The Affordable Care Act, like most healthcare reform efforts, focuses on uninsurance. That's fine, as people without insurance do face significant problems accessing the healthcare system in the United States. But underinsurance is a real issue too, and it's often ignored.  Underinsurance is the topic of this week's Healthcare Triage. 

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Now, most of the data and examples I'm gonna use today come from the United States, but underinsurance is an issue in other countries as well. Go ahead and watch some of our series we've done on international healthcare systems, and you'll see that a fair number expect people to spend quite a bit of money out of pocket for care. 

The Commonwealth Fund defines a person as being underinsured if one's out-of-pocket healthcare costs exceed 10% of their income, or 5% if their income is less that 200% of the federal poverty line, or when one's insurance deductible is more than 5% of their total income. 

The concept is important because research shows that those who are underinsured are more likely to go without needing care. Before the Affordable Care Act was passed, underinsurance was prevalent. If we looked at adults age 19 to 64 in 2010, then 16%, or 29 million of them, met the criteria for underinsurance. 

The number of underinsured Americans had grown by 80% from 2003 to 2010. Some of the ACA's regulations, such as removing annual or lifetime limits, were aimed at reducing the potential out-of-pocket spending that people might have to make. 

Last fall, the political media went crazy because many people could not "keep their policies if they like them." One of the reasons that those policies went away, though, is because they left people underinsured, even if they didn't realize it.

Unfortunately, the ACA hasn't made the strides many have hoped for in reducing underinsurance. In fact, it may be helping to spread it further. A number of politicians have proposed modifications to the law, such as a new tier of copper plans, in addition to bronze, silver, gold, and platinum, which might make underinsurance worse. 

In the most recent update of the Commonwealth Fund's survey, tracking the fall of 2014, investigators found that 13% of adults 19 to 64 spent more than 10% of their income on out-of-pocket healthcare costs. Poor adults were the most likely to spend this amount. 

More than 30% of non-elderly adults making less than the poverty line spent more than 10% of their income in out-of-pocket costs, and 18% of those making between 100% and 200% of the poverty line did so. All of those people were insured.

Deductibles remain high for many Americans. Overall, 13% of people age 19 to 64 had a deductible which was 5% of their income or more. Ironically, since Medicaid traditionally doesn't have deductibles, pretty much all of those underinsured people have private insurance.

Still, those at the lowest end of the socioeconomic spectrum are hit the hardest. A full quarter of non-elderly adults below the poverty line have deductibles this large, and 20% of those making between 100% and 200% of the poverty line do too.

This is too much people for many people to spend. More than 40% of those who were surveyed said their deductibles were unaffordable. Almost two-thirds of people making between 100% and 200% of the poverty line said they were unaffordable.

The point of having insurance is to be able to get care when you need it, without too large of a financial burden. Underinsured Americans are not receiving this benefit, though. They can't get the care they need when they need it.

27% of adults with a deductible rendering them underinsured didn't see the doctor when they were sick. 23% didn't get a preventive care test. 29% skipped a test, treatment, or follow-up appointment. And 22% didn't see a specialist to whom they were referred. 40% of them had at least one of these cost-related access problems.

These are people who had private health insurance for a full year. They are not the uninsured. Silver plans have what we call a 70% actuarial value. That means that the insurance company covers 70% of the cost of care after premiums are paid. You're on the hook for 30%, which can be a lot. Gold plans are 80%, and platinum are 90%. That means there's much lower out-of-pocket payments.

Last year, the average deductible for a silver level plan offered in the insurance exchanges was more than $2,500. Some plans had deductibles as high as $5,000. These are likely at least 5% of income for most Americans, even for those who qualify for cost sharing subsidies.

If people chose bronze plans, then things were even worse. The average deductible for such plans was more than $5,000 a year, with some plans hitting the out-of-pocket maximum of $6,350. Almost anyone purchasing such plans would be, by definition, underinsured.

Moreover, efforts are underway to go even further. The Expanded Consumer Choice Act, co-sponsored by six Democratic senators and one independent senator, seeks to add a new level of insurance coverage.

Copper plans would have 50% actuarial value. Such plans would have significantly lower premium costs than bronze plans, which might increase the number of people who would buy insurance.

But this would be accomplished at the expense of higher out-of-pocket costs. Deductibles for such plans might have to be as high as $9,000, which would mean increasing the out-of-pocket maximum allowable by law. This would lead to even more people being underinsured.

As I've highlighted in other videos and articles I've written, people who have chronic illnesses fare worse when they have more cost sharing. They're also more likely to be underinsured.

The Commonwealth Fund found that 17% of people who were in fair or poor health, or who had a chronic condition, spent at least 10% of their income on out-of-pocket costs. This was on top of the cost of their insurance premiums, because all of them were insured.

Just a few months ago, Gallup asked Americans what the most urgent health problem facing this country at the present time was. 18% replied that it was access to healthcare, or universal health coverage. But more, or 19%, replied that it was affordable healthcare or costs.

In the quest to achieve universal coverage, it's important that we not lose sight of coverage in order to achieve universal. The point of improving access is, after all, to make sure that people can get the care when they need it.

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