Last week the CDC’s National Center for Health Statistics published a report documenting a decline in the number of people with problems paying their medical bills. The report is based on data from the National Health Interview Survey between January 2011 and June 2013 and found that the number of people under age 65 reporting problems paying medical bills dropped from 21.7 percent (57.6 million) in 2011 to 19.8 percent (52.8 million) in 2013. The amount of the decline differed, depending on the respondent’s source of coverage:

• Uninsured individuals experienced no significant change in their ability to pay medical bills.
• Individuals with private health insurance coverage experienced a small drop, from 15.7 percent reporting problems paying medical bills in 2011 to 14.1 percent in 2013.
• Individuals with public coverage experienced the most significant drop of the three coverage sources, from 28.0 percent reporting problems paying medical bills in 2011 to 24.7 percent in 2013.

This trend is good news, to be sure. However, the fact remains that 52.8 million Americans continue to have trouble paying for their health care, leading many to delay or forego care or dip into savings. Another study, published in March by the Commonwealth Fund, found that 31.7 million people with insurance in 2012 were “underinsured,” meaning they spent a high percentage of their income on health care. Both studies help explain why medical debt is a top cause of personal bankruptcies in the U.S.

Why are fewer people reporting problems paying medical bills?

That’s a good question, and the CDC’s report doesn’t speculate. First, it’s important to note that the uninsured continue to report essentially the same level of difficulty paying for medical care – no surprise. The good news is that the number of uninsured in this country is declining, and millions more people gained insurance this year, thanks to the Affordable Care Act (ACA).

Second, another reason that fewer people report problems paying medical bills may be that they’re getting less care. In the last few years we’ve experienced an overall decline in health care spending, due in part to the economic slowdown. When people feel pinched financially, they are more likely to delay or forego medical care, even if they have insurance. Perhaps obviously, the less care they receive, the fewer bills they have to pay.

Third, the ACA may have had some impact on the decline in people with private coverage reporting fewer problems paying medical bills, but it is unlikely to be a huge factor at this stage. The survey was conducted through June of 2013, so it doesn’t pick up the significant coverage improvements that went into effect in January of 2014. The ACA did include a set of early reforms that went into effect in 2011. These include free preventive care, a ban on lifetime dollar limits, and restrictions on annual dollar limits. There is no doubt these provisions have improved the adequacy of coverage for millions of Americans. According to one study by the U.S. Department of Health and Human Services, between 2011 and 2012, 71 million Americans received free preventive care because of the ACA.

However, the overall decline was modest among people with private coverage (from 15.7 percent to 14.1 percent). Most of the decline occurred among people enrolled in public coverage, primarily through Medicaid and the Children’s Health Insurance Program (CHIP). It’s not yet clear why this decline occurred, and it’s worth additional study.

Next year’s CDC report will begin to capture the effects of the ACA’s 2014 market reforms, many of which are designed to improve the adequacy of coverage for people with private coverage: a minimum essential health benefit package, minimum actuarial value requirements, caps on annual out-of-pocket costs, and the prohibition on pre-existing condition policy exclusions. These reforms should allow us to make a more significant dent in the 52.8 million Americans reporting trouble paying medical bills.