As the rollout of coverage expansions under the Affordable Care Act (ACA) continues across the country, more Americans are gaining insurance coverage, with all the benefits that that implies in terms of health care access and financial protections. However, if, as President Obama has argued, affordable health care is a cornerstone of economic security for American families, findings from a survey of Massachusetts residents suggest that insurance coverage alone will not be enough.

Since its 2006 health reform initiative, Massachusetts has had the nation’s highest level of insurance coverage. But though there have been improvements in access to health care and health care affordability, insurance coverage has not eliminated the burden of high health care costs for Massachusetts families.

Health care costs are a problem for many insured adults.  In 2012, more than one-third (38.7 percent) of Massachusetts adults with health insurance coverage for all of the past year reported problems with health care costs, with the level much higher for low-income insured adults (41.6 percent for those with family income at or below 138 percent of the poverty line—the income eligibility standard for the Medicaid expansion under the ACA) and middle-income insured adults (49.5 percent for those with income from 139 to 399 percent of poverty—the income group targeted by the new health insurance Marketplaces). Insured adults in Massachusetts report going without needed health care, cutting back on other spending, reducing savings, and taking on debt to deal with health care costs.

The challenges faced by low-income and middle-income Massachusetts families are particularly worrisome given that the consumer protections for out-of-pocket health care costs are generally better in Massachusetts than those required under the ACA. For individuals with family income between 100 and 200 percent of poverty who are enrolled in the state’s subsidized health insurance program, out-of-pocket spending for covered prescriptions and medical services is limited to $1,000 per benefit year. The ACA allows individuals in this income cohort to have out-of-pocket costs that can sum to more than double this amount ($2,250).

Even with these stronger consumer protections, more than 4 in 10 insured low-income Massachusetts adults had trouble covering their health care costs in 2012. Nearly a third (31.6 percent) reported problems related to their spending on health care (e.g., problems paying medical bills or medical debt), and 23.6 percent reported going without some type of needed health care because of the cost.

The experience in Massachusetts demonstrates that while expansions in insurance coverage do lead to improved access to care – as evidenced, for example, by the higher shares of Massachusetts adults with preventive care visits and dental visits after reform – having insurance is not necessarily sufficient to provide protection from the challenge of health care costs.

Taking the next step to address costs.  While health insurance coverage is a necessary component of affordable health care, high cost-sharing requirements combined with high health care costs can make access to needed health care services a challenge for many American families, leading to gaps in health care use, problems paying health care bills, and medical debt. To achieve the promise of health care affordability for all, we must consider the implications for families with limited resources of policy initiatives aimed at reducing health care costs.