policies before and after the Affordable Care Act (ACA) took effect. For example, California and New York both expanded eligibility for Medicaid years before the ACA was implemented, making coverage available to more people than in many states, and then expanded it fully under the law. Texas and Florida, meanwhile, have not. As a result, uninsured rates for residents with low incomes are lower in California and New York than in Florida and Texas.

“Policy decisions states have made are likely having an effect on the number of their residents who have health insurance,” said Sara Collins, Vice President for Health Care Coverage and Access at The Commonwealth Fund. “Fully expanding Medicaid would help reduce the high uninsured rates in Florida and Texas and help improve people’s ability to afford the care they need.” The report found significant differences among the four states in rates of health insurance coverage, delays in care because of cost, and problems paying medical bills:

  • Texas had the highest uninsured rate among working-age adults (30%), followed by Florida (21%), California (17%), and New York (12%). These differences were not explained by variations in the demographic composition of these states’ populations.
  • Adults with low incomes ($11,490 for an individual or $23,550 for a family of four) had higher uninsured rates in Florida (33%) and Texas (51%) than in California (23%) and New York (13%).
  • Of the four states, New York has the lowest uninsured rate for young adults ages 19 to 34—14 percent. Rates for this group are 34 percent in Texas, 26 percent in Florida, and 23 percent in California.
  • Even for people with insurance, affording health care was more of a problem for Floridians and Texans. Thirty-six percent of insured adults in Texas and 39 percent in Florida reported at least one problem getting needed care in the past 12 months because of the cost, compared to 28 percent in California and 27 percent in New York.
  • About three of 10 adults in Florida (29%) and one of four in Texas (26%) reported having a medical problem but not going to a doctor or clinic for cost reasons, compared to 18 percent in New York and California.
  • One-fifth of adults in Texas (21%) and 17 percent in Florida reported being contacted by a collection agency for unpaid medical bills in past year, compared to 9 percent in California and 11 percent in New York.

Moving Forward

Despite significant declines in uninsured rates following implementation of the Affordable Care Act, millions of people lack access to affordable health insurance in states that have not yet expanded their Medicaid programs, the authors note.

“The bottom line is that states’ health policy decisions are a factor in whether or not millions of people have health insurance coverage,” said Commonwealth Fund President David Blumenthal, M.D. “If states don’t take the necessary steps to help their residents obtain insurance, we may see ever-widening disparities between states in their residents’ coverage and the financial protection it provides.”


The Commonwealth Fund Biennial Health Insurance Survey, 2014, was conducted by Princeton Survey Research Associates International, with a general population sample collected from July 22 to December 14, 2014, and an oversampling of the four largest states, California, Florida, New York, and Texas, collected until December 27, 2014. The survey consisted of 25-minute telephone interviews in either English or Spanish and was conducted among a random, nationally representative sample of adults ages 19 and older living in the continental United States. A combination of landline and cellular phone random–digit dial (RDD) samples was used to reach people.

The general sample was designed to generalize to the U.S. adult population and to allow separate analyses of responses of low-income households. The majority of this report looks at adults ages 19 to 64 in the four largest states (California sample=758, Florida=659, New York=710, and Texas=714). Statistical results are weighted to correct for the stratified sample design, the overlapping landline and cellular phone sample frames, and disproportionate nonresponse that might bias results. Each state sample is weighted to match population parameters for sex by age, sex by education, age by education, race/ethnicity, population density, household telephone use, household size, and region, using the U.S. Census Bureau’s 2012 American Community Survey data.

The resulting weighted general population sample is representative of the approximately 182.8 million U.S. adults ages 19 to 64 and has an overall margin of sampling error of +/– 2 percentage points at the 95 percent confidence level. The California sample has a margin of error of +/– 4.2 percentage points at the 95 percent confidence level, the Florida sample margin of sampling error is +/– 4 percentage points; the New York sample margin of sampling error is +/– 4.1 percentage points; and the Texas sample margin of sampling error is 3.9 percentage points. The landline portion of the survey achieved an 11.5 percent response rate and the cellular phone component achieved an 11.3 percent response rate.


Publication Details


Apr 10, 2015


Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]