An online survey of more than 1,400 Pennsylvania respondents, weighted to be demographically
balanced to the state was conducted from July 11 to July 24, 2023, and found that:
Like many Americans, Pennsylvania adults experience hardship due to high health care costs. Overall, over half (57%) 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
Nearly 4 in 10 (39% of) uninsured respondents cited coverage being “too expensive” as the major reason
for not having coverage, far exceeding other reasons like “don’t need it” and “don’t know how to get it.”
2) Delaying or Going Without Healthcare Due to Cost
Over half (51%) of all respondents reported delaying or going without health care during the prior 12
months due to cost:
Moreover, out of those who experienced a barrier to accessing care, respondents most frequently cited
cost as the reason for them or their family members not getting care in the last year (39%) followed by
not being able to get an appointment (37%), exceeding a host of other barriers like getting time off work
(21%), transportation barriers (19%), and lack of childcare (8%).
3) Struggling to Pay Medical Bills
Other times, respondents got the care they needed but struggled to pay the resulting bill. Overall, nearly 1
in 4 (24% of) respondents said that they or a family member have medical bills overdue, and one-third
(33%) of respondents reported experiencing one or more of these struggles to pay their medical bills:
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 Pennsylvania respondents seek these services. In
addition, trouble paying for dental bills likely reflects lower rates of coverage for these services (27% said
they were partially or completely without dental coverage in the past year).
Pennsylvania respondents also exhibit high levels of worry about affording health care in the future. Over
four in five (83%) reported being “worried” or “very worried” about affording some aspect of health care
in the future, including:
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 25-54. This finding suggests that Pennsylvania 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- and middle-income
households, among those living in households with a person with a disability, and those living in Northwest Pennsylvania (see Table 1). Overall, 86% 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 90% of those earning $50,000 to $75,000 per year.2 Still, most Pennsylvania 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
Pennsylvania respondents. Respondents with household incomes below $50,000 per year reported the
highest rates of worry about losing coverage, while those earning $50,000 to $75,000 reported the
highest rates of worry about not being able to afford coverage in the future (see Table 2). Respondents
living in households with a person with a disability reported higher rates of being concerned about losing
health insurance than those living in a household without a person with a disability. Respondents living in Northwest PA and South Central PA and the Lehigh Valley reported the highest rate of worry about
affording insurance in the future compared to residents in other geographic areas.
Concerns about affording coverage exceeded fears about losing coverage across all income groups,
disability statuses, geographic settings, and race/ethnicity groups.
The survey also revealed differences in how Pennsylvania respondents experience health care affordability burdens by income, geographic setting, race/ethnicity, and disability.
Unsurprisingly, respondents at the lowest end of the income spectrum most frequently reported
experiencing one or more health care affordability burdens, with roughly two-thirds (67%) of those
earning less than $50,000 per year reporting struggling to afford some aspect of coverage or care in the
past 12 months, as did 64% of those earning $50,000 - $75,000 (see Figure 1). 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 2).
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. Seven in ten (70% of)
respondents in this group reported going without some form of care and 41% reported rationing
medication, compared to 43% and 20% 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 mental health care, addiction treatment, and dental
care, 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—22% 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 5% 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.
Geographic Area and Rural vs. Urban
Respondents living in rural counties reported higher rates of going without care due to cost and rationing
medication compared to respondents living in urban counties. Overall, 57% of those in rural areas went
without care due to cost compared to 48% of those living in urban areas (see Table 4). Further analysis
found that rationing medication due to cost was most frequently reported among respondents in
Northwest and North Central PA, Northwest PA, and Southwest PA.
Race and Ethnicity
Overall, fifty-three percent of Black or African American respondents and 76% of Hispanic/Latino
respondents reported going without care due to cost in the past twelve months compared to 49% of
white alone, non-Hispanic/Latino respondents (see Table 4). Further analysis showed that Black or African
American and Hispanic/Latino respondents reported higher rates of challenges receiving mental health
care and skipping needed dental care compared to White alone, non-Hispanic/Latino respondents, and
Hispanic/Latino respondents had the highest rates of going without care across multiple care types
compared to other groups.
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).
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. Forty-five percent of
Black or African American respondents and 56% of Hispanic/Latino respondents reported going into debt,
depleting savings, or going without other needs due to medical bills, compared to 29% 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 one-half (53%) reporting going into debt or going without other needs due to medical bills,
compared to 24% of respondents without a disabled household member. Geographically, residents in
Northwest and Southwest Pennsylvania reported higher rates of going into debt or going without other
needs due to medical bills, although all geographic groups reported somewhat similar levels. In addition,
respondents earning less than $50,000 per year reported the highest rate of the above financial burdens
due to medical bills (40%) compared to respondents with higher incomes.
In addition to the above health care affordability burdens, a small share of Pennsylvania respondents were negatively impacted by health system consolidation. In the past year, 32% of all respondents were aware of a merger or acquisition in their community, and 12% of those respondents 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:
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:
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 or acquisitions
were happening in their community, they would be somewhat, moderately or very worried. When asked
about their largest concern respondents most frequently reported:
*Note: The sample size of respondents who said they were affected by a merger was not large enough to report reliable estimates, so the values in this section should be interpreted with caution.
In light of Pennsylvania respondents’ health care affordability burdens and concerns, it is not surprising
that they are dissatisfied with the health system:
To investigate further, the survey asked about both personal and governmental actions to address health
Pennsylvania respondents see a role for themselves in addressing health care affordability. When asked
about specific actions they could take or have taken:
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:
But far and away, Pennsylvania 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 the top 3 issues the government should address
in the upcoming year. The top vote getters were:
When asked about the top three health care priorities the government should work on, the top vote
Of more than 20 options, Pennsylvania respondents believe the reason for high health care costs is unfair
prices charged by powerful industry stakeholders:
When it comes to tackling costs, respondents endorsed a number of strategies, including:
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 last several years have 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.
Northeast and North Central PA: Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming
Northwest PA: Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren
South Central PA and the Lehigh Valley: Adams, Berks, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry, York
Southeast PA: Bucks, Chester, Delaware, Montgomery, Philadelphia
Southwest PA: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, Westmoreland
Rural: Adams, Armstrong, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Carbon, Centre, Clarion, Clearfield, Clinton, Columbia, Crawford, Elk, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lawrence, Lycoming, Mckean, Mercer, Mifflin, Monroe, Montour, Northumberland, Perry, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Wyoming
Urban: Allegheny, Beaver, Berks, Bucks, Chester, Cumberland, Dauphin, Delaware, Erie, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Montgomery, Northampton, Philadelphia, Westmoreland, York
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 July 11 to July 24, 2023, used a web panel from online survey company Dynata with a approximately 1,500 respondents who live in Pennsylvania. Data was cleaned and weighted to the appropriate demographic balance of the state. While this survey is not generalizable to the entire state, it does allow for important insights into a balanced sample of adults in Pennsylvania. 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 1,444 cases for analysis. After those exclusions, the demographic composition of respondents was as follows, although not all demographic information has complete response rates: