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Press Release


Jan 15, 2015

New Survey: More Americans Could Get Needed Health Care and Afford to Pay Their Medical Bills in First Year of ACA Enrollment

For the First Time, Commonwealth Fund’s Biennial Health Insurance Survey Also Finds Sharp Declines in Uninsured Rates, Particularly Among Young Adults and People with Low Incomes

New York, NY, January 15, 2015—The number of Americans reporting they did not receive needed health care because of its cost dropped for the first time since 2003, falling from 80 million in 2012 to 66 million, according to The Commonwealth Fund’s 2014 Biennial Health Insurance Survey. And the number saying they had trouble paying their medical bills or were paying off medical debt fell from 75 million in 2012 to 64 million—the first time it declined since this question was initially asked in 2005.

The survey, discussed in the new brief, The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect, was fielded between July and December 2014 and asked respondents about their health insurance status, access to health care, and medical bill problems and debt over the previous 12 months. It found improvements on nearly every measure, including the percentages of adults who reported that, because of the cost, they:

  • did not visit a doctor or clinic when they had a medical problem, which fell from 29 percent in 2012 to 23 percent in 2014;
  • did not fill a prescription, which fell from 27 percent to 19 percent;
  • skipped a recommended test, treatment, or follow-up visit, which declined from 27 percent to 19 percent; and
  • did not see a specialist, which dropped from 20 percent to 13 percent.

In addition, the share of adults who said they had trouble paying their medical bills, or could not pay them at all, fell from 30 percent in 2012 to 23 percent in 2014; the percentage who had been contacted by a collections agency about unpaid medical bills fell from 18 percent to 15 percent; and the rate of adults paying off medical debt over time fell from 26 percent to 22 percent.

“These declines are remarkable and unprecedented in the survey’s history,” said Sara Collins, vice president for Health Care Coverage and Access at The Commonwealth Fund and the study’s lead author. “They indicate that the Affordable Care Act is beginning to help people afford the health care they need. We also found sharp declines in the uninsured rate nationwide. Unfortunately, we’re still seeing high uninsured rates in states that haven’t expanded Medicaid.

According to the report, the number of uninsured working-age Americans fell from 37 million, or 20 percent, in 2010 to 29 million, or 16 percent, in 2014. The largest declines were among people who were the most likely to have been uninsured in the past—young adults and individuals with low incomes. The uninsured rate for young adults ages 19 to 34 fell from 27 percent in 2010 to 19 percent in 2014. Among adults with incomes below 200 percent of the federal poverty level ($22,980 for an individual and $47, 100 for a family of four), the uninsured rate dropped from 36 percent in 2010 to 24 percent in 2014—the lowest rate for people in this income range since the Commonwealth Fund survey was first fielded in 2001.

In states that have not expanded eligibility for Medicaid, however, uninsured rates among people with low incomes are still high: more than one-third (35%) of adults with incomes below the poverty level ($11,490 for an individual and $23,550 for a family of four) remained uninsured in 2014 in the 24 states that had not expanded Medicaid and started enrolling people by July 2014, when the survey was fielded. In contrast, only about one-fifth (19%) of low-income adults were uninsured in states that did expand Medicaid. Sixty-one percent of the remaining 29 million people without health insurance live in states that have not expanded Medicaid.

Uninsured and Insured Low-Income Adults Still Struggle to Afford Health Care

People without health insurance, including those with low incomes in states not expanding Medicaid, are still often finding health care costs beyond their reach. According to the report, nearly three of five (57%) adults who were uninsured during the year went without care because of the cost in the past year and half (51%) reported medical bill problems.

Among those who were insured all year, people with lower incomes were the most likely to report affordability problems. According to the survey, 34 percent of insured adults making less than about $23,000 a year had trouble paying their medical bills or were paying off medical debt over time, and 33 percent reported they had not gotten needed health care because of the cost.

“Getting millions of Americans good, secure health insurance is essential to improving people’s health and helping our health care system work smarter,” said Commonwealth Fund President David Blumenthal, M.D. “These significant improvements in people’s ability to get and afford care should continue as more people gain health insurance. At the same time, our surveys will continue to track whether increasing cost-sharing requirements are placing undue burdens on families.” 

Additional Survey Findings

  • Non-Hispanic whites, Latinos, and African Americans see similar declines in uninsured rates. Although uninsured rates declined among African Americans and Latinos, whites are still much more likely to have health insurance. The uninsured rate for whites fell from 15 percent in 2010 to 10 percent in 2014; among African Americans, it fell from 24 percent to 18 percent, and among Latinos, it fell from 39 percent to 34 percent.
  • Uninsured adults are less likely to have a regular doctor or to get preventive care. Seven of 10 (71%) adults who were uninsured during the year reported having a regular doctor or source of care, compared to 94 percent of those insured all year. Only 32 percent of uninsured adults ages 50 to 64 had a colon cancer screening in the past five years, compared to 61 percent of adults with health insurance. Among women, 49 percent of uninsured women ages 40 to 64 had a mammogram in the past two years, compared to about three-quarters of women with coverage.

View the interactive feature.


The Commonwealth Fund Biennial Health Insurance Survey, 2014, was conducted by Princeton Survey Research Associates International from July 22 to December 14, 2014. The survey consisted of 25-minute telephone interviews in either English or Spanish and was conducted among a random, nationally representative sample of 6,027 adults age 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.

This report limits the analysis to respondents ages 19 to 64 (n=4,251). 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. The resulting weighted sample is representative of the approximately 182.8 million U.S. adults ages 19 to 64.

The survey has an overall margin of sampling error of +/– 2 percentage points at the 95 percent confidence level. The landline portion of the survey achieved a 15.8 percent response rate and the cellular phone component achieved a 13.6 percent response rate.

We also report estimates from the 2001, 2003, 2005, 2010, and 2012 Commonwealth Fund Biennial Health Insurance Surveys. These surveys were conducted by Princeton Survey Research Associates International using the same stratified sampling strategy that was used in 2014, except the 2001, 2003, and 2005 surveys did not include a cellular phone RDD sample. In 2001, the survey included 2,829 adults ages 19 to 64; in 2003, 3,293 adults ages 19 to 64; in 2005, 3,353 adults ages 19 to 64; in 2010, 3,033 adults ages 19 to 64; and in 2012, 3,393 adults ages 19 to 64.

Publication Details


Jan 15, 2015


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

[email protected]