The protective promise under pressure
THE CRACKS
IN HEALTH
INSURANCE.
Coverage is becoming less protective.
A broad repair will take time.
of working-age adults
were inadequately insured.
Underinsured, a coverage gap, or uninsured.
Commonwealth Fund survey, 2026. Evidence [6] (opens in a new tab)
The system can remain financially operational while patients carry more expense, uncertainty, and work.
An insurance card is only the start.
Coverage adequacy among U.S. adults ages 19–64 in 2026. Select a segment to examine what it means.
54% · Insured all year, not underinsured
54% is the complement of the survey’s 46% inadequately insured. Being outside the underinsured definition does not guarantee that every patient received timely care.
23% · Underinsured all year
Continuous coverage, with medical spending or a deductible high relative to household income. This is 23% of all adults ages 19–64, not 23% of insured adults.
12% · Insured now, gap during year
Covered at the survey date, with an interruption in coverage during the year. A gap can interrupt a treatment pathway even after insurance resumes.
11% · Uninsured at survey
The rounded share uninsured when surveyed. The report also gives the unrounded rate of 11.2%; the chart uses the published rounded categories.
How underinsurance is measured
The survey classifies a continuously insured adult as underinsured if annual out-of-pocket medical spending, excluding premiums, is at least 10% of household income; at least 5% for households below 200% of the federal poverty level; or the deductible is at least 5% of income.
Survey fielded May 7–July 20, 2026; working-age sample n = 7,362. Categories are rounded and sum to 100%. The 54% share is derived as 100 minus 46. Confidence intervals are not plotted. This is a survey-defined affordability measure, not a clinical audit.
The price of having coverage.
The cost of using it comes next.
Average employer-sponsored family premiums, 2026. These figures exclude deductibles and other cost sharing.
Firm size affects the average contribution. This comparison does not establish the cause of an individual worker’s benefit cost.
*Employer contribution is derived as $28,303 minus $7,471. Weighted means for covered workers at firms with 10 or more workers; survey n = 1,937 employers. The employer amount is not a family’s direct premium payment. KFF, 2026 [11] (opens in a new tab)
The cracks have different causes.
Choose a market. Follow its financing, its access barriers, and the outcome that would count as repair.
The bill reaches families through more than one door.
Medical costs and employer benefit choices shape the burden. In self-funded plans, the employer generally bears claims risk; the company on the card may administer the plan.
Affordable worker contributions, appropriate cost sharing, and reliable care completion.
Paid coverage is contracting.
Paid enrollment fell from 21.8 million in February 2025 to 19.2 million in February 2026, about 12%. A median proposed 2027 rate increase of 15% adds pressure.
Affordable net premiums, paid coverage retention, usable benefits, and local plan choice.
Continuity depends on the rules and their execution.
Requirements for certain adults generally begin January 1, 2027. Qualifying activities, lawful exemptions, and verification procedures will matter to coverage continuity.
Eligible patients stay covered and complete care without avoidable paperwork or renewal gaps.
Broad availability can coexist with access friction.
Plan networks, cost sharing, benefits, and authorization processes determine how coverage works for an individual patient. A broad market can still contain difficult care pathways.
Timely covered care and continuity, together with sustainable payments and effective oversight.
Fewer choices make the actual medicines matter more.
The average beneficiary’s standalone plan choices fall from 11 to 9. The analysis identifies no zero-premium standalone plans for people without low-income subsidies in 2027.
Affordable access to the person’s actual medicines across the full year, considering premiums, formularies, and cost sharing.
Two warning signals.
Two different denominators.
Claims payment and approval before treatment are different workflows. These percentages must not be treated as comparable rates.
of in-network claims ultimately denied
Among reporting marketplace plans. The overall rate was similar to prior years.
What this number does and does not show
A claim is not a unique patient or a direct measure of treatment withheld. These data include administrative and benefit-related denials and exclude major parts of the insurance market. Fewer than 1% of denied claims were appealed.
of appealed skilled-nursing denials overturned
In an OIG review of 19 large Medicare Advantage organizations, published June 2026.
Why the appeal denominator matters
Plans denied about 12% of skilled-nursing admission requests; about 18% of denials were appealed. Nearly 95% of that selected appealed subgroup were overturned. This does not mean 95% of all initial denials were improper and does not measure all services.
Financial recovery is only half the test.
Explore this conceptual matrix. Financial strength and patient protection are separate dimensions; no company is scored or assigned to a quadrant.
Financial recovery with weak protection
Premiums or margins can improve while patients still struggle to obtain care. Company financial results alone cannot establish access or outcomes.
Leadership test: Track care completion and household exposure alongside financial results.
Durable protection
Adequate funding supports timely, affordable care. Financial resilience and usable coverage reinforce each other.
Leadership test: Maintain access, continuity, appropriate care, and financial sustainability together.
Compounding failure
Financial stress and poor access can reinforce each other. A falling claims bill may conceal unfinished care.
Leadership test: Find the source of financial pressure and identify care pathways already breaking down.
Protection under pressure
Access may remain strong while funding becomes strained. Sustaining protection requires an explicit financing response.
Leadership test: Protect high-value care while evaluating payment, purchasing, and delivery capacity.
Evidence behind the distinction
UnitedHealth Group reported a third-quarter 2026 medical care ratio of 88.4%, versus 89.9% a year earlier. Elevance reported a benefit expense ratio of 90.6%, improving 70 basis points. These are company-reported financial measures, not evaluations of patient outcomes. A medical expense ratio is not a profit margin, and its remainder includes other expenses.
UnitedHealth Group Q3 [16] (opens in a new tab) Elevance Q3 [9] (opens in a new tab)
Original conceptual synthesis by Kelly Emrick. Not a validated model, prediction, or investment rating.
Too late for a quick reset.
Not too late to protect people.
Choose a planning horizon. These windows are author recommendations, not empirical forecasts or promises of policy enactment.
Protect the care already in motion.
Identify coverage lapses during active treatment. Support lawful enrollment and exemptions. Correct administrative errors and escalate urgent review.
Practical limit: Near-term work can reduce immediate harm; it cannot reset the entire medical cost base.
- Flag interruptions in active treatment.
- Track unresolved authorizations and appeals.
- Record why ordered care was not completed.
Change what the benefit actually protects.
Redesign cost sharing around clinical value. Improve purchasing and lower-cost care pathways. Stabilize financial assistance where authorized.
Practical limit: Funding, contracts, accurate projections, and monitoring are prerequisites. Savings may otherwise be transferred to patients.
- Compare the full household burden.
- Protect high-value treatment in benefit design.
- Assess savings together with care completion.
Repair the conditions that keep producing pressure.
Address market power, payment incentives, administrative fragmentation, and essential service capacity.
Practical limit: Sustained policy and delivery reform take time. Poorly designed changes can disrupt services.
- Examine prices and bargaining conditions.
- Simplify repeat administrative requirements.
- Protect essential services during financing changes.
Measure unfinished care.
For an imaging service, follow each eligible order from authorization through scheduling, examination, interpretation, and report delivery.
- ContinuityCoverage interruptions during active treatment.
- CompletionCompleted services / eligible orders, within a clinically appropriate interval.
- FrictionAuthorization times, appeal outcomes, and documented cost-related cancellations.
- SustainabilityNet collections, patient balances, and administrative effort per completed episode.
Proposed operating measures, not national benchmarks. Set local definitions and clinical thresholds; account for patient and service mix before comparing plans.
Look past the headline.
This interactive guide adapts The Cracks in Health Insurance, a document-based U.S. investigation by Kelly Emrick. Publication dates and measurement dates differ. Evidence is frozen at October 26, 2026.
Open all 17 report references
Brot-Goldberg, Z. C., Chandra, A., Handel, B. R., & Kolstad, J. T. (2017). What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. The Quarterly Journal of Economics, 132(3), 1261–1318.
Read source (opens in a new tab)Centers for Medicare & Medicaid Services. (2024, January 17). CMS interoperability and prior authorization final rule CMS-0057-F.
Read source (opens in a new tab)Centers for Medicare & Medicaid Services. (2026a, June 1). Medicaid community engagement requirement for certain individuals interim final rule with comment period (CMS-2454-IFC).
Read source (opens in a new tab)Centers for Medicare & Medicaid Services. (2026b, September 28). Medicare Advantage and Medicare prescription drug programs expected to remain stable in 2027.
Read source (opens in a new tab)Chandra, A., Flack, E., & Obermeyer, Z. (2024). The health costs of cost sharing. The Quarterly Journal of Economics, 139(4), 2037–2082.
Read source (opens in a new tab)Collins, S. R., Cil, G., & Richards, C. (2026, October 22). The state of health insurance coverage in 2026: Findings from the Commonwealth Fund 2026 Biennial Health Insurance Survey. Commonwealth Fund.
Read source (opens in a new tab)Cooper, Z., Craig, S. V., Gaynor, M., & Van Reenen, J. (2019). The price ain’t right? Hospital prices and health spending on the privately insured. The Quarterly Journal of Economics, 134(1), 51–107.
Read source (opens in a new tab)Cubanski, J., Ochieng, N., & Freed, M. (2026, October 2). Many Medicare Part D stand-alone drug plan enrollees will see modest premium increases for 2027, but others could pay much more if they don’t switch plans. KFF.
Read source (opens in a new tab)Elevance Health. (2026, October 21). Elevance Health reports third quarter 2026 results; raises full-year guidance.
Read source (opens in a new tab)Hartman, M., Martin, A. B., Lassman, D., Catlin, A., & The National Health Expenditure Accounts Team. (2026). National health care spending increased 7.2 percent in 2024 as utilization remained elevated. Health Affairs, 45(2), 110–120.
Read source (opens in a new tab)KFF. (2026, October 22). 2026 Employer Health Benefits Survey.
Read source (opens in a new tab)Lo, J., McGough, M., & Cox, C. (2026, July 28). How has ACA marketplace enrollment changed across states in 2026? KFF.
Read source (opens in a new tab)Long, M., Lo, J., & Pestaina, K. (2026, March 24). Claims denials and appeals in ACA marketplace plans in 2024. KFF.
Read source (opens in a new tab)McGough, M., Ortaliza, J., Ferguson, A., Telesford, I., Rakshit, S., Wager, E., Cotter, L., & Cox, C. (2026, August 3). How much and why ACA marketplace premiums are going up in 2027. Peterson-KFF Health System Tracker.
Read source (opens in a new tab)Sommers, B. D., Chen, L., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2020). Medicaid work requirements in Arkansas: Two-year impacts on coverage, employment, and affordability of care. Health Affairs, 39(9), 1522–1530.
Read source (opens in a new tab)UnitedHealth Group. (2026, October 13). UnitedHealth Group reports third quarter 2026 results.
Read source (opens in a new tab)U.S. Department of Health and Human Services, Office of Inspector General. (2026, June). Medicare Advantage organizations overturned nearly all appealed prior authorization denials for skilled nursing facility admission, raising concerns about initial denials (OEI-09-24-00331).
Read source (opens in a new tab)
The evidence does not establish inevitable collapse, universal insurer insolvency, or a single cause of rising costs. National averages do not determine an individual plan’s value. The central question remains whether coverage delivers affordable, timely, usable care.