Concerns about unaffordable health care costs have been climbing for years, with Gallup reporting that Americans perceive cost of health care as the “most urgent health problem” facing the country, now ahead of concerns over access to health care and obesity (the 2nd and 3rd top health concerns for polled Americans).[1]
These concerns regarding health care costs align with reported health care expenditure data: the Centers for Medicare and Medicaid Services’ (CMS’) report National Health Expenditures 2024 Highlights states that “health care spending in the United States rose to $5.3 trillion [in 2024], marking a 7.2 percent increase,” following a similar increase of 7.4% in 2023.[2],[3]
The CMS report goes on to say that much of this growth was “reflected in personal health care spending, which rose by an average of 8.9 percent annually over the two-year period, marking the fastest pace of growth since 1991–1992.”
So, health care costs are high, and growing; Americans are increasingly concerned with these high health care costs, and much of the increased spending is falling on individuals via personal health care spending.
How are these increased health care costs impacting adults in the U.S.?
Concern about and experience of unaffordable or high health care costs can lead to a number of negative outcomes for both individuals and general public health, including forgoing needed medical care due to cost. Forgoing, or skipping, medical care can impact overall health beyond not receiving needed care, as skipping or delaying care has also been linked to worsened health outcomes, delayed diagnoses, and higher overall health care costs.[4],[5],[6]
Exploring trends in forgone care can help us understand how unaffordable health care costs impact the nation overall as well as different states, communities, and demographic groups. This blog will explore rates of forgone care due to cost over time, by state, and by subgroup using SHADAC’s free and interactive data tool, State Health Compare.
What Is Forgone Care?
Forgone care is when an individual skips or goes without (aka “forgoes”) health care. There are a number of reasons why individuals may forgo or skip care, such as lack of transportation, being unable to take time off work, and, for many, unaffordable health care costs.
This blog post explores forgone care using the “Forgone Care” measure on State Health Compare. This measure’s data comes from SHADAC analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey, specifically looking at data on forgone care due to cost.
BRFSS respondents are asked, “Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?” with response options of “Yes”; “No”; “Don’t know / Not sure”; and “Refused.”[7]
SHADAC’s State Health Compare measure of forgone care allows users to disaggregate the data by state and by five additional breakdowns: Chronic Disease Status, Coverage Type, Education, Race/Ethnicity, and Sexual Orientation.
Let’s start by looking at rates of forgone care in the United States as a whole over the last five years.
5-Year Trend: After Declines from 2019 to 2021, Forgone Care Rises Steadily from 2021-2024
Figure 1. Forgone Care Due to Cost, United States, 2011-2024
After declining from 2019 to 2021, rates of forgone care have been steadily increasing in recent years, reaching 12.4% in 2024.
Forgone Care Due to Cost by State
Figure 2. Forgone Care Due to Cost by State, Map, 2024
Using State Health Compare’s ‘Map’ feature, we can look at data on forgone care due to cost by state easily and visually; hovering over each state will display its individual rate of forgone care. Interestingly, using the map feature, we can see some regional patterns emerge, with many Southern and Southwestern states falling into 2024’s highest forgone care rate range of 13.1% to 17.4% (such as Texas, Nevada, Georgia, and Arkansas), and with a number of the states with low or the lowest rates of forgone care ranging from 6.4% to 8.8% clustered in the Northeast and Midwest (such as Massachusetts, Vermont, Iowa, and North Dakota).
If you want to easily see each of the states’ individual rates of forgone care all in one place, try using State Health Compare’s ‘Rank’ feature. This displays all of the states’ rates that can be sorted alphabetically, from lowest to highest, or from highest to lowest, allowing for quick and easy state-to-state comparisons. If a state does not have data available for the measure, like Tennessee in this case, it will display “N/A”.
Figure 3. Forgone Care Due to Cost by State, Rank, Highest to Lowest
2024 Rates of Forgone Care Increased Across Insurance Coverage Types, Uninsured and Medicaid Enrollees with Highest Rates and Increases
Breaking down this data by insurance coverage type reveals that 2024 rates of forgone care increased across coverage types with the largest increases seen amongst the uninsured and Medicaid enrollees.
Along with creating charts directly on the website, SHC allows users to download data to use in analysis and data visualizations outside of the tool. For example, we downloaded data on forgone care due to cost by insurance coverage type to create Figure 4 (see below).
As you can see in the figure below, rates of forgone care vary considerably by coverage type. Nearly half of those who are uninsured (43.3%) reported forgone care due to cost in 2024, which is more than eight times the rate of forgone care among Medicare enrollees (5.7%). Although the rates are considerably lower than the uninsured, 17.3% of Medicaid enrollees also report forgone care due to cost, close to triple the rate among Medicare beneficiaries. These two groups also saw the largest increases (approximately 1.5 PPs) between 2023 and 2024.
Figure 4. Forgone Care Due to Cost by Insurance Coverage Type, U.S., 2021-2024
Continuing with disaggregation by insurance coverage type at the state level can also reveal disparities in experiences of forgone care that might be masked by the aggregated data.
For example, Vermont had one of the lowest rates of forgone care due to cost in the country at 7.9% in 2024. However, when you break down rates of forgone care in Vermont by insurance coverage type, differences are revealed:
Figure 5. Forgone Care Due to Cost by Insurance Coverage Type, Vermont, 2024
We can see that those with individual coverage, employer-sponsored/military coverage, or Medicare in Vermont had around or below the state’s overall rate of forgone care (at 7.4%, 5.2%, and 2.9%, respectively). Those enrolled in Medicaid in Vermont, however, skipped care due to cost at a rate of 13.5%, almost double the state’s overall rate, while the uninsured in Vermont skipped care due to cost at a rate of 46.2% in 2024—more than five times the state’s overall rate.
As we can see from this example, disaggregating data and examining the experiences and rates in different subpopulations can reveal hidden disparities between groups.
U.S. Adults with Chronic Disease More Likely to Forgo Care Due to Cost
Let’s look at another example. Chronic disease is generally defined as any disease, illness, or condition that lasts one year or longer, and requires ongoing health or medical care, or limits daily life (or both). According to the Centers for Disease Control and Prevention (CDC), approximately 75% of American adults have at least one chronic condition, and chronic diseases are the leading cause of disability, sickness, and death in the U.S.[8] Some of the most common chronic diseases impacting Americans include:
- Heart disease
- Cancer
- Diabetes
The forgone care measure on State Health Compare allows for disaggregation by chronic disease status. We downloaded data on forgone care by chronic disease status directly from SHC to create Figure 6 (see below):
Figure 6. Forgone Care Due to Cost by Chronic Disease Status, U.S., 2019-2024
Those who report having one or more chronic diseases reported forgoing care due to cost at a rate of 14.0% in 2024, while those with no chronic diseases reported forgoing care at a rate of 11.8% (2.2PP lower than those with at least one chronic disease).
People with chronic conditions require more medical care, and have higher costs, so it is not surprising that they are more likely to forego care because of costs than their healthier counterparts.[9] However, research also shows that going without needed care when you have a chronic disease results in more adverse health outcomes, including increased risk of hospitalization.[10]
Forgone Care and Current Context: Continue the Research on State Health Compare
With rising health care costs affecting millions across the country, it’s important to understand exactly how these costs are impacting both individuals and public health as a whole. Forgoing care can be seen as a way to save on costs in the short-term, but it can also come with consequences such as impacts to health and finances.
Alongside overall rising costs in many areas (e.g., health care, rent, etc.), changes to Medicaid under H.R.1 could also impact forgone care. H.R. 1 is expected to reduce Medicaid enrollment and increase uninsurance by millions of people nationally.[11] As we saw earlier, the uninsured are the group most likely to forgo care due to cost; if uninsurance continues to increase (as 2024 American Community Survey data shows it did from 2023 to 2024), we could also see large increases in forgone care.
Changes to the health insurance marketplace and associated subsidies could also impact forgone care; for example, recent data have shown that not only are fewer people enrolling in marketplace coverage altogether as a result of unaffordable costs, but those who do choose to enroll are increasingly choosing cheaper plans that have less comprehensive coverage.[12] This can lead to higher health care costs, which, again, could lead to more people choosing to forgo care due to cost.
“People are leaving the ACA marketplace because the trade-offs have just become harder to justify […] when the coverage becomes unaffordable, it isn’t that people suddenly stop needing care. They just lose the protection that insurance offers, and those health care costs don’t go away,” said SHADAC Director Elizabeth Lukanen in an interview with Stateline.[12] She goes on to say that if more people forgo care, or if people do go to the doctor without insurance coverage, the costs are not gone, they “are then just shifted. They’re shifted to hospitals, ultimately to the community and the taxpayer.”
You can continue to monitor rates of forgone care along with other measures of public health, health care costs and affordability, and more for free on State Health Compare. Stay up-to-date with the latest data releases and measure updates by joining our monthly mailing list or following us on LinkedIn.
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