The Shadow Price of Uncertainty: Consequences of Unpredictable Insurance Coverage for Access, Care, and Financial Security.

Policy Points Health insurance reform in the United States has fostered enrollment to promote access to care and reduce financial insecurity. However, enrollees' inability to reliably predict what insurance will cover (a.k.a. "coverage uncertainty") impedes these goals, often as much as being uninsured. The Patient Protection and Affordable Care Act initially expanded enrollment and reduced coverage uncertainty. After the mid-2010s, trends in coverage uncertainty plateaued, and it now impedes access to care for four times as many households as lack of health insurance. A variety of policies can moderate coverage uncertainty, but other popular reform strategies exacerbate it instead. Our findings suggest that structural reforms represent the most promising remedial strategies, particularly those that can enhance support for households negotiating coverage denials with insurers.

Context: Health insurance reform in the United States has focused on expanding enrollment, a goal inhibited by complex insurance provisions. Research documents this complexity and shows how it increases consumers' challenges in anticipating needs and making informed choices, potentially deterring policy purchases. Little is known about how coverage uncertainty impacts those who have insurance.

Methods: Drawing on a multiwave survey with nationally representative data, we assessed consumer experiences and expectations in 2009, 2014, and 2021. Respondents identified (a) worries about the reliability of health insurance coverage, and (b) experiences of insurance not covering major medical expenses. Respondents also reported on three health care-related experiences-whether they delayed access to needed care, had been unable to effectively care for chronic health conditions, or felt anxious about future medical expenses. We estimated regressions associating metrics of coverage uncertainty with the three health care-related outcomes, controlling for socioeconomic status and other household characteristics.

Findings: Of American households, 32% reported intense worry about coverage reliability in 2009. This declined to 27% in 2014, then rebounded to 31% in 2021. Experiences of coverage shortfalls followed a similar pattern, declining from 27% to 17%, then rising back to 21%. Coverage uncertainty has statistically significant associations with all three outcomes, with access being the most sensitive to low-level uncertainty. By 2021, coverage uncertainty deterred timely access in care for one in five American households, five times as many as among the uninsured.

Conclusions: Coverage uncertainty has become the predominant barrier to timely access. It also disrupts care for chronic conditions and exacerbates anxiety over medical expenses. These harms can be reduced. However, several popular health care reform strategies instead exacerbate coverage uncertainty. We explicate these overlooked cross-policy connections and identify alternative strategies that could moderate the impact of coverage uncertainty in the United States.