Time for change: PhRMA survey shows insurance creates barriers to healthcare in US


Health insurance is not enough to provide the necessary affordable access to care for the US’ most vulnerable, finds new PhRMA report.

For too many Americans, insurance coverage is not providing the health security it’s meant to.

The Pharmaceutical Research and Manufacturers of America’s (PhRMA) first Patient Experience Survey (PES) has found that three in ten people with medical insurance still face financial barriers to accessing healthcare and prescription medicines.

This is leading to poor adherence and worsening outcomes according to Stephen Ubl, President and Chief Executive officer of the organisation.

The in-depth survey of almost 5,000 people, including more than 3,500 who rely on prescription medicines, suggests that “insurance policies and practices create barriers to life-saving care” with “devastating results”

“These include worse health outcomes for patients and higher costs throughout the healthcare system," he said, adding that the system was not working for the “sickest and most vulnerable” in society.

Out of pocket costs

Launched in the wake of the COVID-19 pandemic, the PES has been designed to explore common barriers to accessing healthcare and prescription medicines in the US.

“This insecurity in health care access disproportionately affects those reporting the poorest health, the disabled, and patients suffering from the most serious health conditions.”

It aims to understand how patients engage with the healthcare system, uncover the challenges Americans face around access and affordability, and identify solutions.

This first piece of work found that while 70% of people were satisfied with the ease at which they could access the care they needed, this certainly wasn’t the case for everyone.

Thirteen per cent said they had to forgo needed care, had trouble paying medical bills, had out-of-pocket costs they could not afford, or had no savings to cover medical expenses.

“This insecurity in health care access disproportionately affects those reporting the poorest health, the disabled, and patients suffering from the most serious health conditions,” says the report.

Importantly, these “systematic challenges” are not confined to the uninsured. In fact, almost a third of people with insurance, 30%, said they could not afford medical bills or out-of-pocket costs.

Americans spent an average of $1,568 on out-of-pocket healthcare costs over the past year, but 44% of respondents had less than $1,000 in savings to pay for emergency or unforeseen expenses.

Poor adherence, poor outcomes

Unaffordable out-of-pocket costs are “strongly correlated with prescription abandonment”, warns the report.

The survey found that 52% of patients who take prescription medicines and have a high-deductible health plan reported at least one episode of non-adherence in the past year. That figure rose to 87% in those who had accumulated medical debt.

“Predictably, Americans who forego strict adherence to their prescription medicines face adverse health outcomes. Half, 48%, of all those reporting one or more episodes of non-adherence say their health suffered consequently. That number increases to 82% of patients with an infectious disease,” said the report.

Disproportionate utilisation

The survey also shows how health plan utilisation management tools create significant barriers that disproportionately impact the sick and the vulnerable.

“Health insurers use utilisation management tools to determine when and how a patient can access a particular medicine, through methods such as prior authorisation and step therapy,” explained the report.

“These additional barriers to accessing prescription medicines can result in delays, prevent patients from picking up their prescriptions, or require patients to take an alternative medicine (which is) preferred by the insurance company.”

Crucially, these hurdles disproportionately affect patients who have the most concerns about accessing and affording their care.

Seven in ten, 68%, of those who said they were “very worried” about accessing and affording the care they need reported utilisation management barriers, compared with just 38% of the rest of the population.

Patients with chronic diseases, such as autoimmune diseases, allergies, and diabetes, were more likely to report experiences with utilisation management than those who take prescription medicines for other conditions.

In addition, 56% of Black Americans and 60% of Hispanic Americans surveyed were subject to utilisation management practices, compared to just 36% of white Americans.

“The data reveal that health insurance benefit design – including out-of-pocket expenses not covered by insurance and utilisation management practices – is contributing to healthcare access insecurity, and may be leading to poor health outcomes,” say the authors.

Patient-centred solutions

The report notes that access and affordability challenges are “largely driven by deteriorating health insurance coverage”, and calls on the sector to make changes that consider the “entire healthcare landscape and the patient experience”.

“The policy solutions that Americans value tend to focus on demystifying their coverage – promoting transparency and predictability – and lowering their out-of-pocket costs.”

This could include limiting out-of-pocket expenses to a certain percentage of a household income, making it easier to find and understand cost estimates before embarking on treatment, and providing fixed co-pays instead of co-insurance, for example.

Interestingly, the survey respondents said they would prefer the lowering of out-of-pocket costs to a decrease in health insurance premiums.

It is time, the report makes clear, to make a change.

“Missing from the current healthcare debate are any reforms that will help address the structural problems many patients say they face in the healthcare system today.

“This survey shows that policymakers should focus on the real problems patients are experiencing, by advancing solutions that address healthcare inequities, lower out-of-pocket costs, and remove barriers to care,” said Ubl.

About the author

Amanda BarrellAmanda Barrell is a freelance health and medical education journalist, editor and copywriter. She has worked on projects for pharma, charities, and agencies, and has written extensively for patients, HCPs, and the public