The Hidden Healthcare Gap: Why Millions Can’t Afford to Use Their Insurance

Having health insurance through an employer doesn’t mean someone can afford to see a doctor. In fact, two in three underinsured individuals receive their health benefits from an employer, and nearly half of insured individuals are concerned about simply paying their premium every month.

The Reality of Underinsurance

Underinsurance happens when out-of-pocket costs (excluding premiums) exceed 10% of a household’s income—or 5% for low-income households earning less than 200% of the federal poverty level. High deductibles that surpass 5% of household income also classify individuals as underinsured.

In 2024, 23% of adults (ages 19–64) fell into this category, with the majority receiving coverage through their employers. Despite having insurance, high cost-sharing requirements force many to forgo necessary medical care—even when they understand the long-term benefits of routine treatment.

Take dentistry, for example. The industry has done an excellent job of educating the public on the importance of routine cleanings and exams. But awareness alone isn’t enough when cost remains a barrier.

• According to the American Dental Association (ADA), only 40% of adults (ages 19–64) saw a dentist in 2022.
• Even among those with dental insurance, 40% still skipped needed care in the past year.
• Among the uninsured, that number jumps to 6 in 10 avoiding care.

Cost is a primary reason: the ADA reports that 12.7% of people who didn’t visit a dentist cited cost as the barrier, compared to 5.2% for medical care and 4.8% for prescriptions. Meanwhile, the Biennial Health Insurance Survey found that 32% of underinsured individuals didn’t fill a prescription last year—even 16% of those with “adequate” coverage skipped their medications. For the uninsured, that number climbs to 41%.

These statistics are troubling, given that preventative healthcare improves population health and reduces overall spending.

What Does This Mean for PT?

This data doesn’t mean we should stop pushing for ChoosePT or Get PT First awareness. Many people still don’t know how effective physical therapy can be, and only 8–12% of people with MSK issues receive PT.

But education alone won’t fix the problem if cost and access remain barriers—just as we see in dentistry.

• What if a patient’s plan has no copay, but they need to meet a $10,000 deductible first?
• What if their PT prescribes a 20-visit post-surgical plan of care?
• What if both scenarios apply?

Even a $25 copay per visit adds up quickly, especially for someone living paycheck to paycheck. You can cite studies on long-term cost savings, but those won’t change the immediate financial reality for most patients.

The Systemic Impact of Underinsurance

The consequences of underinsurance extend far beyond individual health—they widen systemic inequities, particularly for low-income families relying on high-deductible employer-based plans.

Skipping necessary care doesn’t just impact patient health—it drives up long-term healthcare costs. Patients who delay treatment often develop more complex conditions, requiring more expensive interventions down the road.

And then there’s access:

• Does the in-network PT clinic have a long waitlist?
• Do they offer telehealth or flexible scheduling?
• Does the insurance plan require prior authorization?
• Is there a cap on covered visits?

Each of these barriers further delays or prevents care—which is where direct-to-employer contracts can change the equation.

Solving Barriers to Care with Direct Contracting

When healthcare providers contract directly with employers, they can design custom programs that meet the needs of employees—without complexity from insurance companies.

Key Benefits of Employer Partnerships:

No Copays or Financial Burdens for Employees

Employers can waive copays and other cost-sharing requirements, eliminating financial barriers to care.

No Prior Authorizations

Removing insurance companies from the equation means no more delays due to prior authorization.

Reduced Administrative Burden

Without insurance red tape, providers can spend less time on paperwork and more time delivering care.

Improved Access with Digital & On-Site Services

Many direct-to-employer programs include:

• Telehealth & digital support for scheduling flexibility.
• Preventative education through articles, webinars, and screenings.
• On-site PT & wellness clinics to meet employees where they are.

By aligning incentives across all stakeholders, these programs create a win-win for employers, employees, and providers alike.

The Power of Early Intervention

By waiving copays and improving access, employees can seek care at the acute stage of an injury—when treatment is most effective. Studies show that patients who receive early PT achieve better outcomes in fewer visits compared to those who delay care.

This not only improves individual health but reduces long-term costs for employers and the healthcare system.

The Bottom Line

Direct-to-employer partnerships help remove cost and access barriers so employees can get the care they need before conditions become chronic and costly. By focusing on early intervention and preventative care, these programs help reduce overall healthcare spending while improving workforce health.