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Enigma Variations

Inside health care affordability

By Beth Beaudin-Seiler, PhD

The Consumer Healthcare Experience State Survey (CHESS), developed in 2018 by Altarum, is a state-level survey designed to capture consumer perspectives on health care affordability and system navigation. Altarum is a nonprofit mission-driven organization, founded in 1946, partnering with government agencies and communities to advance their missions and improve health for all. On a state-specific basis, CHESS identifies both objective financial measures and subjective experiences of affordability, including the worry associated with health care costs.

CHESS employs a web-based panel methodology, surveying approximately 1,500 adults (aged 18 and older) in each participating state. The survey has approximately 100 questions that deal with health insurance coverage and adequacy, health literacy, experiences with surprise medical bills and medical debt, system navigation, burden and worry related to affording care and support for policy actions. Responses are weighted using post-stratification methods to align with state demographic profiles based on U.S. Census data.

Concern about affording health care is nearly universal in Minnesota.

Since its launch, CHESS has been implemented in 37 states plus the District of Columbia, with 64 survey waves completed. Applications span legislative action, government reports, legal proceedings, academic research, media coverage, policy implementation and public campaigns such as prescription affordability awareness across multiple states. The survey’s consistent methodology, large sample sizes, rigorous quality controls and weighting support its use as a reliable source of consumer perspectives on state-level health care affordability. In 2026, Altarum developed the CHESS National dataset by merging 64 survey waves to include nearly 20,000 respondents. The dataset documents how deeply and widely shared these burdens are across the United States while allowing findings to be compared at the individual state level.

CHESS has been deployed in Minnesota in 2019, 2021 and 2024. Altarum's 2024 CHESS of more than 1,400 Minnesota adults found that affordability burdens are widespread, care is being skipped and medications rationed, worry about the future is high across all income levels and support for government action to address costs is strong and remarkably bipartisan.

Minnesota Isn’t an Exception

In the CHESS National dataset, 71.2% of respondents reported at least one affordability burden in the past year — skipping or rationing care, financial strain from medical bills or going without insurance because of cost.

Skipping needed care because of cost is nearly as common, 68.8% of respondents said they had done so. The CDC attributes chronic-disease treatment failures to poor medication adherence, much of it cost-driven, and links nonadherence to worse outcomes in hypertension, diabetes and cardiovascular disease. Nearly one in five adults nationally say their health worsened because they delayed or skipped needed care. Among people with diabetes, roughly one in six reported rationing or abandoning medication to save money. Among respondents in the CHESS National dataset, 27.4% reported rationing medication in the past year because of cost.

Financial strain follows the same pattern, 38.4% reported financial burdens from health care costs, including depleted savings, difficulty covering food, housing or utilities because of medical bills and being contacted by a collection agency about medical debt. Nationally, medical debt is estimated in the tens of billions of dollars and affects tens of millions of Americans. Roughly half of U.S. adults say they could not cover an unexpected medical bill of over $500 without going into debt or being unable to pay it at all.

Worry compounds the financial reality — 77.9% of respondents reported at least one health care worry, most commonly losing coverage, health care coverage becoming unaffordable or being unable to afford care in the event of a serious illness.

Comparably, from the 2024 Minnesota CHESS, nearly two in three Minnesota adults (64%) experienced at least one health care affordability burden in the prior year. Financial fallout from that burden is common, 41% of Minnesota respondents reported at least one financial strain tied to medical bills in the past year. Examples of this include:

• 20% used up all or most of their savings
• 16% were contacted by a collection agency
• 16% could not afford basic necessities like food, heat or housing because of a medical bill
• 14% incurred large amounts of credit card debt
• 11% borrowed money or took out a loan or mortgage
• 10% were placed on a long-term payment plan

These burdens are not evenly distributed. Households that include a person with a disability were nearly twice as likely to report medical debt, depleted savings or sacrificed basic needs (60%) as households without a person with a disability (35%). Black, Indigenous and other Minnesotans of color reported this financial strain at notably higher rates (52%) than white, non-Hispanic respondents (38%). Medicaid enrollees, people already covered by a public program designed to protect against cost, reported the highest rate of financial burden from medical bills of any insurance type (51%), essentially matching the 47% reported by people with employer or self-purchased private coverage.

Skipping or Foregoing Care and Rationing Medication

Over half of Minnesota adults delayed or went without needed health care in the past year because of cost. The most common forms include:

• 34% skipped needed dental care
• 34% delayed going to the doctor or having a procedure done
• 29% avoided going to the doctor or having a procedure altogether
• 27% cut pills in half, skipped doses or did not fill a prescription
• 27% skipped a recommended medical test or treatment
• 22% skipped needed vision services
• 20% had problems getting mental health care or addiction treatment
• 13% skipped needed hearing services or a medical assistive device

This burden concentrates sharply where cost pressure is highest. Nearly three-fourths of respondents earning less than $50,000 a year (72%) reported an affordability burden, and 65% in that income group went without care altogether, compared with roughly half of higher earners. Younger adults went without care at far higher rates than older adults — 66% of 18- to 24-year-olds and 64% of 25- to 34-year-olds, compared with 43% of 55- to 64-year-olds and just 31% of those 65 and older. Medication rationing follows the same age pattern — 36-37% of adults under 35 rationed medication due to cost, versus 9% of those 65 and older.

Disability status produces the widest gap anywhere in the Minnesota dataset — 74% of respondents living in a household with a person with a disability went without care due to cost, compared with 50% of those in households without a person with a disability. Similarly, 45% rationed medication, compared with 21% who did not.

Respondents with a disabled household member also reported delaying a medical assistive device such as a wheelchair, hearing aid or prosthetic limb due to cost at higher rates than households without a disabled member (31% vs. 7%).

Over half of Minnesota adults delayed or went without needed health care.

By insurance type, Minnesota Medicaid enrollees reported the highest rate of going without care of any group (71%) and the highest rate of skipping or rationing medication (46%), despite having active coverage. Medicare, the only insurance option for most seniors and people with serious disabilities, does not fully insulate enrollees — 39% went without care due to cost in the prior year.

In their own words, Minnesota respondents described skipped surgeries, abandoned prescriptions and dental problems left untreated for years. These patterns recur across people with Medicaid, Medicare, employer coverage and no coverage at all.

Affordability Concerns

Concern about affording health care is nearly universal in Minnesota — 83% of respondents said they worry about affording some aspect of health care in the future, most commonly the cost of nursing home or home care (67%), medical costs in old age (65%), health insurance becoming unaffordable (65%) and the cost of care from a serious illness or accident (63%).

Worry does not track income the way skipped care does. It is not highest among the lowest earners but among middle- and upper-middle-income households — 88% of respondents earning $75,000–$100,000 and 84% of those earning more than $100,000 reported worry, compared with 79% of those earning under $50,000. Respondents ages 35 to 54 most frequently cited worry about long-term or elder care costs, suggesting many are weighing the cost of caring for aging parents alongside their own future needs.

Worry also varies sharply by insurance type and disability status. It was highest among people who buy insurance on their own (87%) and those with employer coverage (87%), somewhat lower among Medicaid enrollees (83%) and lowest among Medicare enrollees (71%), though even that “lowest” figure represents more than two in three seniors. Households with a person with a disability reported the highest worry of any subgroup (89%).

Fear of losing coverage entirely follows a different pattern than fear of unaffordability — Medicaid enrollees were most worried about losing coverage outright (48%), while people who purchase insurance on their own were most worried that it would become unaffordable even if they kept it (73%). Across every income group, insurance type and geographic region, concern about affordability exceeded concern about losing coverage. Minnesotans are less worried about coverage disappearing than about coverage becoming something they can no longer use.

Crossing Party Lines

Minnesota's dissatisfaction with the status quo is broad and bipartisan — just 35% agree “we have a great health care system in the U.S.,” while 74% agree “the system needs to change,” including 67% of Republicans, 78% of Democrats, and 73% of Independents.

That shared dissatisfaction translates into shared support for government action. Minnesota respondents supported several policy options that were tested by wide, cross-partisan margins. These included:

• 94% support requiring drug companies to give advance notice and justification for price increases (92% R / 96% D)
• 93% support requiring insurers to give upfront cost estimates
  (91% R / 95% D)
• 92% support capping out-of-pocket costs for life-saving medications like insulin (88% R / 96% D)
• 92% support expanding health insurance options so more people can afford coverage (87% R / 95% D)
• 90% support funding home and community-based services for people with disabilities (85% R / 95% D)

Even the policies with the widest partisan gap in the survey — 8 to 10 points — still command support from roughly 85% or more of Republican respondents. On health care affordability, Minnesota's political divide is far narrower than national rhetoric would suggest.

Trusting Data-driven Solutions

The data that CHESS collects does not examine its causes or speculate around potential solutions to the problems it clearly defines. It is, however, fair to say that there is no underlying single problem and that the data presents the results of a complex and imbalanced network of systems interactions that can not be solved with a single simple solution.

Minnesota's data does more than describe one state's experience, it demonstrates the reason CHESS exists. Only a state-level survey can tell Minnesota policymakers whether their residents are the ones facing the affordability burden, the skipped care, the worry and the resulting bipartisan support for state-level solutions documented above.

The Minnesota CHESS data gives state policymakers and agencies the evidence base needed to accurately assess the scope of the problem, target interventions where they are needed most and track whether policy changes are actually moving the numbers over time. As federal changes to Medicaid and ACA Marketplace coverage unfold in the coming years, that kind of direct, state-level measurement will be indispensable for understanding what is actually happening to Minnesotans and residents of every state rather than relying on national projections alone.

Beth Beaudin-Seiler, PhD, is the senior manager of the Health Economics and Policy team in the Health Research and Insights program at Altarum Institute.