A majority of Americans with health insurance reported experiencing barriers to coverage in their plans, including denial of medical care, higher bills and a lack of doctors in their plans. survey from KFF, a non-profit health research group. As a result, some people delayed or skipped treatment.

Those most likely to need medical care—people who described themselves as being in fair or poor health—reported more difficulties; three-quarters of those who received mental health treatment had problems.

“The consequences of delayed and missed care due to the sheer complexity of the system are significant, especially for people who are sick,” said Drew Altman, executive director of KFF, formerly known as the Kaiser Family Foundation.

The survey also highlighted the persistent problem affordability as people struggled to pay their share of health care costs. About 40 percent of those surveyed said they had delayed or neglected care in the past year because of expenses. People in fair or poor health were more than twice as likely to report having trouble paying medical bills as those in better health, and black adults were more likely than white adults to indicate that they were struggling.

Almost half of those who encountered a problem with their insurance said they could not resolve it satisfactorily. Some couldn’t get the care they were looking for, while others said they paid more than they expected. Among the nearly 60 percent who reported difficulty with insurance coverage, 15 percent said their health had deteriorated.

“This survey shows that it’s not enough to just have a card in your pocket — the insurance has to work or it’s not exactly coverage,” said Karen Pollitz, co-director of KFF’s Patient and Consumer Protection Program.

People have a hard time understanding their coverage and benefits, with 30 percent or more having trouble figuring out what they’ll have to pay for care or what exactly their insurance will cover.

“Insurance is a lot more complicated than it should be,” said Amanda Parente, a 19-year-old college student from Nashville who is covered by her mother’s employer plan. She was surprised to find that her out-of-pocket costs had recently increased when she sought treatment for strep throat. While she realized her deductible would be higher, “I think we didn’t know how drastic it was going to be,” she said.

Orientation to the complexity of coverage and benefits was similar regardless of what insurance people had. At least half of those surveyed with private coverage through an employer, those with an Obamacare plan or a government program like Medicare or Medicaid, said they were struggling.

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