Data Brief | | December 2023

North Carolina Survey Respondents Struggle to Afford High Health Care Costs; Worry about Affording Health Care in the Future; Support Government Action Across Party Lines

Key Findings

A survey of more than 1,400 North Carolina adults, conducted from October 18 to October 23, 2023,
found that:

  • Over 2 in 3 (68%) experienced at least one health care affordability burden in the past year;
  • Over 4 in 5 (85%) worry about affording health care in the future;
  • Over 3 in 5 (61%) of all respondents delayed or went without health care due to cost in the last twelve months;
  • Low-income respondents and those with disabilities had higher rates of going without care due to cost and incurring medical debt, depleting savings, and/or sacrificing basic needs due to medical bills; and
  • Across party lines, respondents express strong support for government-led solutions.

A Range of Health Care Affordability Burdens

Like many Americans, North Carolina adults experience hardship due to high health care costs. Overall,
over two-thirds (68%) of respondents experienced one or more of the following health care affordability
burdens in the prior 12 months:

1) Being Uninsured Due to High Costs

Over half (54%) of uninsured respondents cited “too expensive” as the main reason for not having health
insurance, far exceeding other reasons like “don’t need it” and “don’t know how to get it.” In addition, 54%
of respondents without dental insurance cited cost as the main reason for not having coverage, and 44%
those without vision insurance cited cost as the main reason for not having coverage.

2) Delaying or Going without Health Care Due to Cost

Over 3 in 5 (61%) of all respondents reported delaying or going without health care during the prior 12
months due to cost:

  • 38%—Skipped needed dental care
  • 35%—Delayed going to the doctor or having a procedure done
  • 33%—Cut pills in half, skipped doses of medicine, or did not fill a prescription1
  • 31%—Skipped a recommended medical test or treatment
  • 29%—Avoided going to the doctor or having a procedure done altogether
  • 28%—Skipped needed vision services
  • 22%—Had problems getting mental health care or addiction treatment
  • 13%—Skipped needed hearing services
  • 12%—Skipped or delayed getting a medical assistive device

Moreover, respondents reporting a barrier to getting care in the past year, most frequently cited cost
(29%) followed by not being able to get an appointment (19%), exceeding a host of other barriers like
getting time off work, transportation, and lack of childcare.

3) Struggling to Pay Medical Bills

Other times, respondents got the care they needed but struggled to pay the resulting bill. One-third
(43%) of respondents reported experiencing one or more of these struggles to pay their medical bills:

  • 20%—Were contacted by a collection agency
  • 17%—Used up all or most of their savings
  • 15%—Were unable to pay for basic necessities like food, heat, or housing
  • 12%—Incurred large amounts of credit card debt
  • 10%—Borrowed money, got a loan, or another mortgage on their home
  • 8%—Were placed on a long-term payment plan

Of the various types of medical bills, the ones most frequently associated with an affordability barrier
were doctor bills, dental bills, and prescription drugs. The high prevalence of affordability burdens for
these services likely reflects the frequency with which North Carolina respondents seek these services.
Trouble paying for dental bills likely reflects lower rates of coverage for these services (33% of
respondents reported that said they were partially or completely without dental coverage in the past

High Levels of Worry About Affording Health Care in the Future

North Carolina respondents also exhibit high levels of worry about affording health care in the future.
Over four in five (85%) reported being “worried” or “very worried” about affording some aspect of health
care in the future, including:

  • 70%—Cost of nursing home or home care services
  • 68%—Medical costs when elderly
  • 67%—Health insurance will become unaffordable
  • 65%—Medical costs in the event of a serious illness or accident
  • 58%—Prescription drugs will become unaffordable
  • 56%—Cost of dental care
  • 51%—Cost of needed vision services
  • 48%—Cost of needed hearing services

While two of the most common worries—affording the cost of nursing home or home care services and
medical costs when elderly—are applicable predominantly to an older population, they were most
frequently reported by respondents ages 35-54. This finding suggests that North Carolina respondents
may be worried about affording the cost of care for both aging relatives and themselves.

Worry about affording health care was highest among respondents living in low-income households,
among those living in households with a person with a disability, and those living in non-rural regions (see
Appendix) of North Carolina (see Table 1). Overall, 88% of respondents with household incomes less than
$50,000 a year reported worrying about affording some aspect of coverage or care in the past year, as
did 85% of those earning $50,000 to $75,000 per year.2  Still, most North Carolina respondents of all
incomes, races, ethnicities, geographic setting, and levels of ability were somewhat or very concerned.


Concern that health insurance will become unaffordable is also more prevalent among certain groups of
North Carolina respondents. By insurance type, respondents with Medicaid coverage most frequently
reported worrying about affording coverage, followed by respondents with coverage they buy on their
own and respondents with coverage through an employer (see Figure 1).

Respondents living in rural areas reported the highest rate of worry about affording insurance in the
future, compared to residents in other geographic areas. Likewise, respondents of color, respondents with
household incomes below $50,000 per year, and respondents living in households with a person with a
disability reported the highest rates of worry about losing coverage and not being able to afford coverage
in the future (see Table 2).

Concerns about affording coverage exceeded fears about losing coverage across all income groups,
disability statuses, geographic settings, races/ethnicities, and coverage types.



Differences in Health Care Affordability Burdens

The survey also revealed differences in how North Carolina respondents experience health care affordability burdens by income, age, geographic setting, race/ethnicity, and disability.

Income and Age

Unsurprisingly, respondents at the lowest end of the income spectrum most frequently reported
experiencing one or more health care affordability burdens, with over three-fourths (76%) of those earning
less than $50,000 per year reporting struggling to afford some aspect of coverage or care in the past 12
months (see Figure 2). This may be due, in part, to respondents in this income group reporting higher rates of going without care and rationing their medication due to cost (see Figure 3).



Further analysis found that North Carolina respondents ages 25-34 reported higher rates of going
without care due to cost than respondents in other age groups (see Figure 4). Respondents ages 25-34
also most frequently reported rationing medication due to cost compared to other age groups. 



Respondents living in households with a person with a disability reported the highest rates of going
without care and rationing medication due to cost in the past 12 months. Almost three-quarters (74%) of
respondents in this group reported going without some form of care and 48% reported rationing
medication, compared to 56% and 27% of respondents living in households without a person with a
disability, respectively (see Table 4). Respondents living in households with a person with a disability also
more frequently reported delaying or skipping getting health care, addiction treatment, and dental care,
among other health care services, than those in households without a person with a disability due to cost
concerns (see Table 3).

Those with disabilities also face health care affordability burdens unique to their disabilities—26% of
respondents with a disabled household member reported delaying getting a medical assistive device such
as a wheelchair, cane/walker, hearing aid, or prosthetic limb due to cost. Just 6% of respondents without a
person with a disability in their household (who may have needed such tools temporarily or may not
identify as having a disability) reported this experience.


Insurance Type

Respondents with North Carolina Medicaid coverage reported the highest rates of going without care due
to cost and rationing medication, followed by respondents with insurance bought on their own, such as
through the Health Insurance Marketplace (see Table 4). Still, over two-fifths (46%) of respondents with
Medicare coverage also went without care due to cost in the twelve months prior to taking the survey.


Survey respondents also had the opportunity to share their own stories about going without care due to
cost in the past year. Notably, respondents with both private insurance and Medicaid coverage reported
challenges affording care (see Table 5).


Race and Ethnicity

North Carolina respondents of color reported higher rates of rationing medication and forgoing care than
white alone, non-Hispanic/Latino respondents. Sixty-two percent of Black or African American
respondents and 70% of Hispanic/Latino respondents reported going without care due to cost in the past
twelve months compared to 59% of white alone, non-Hispanic/Latino respondents (see Table 4). Further
analysis showed that BIPOC respondents also reported higher rates of challenges accessing addiction
treatment and skipping needed dental care (see Figure 5).


Encountering Medical Debt

The survey also showed differences in the prevalence of financial burdens due to medical bills, including
going into medical debt, depleting savings, and being unable to pay for basic necessities (like food, heat,
and housing) by income, race, ethnicity, disability status, and geographic setting. Fifty-one percent of
Black or African American respondents and 58% of Hispanic/Latino respondents reported going into debt,
depleting savings, or going without other needs due to medical bills, compared to 38% of white alone,
non-Hispanic/Latino respondents (see Table 6).


The rate of financial burden is even higher for respondents who have or live with a person with a disability,
with over three in five (62%) reporting going into debt or going without other needs due to medical bills,
compared to 35% of respondents without a disabled household member. Geographically, residents in rural areas reported higher rates of going into debt or going without other needs due to medical bills than
those living in the Black Belt or non-rural regions. In addition, respondents with Medicaid coverage
reported the highest rate of the above financial burdens due to medical bills (63%), compared to
respondents with all other insurance types.

Impact and Worry Related to Hospital Consolidation*

In addition to the above health care affordability burdens, a small share of North Carolina respondents
were negatively impacted by health system consolidation. From 2016 to 2021, there were 27 changes in
ownership involving hospitals through mergers, acquisitions, or changes of ownership (CHOW) in North
Carolina.3,4  North Carolina requires that the State Attorney General be notified of nonprofit hospital
transactions and the state requires Attorney General or court approval for nonprofit hospital merger

In the past year, 26% of respondents reported that they were aware of a merger or acquisition in their
community—of those respondents, 20% reported that they or a family member were unable to access
their preferred health care organization because of a merger that made their preferred organization out-
of-network. Out of those who reported being unable to access their preferred health care provider due to
a merger:

  • 45% delayed or avoided going to the doctor or having a procedure done because they could no longer access their preferred health care organization due to a merger;
  • 31% skipped recommended follow-up visits due to a merger; and
  • 32% changed their preferred doctor or hospital.

Out of those who reported that the merger caused an additional burden for them or their families, the top
three most frequently reported issues were:

  • 45%—The merger created an added financial burden
  • 18%—The merger created a gap in their continuity of care
  • 16%—The merger created an added wait time when searching for a new provider

While a small portion of respondents reported being unable to access their preferred health care
organization because of a merger, far more respondents (58%) reported that, if mergers were happening
in their community, they would be somewhat, moderately or very concerned. When asked about their
largest concern respondents most frequently reported:

  • 27%—I’m concerned I will have to pay more to see my doctor
  • 26%—I’m concerned my doctor may no longer be covered by my insurance
  • 24%—I’m concerned I will have fewer choices of where to receive care
  • 14%—I’m concerned I will have a lower quality of care
  • 9%—I’m concerned I will have to travel farther to see my doctor

*Note: The sample size of respondents who said they were affected by a merger was not large enough to report reliable estimates; the values in this section should be interpreted with caution.

Dissatisfaction with the Health System and Support for Change

In light of North Carolina respondents’ health care affordability burdens and concerns, it is not surprising
that they are dissatisfied with the health system:

  • Just 30% agreed or strongly agreed that “we have a great healthcare system in the U.S.,”
  • While 75% agreed or strongly agreed that “the system needs to change."

To investigate further, the survey asked about both personal and governmental actions to address health
system problems.

Personal Actions

North Carolina respondents see a role for themselves in addressing health care affordability. When asked
about specific actions they could take:

  • 59% of respondents reported researching the cost of a drug beforehand, and
  • 80% said they would be willing to switch from a brand name to an equivalent generic drug if given the chance.

When asked to select the top three personal actions they felt would be most effective in
addressing health care affordability (out of ten options), the most common responses were:

  • 72%—Take better care of my personal health
  • 41%—Research treatments myself before going to the doctor
  • 32%—Do more to compare doctors on cost and quality before getting services
  • 25%—There is not anything I can do personally to make our health system better
  • 23%—Write to or call my state representative asking them to take action on high health care prices and lack of affordable coverage options

Government Actions

But far and away, North Carolina respondents see government as the key stakeholder that needs to act to
address health system problems. Moreover, addressing health care problems is one of the top priorities
that respondents want their elected officials to work on.

At the beginning of the survey, respondents were asked what issues the government should address in the upcoming year. The top vote getters were:

  • 48%—Economy/Joblessness
  • 48%—Health care
  • 38%—Affordable housing

When asked about the top three health care priorities the government should work on, respondents most often chose:

  • 54%—Address high health care costs, including prescription drugs
  • 37%—Get health insurance to those who cannot afford coverage
  • 34%—Improve Medicare, coverage for seniors and those with serious disabilities
  • 32%—Preserve consumer protections preventing people from being denied coverage or charged more for having a pre-existing medical condition

Of more than 20 options, North Carolina respondents believe the reason for high health care costs is
unfair prices charged by powerful industry stakeholders:

  • 77%—Drug companies charging too much money
  • 73%—Hospitals charging too much money
  • 70%—Insurance companies charging too much money

When it comes to tackling costs, respondents endorsed a number of strategies, including:

  • 93%—Show what a fair price would be for specific procedures
  • 92%—Cap out-of-pocket costs for life-saving medications, such as insulin
  • 92%—Require drug companies to provide advanced notice of price increases and information to justify those increases
  • 92%—Make it easy to switch insurers if a health plan drops your doctor
  • 91%—Require insurers to provide up-front cost estimates to consumers
  • 91%—Require hospitals and doctors to provide up-front cost estimates to consumers
  • 91%—Expand health insurance options so that everyone can afford quality coverage
  • 91%—Authorize the Attorney General to take legal action to prevent price gouging or unfair prescription drug price hikes
  • 90%—Set standard prices for drugs to make them affordable
  • 90%—Create a Prescription Drug Affordability Board to examine the evidence and establish acceptable costs for drugs

Support for Action Across Party Lines

There is also remarkable support for change regardless of respondents' political affiliation (see Table 7).
The high burden of health care affordability, along with high levels of support for change, suggest that
elected leaders and other stakeholders need to make addressing this consumer burden a top priority.
Moreover, the COVID crisis has led state residents to take a hard look at how well health systems are
working for them, with strong support for a wide variety of actions. Annual surveys can help
assess whether progress is being made.



  1. Twenty-six percent (26%) did not fill a prescription and 21% cut pills in half or skipped doses of medicine due to cost.
  2. Median household income in North Carolina was $60,516 (2017-2021). U.S. Census, Quick Facts. Retrieved from: U.S. Census Bureau QuickFacts,,US/PST045222.
  3. Centers for Medicare and Medicaid Services. (2023). Hospital Change of Ownership. Retrieved November 9, 2023, from
  4. A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner's identification number and provider agreement (including any Medicare outstanding debt of the old owner) to the new owner. An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been purchased by another enrolled provider. Only the purchaser's CMS Certification Number (CCN) and tax identification number remain. Acquisitions/mergers are different from CHOWs. In the case of an acquisition/merger, the seller/former owner's CCN dissolves. In a CHOW, the seller/former owner's CCN typically remains intact and is transferred to the new owner. A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new business entity. Consolidations are different from acquisitions/mergers. In an acquisition/merger, two entities combine but the CCN and tax identification number (TIN) of the purchasing entity remains intact. In a consolidation, the TINs and CCN of the consolidating entities dissolve and a new TIN and CCN are assigned to the new, consolidated entity. Source: Missouri Department of Health and Senior Services, Change of Ownership Guidelines—Medicare/State Certified Hospice. Retrieved August 23, 2023, from
    StateLicensedHospice.pdf#:~:text=Acquisitions%2Fmergers%20are %20different%20from%20CHOWs.%20In%20the%2
  5. The Source on Healthcare Price and Competition, Merger Review, Retrieved November 9, 2023 from


Altarum’s Consumer Healthcare Experience State Survey (CHESS) is designed to elicit respondents’ unbiased views on a wide range of health system issues, including confidence using the health system, financial burden, and views on fixes that might be needed. 

This survey, conducted from October 18 to October 23, 2023, used a web panel from online survey company Dynata with a demographically balanced sample of approximately 1,500 respondents who live in North Carolina. Information about Dynata’s recruitment and compensation methods can be found here. The survey was conducted in English or Spanish and restricted to adults ages 18 and older. Respondents who finished the survey in less than half the median time were excluded from the final sample, leaving 1,455 cases for analysis. After those exclusions, the demographic composition of respondents was as follows, although not all demographic information has complete response rates:


Percentages in the body of the brief are based on weighted values, while the data presented in the demographic table is unweighted. An explanation of weighted versus unweighted variables is available here. Altarum does not conduct statistical calculations on the significance of differences between groups in findings. Therefore, determinations that one group experienced a significantly different affordability burden than another should not be inferred. Rather, comparisons are for conversational purposes. The groups selected for this brief were selected by advocate partners in each state based on organizational/advocacy priorities. We do not report any estimates under N=100 and a co-efficient of variance
more than 0.30.



Black Belt



Anson County, North Carolina

Alamance County, North Carolina

Alleghany County, North Carolina

Bertie County, North Carolina

Alexander County, North Carolina

Ashe County, North Carolina

Bladen County, North Carolina

Brunswick County, North Carolina

Avery County, North Carolina

Columbus County, North Carolina

Buncombe County, North Carolina

Beaufort County, North Carolina

Cumberland County, North Carolina

Burke County, North Carolina

Camden County, North Carolina

Duplin County, North Carolina

Cabarrus County, North Carolina

Carteret County, North Carolina

Edgecombe County, North Carolina

Caldwell County, North Carolina

Caswell County, North Carolina

Franklin County, North Carolina

Catawba County, North Carolina

Cherokee County, North Carolina

Gates County, North Carolina

Chatham County, North Carolina

Chowan County, North Carolina

Granville County, North Carolina

Craven County, North Carolina

Clay County, North Carolina

Greene County, North Carolina

Currituck County, North Carolina

Cleveland County, North Carolina

Halifax County, North Carolina

Davidson County, North Carolina

Dare County, North Carolina

Hertford County, North Carolina

Davie County, North Carolina

Graham County, North Carolina

Hoke County, North Carolina

Durham County, North Carolina

Harnett County, North Carolina

Lenoir County, North Carolina

Forsyth County, North Carolina

Hyde County, North Carolina

Martin County, North Carolina

Gaston County, North Carolina

Jackson County, North Carolina

Nash County, North Carolina

Guilford County, North Carolina

Lee County, North Carolina

Northampton County, North Carolina

Haywood County, North Carolina

McDowell County, North Carolina

Pitt County, North Carolina

Henderson County, North Carolina

Macon County, North Carolina

Richmond County, North Carolina

Iredell County, North Carolina

Mitchell County, North Carolina

Robeson County, North Carolina

Johnston County, North Carolina

Montgomery County, North Carolina

Sampson County, North Carolina

Jones County, North Carolina

Moore County, North Carolina

Scotland County, North Carolina

Lincoln County, North Carolina

Pasquotank County, North Carolina

Tyrrell County, North Carolina

Madison County, North Carolina

Perquimans County, North Carolina

Vance County, North Carolina

Mecklenburg County, North Carolina

Polk County, North Carolina

Warren County, North Carolina

New Hanover County, North Carolina

Rutherford County, North Carolina

Washington County, North Carolina

Onslow County, North Carolina

Stanly County, North Carolina

Wayne County, North Carolina

Orange County, North Carolina

Surry County, North Carolina

Wilson County, North Carolina

Pamlico County, North Carolina

Swain County, North Carolina


Pender County, North Carolina

Transylvania County, North Carolina


Person County, North Carolina

Watauga County, North Carolina


Randolph County, North Carolina

Wilkes County, North Carolina


Rockingham County, North Carolina

Yancey County, North Carolina


Rowan County, North Carolina



Stokes County, North Carolina



Union County, North Carolina



Wake County, North Carolina



Yadkin County, North Carolina