Despite having health insurance, a significant number of Americans face financial barriers when it comes to getting access to care and medication, according to a recent survey by the country’s largest pharmaceutical lobby.

Drug companies often come under fire for the high cost of medication. But the survey – commissioned by the Pharmaceutical Research and Manufacturers of America, or PhRMA – points a finger at insurance-company practices like utilization management and cost-sharing with patients.

“In order to tackle challenges with affordability and access, policymakers must understand the deeply entrenched systemic barriers insurers impose on patients,” PhRMA wrote in the survey, titled “Covered by Insurance But Still Exposed: Barriers to Care for Insured Americans.” Published in March, it follows up an inaugural survey released in 2021.

The challenges stem, in part, from the burden of out-of-pocket costs, such as copays, co-insurance and high deductibles, according to the survey.

Conducted in late 2021, the survey found that 37% of Americans with health insurance experienced financial barriers to care, with the burden falling disproportionately on women and people of color. Of those facing barriers, 63% were women and 51% reported having a chronic condition.

Overall, slightly than half of those with insurance, or 52%, were confident they could shoulder the additional out-of-pocket costs stemming from a major medical event or a diagnosis of chronic illness, according to the survey.

But more than a quarter, or 29%, said they would have to eat into their savings or use credit cards to cover the extra costs, A fifth, or 19%, said they would have trouble meeting the costs.

The share jumps when broken down by race and ethnicity. Nearly a quarter of Black Americans, or 24%, said they would not be able to afford unforeseen care. The figure was 21% for Hispanic Americans and 17% for white Americans.

The survey also revealed challenges people face from practices like prior authorization and step therapy – two forms of utilization management long criticized by the pharma industry. Prior authorization refers to the need for securing an insurer’s approval before starting on a medication, a medical procedure or diagnostics testing/imaging. Step therapy requires a patient to try a medicine preferred by the insurer rather than the prescribing doctor. Only if the alternative fails, then the insurer covers the original medicine.

According to the survey, nearly half of insured people who take prescriptions, or 49%, faced some kind of insurer-imposed barrier. Prior authorization was most common, affecting 31%, followed by lack of coverage for the prescribed medication, at 29%. Nearly a quarter, or 24%, said their insurers required prescriptions for a different medicine than what their doctors believed would be most effective.

As with costs, the barriers disproportionately affected people of color, with 64% of Hispanic Americans reporting barriers, 55% of Black Americans and 55% of Asian Americans. The figure for White Americans was 44%.

The survey noted the barriers can pose health risks. People fail to follow their prescription guidelines for a variety of reasons. But the survey draws a correlation between prescription non-adherence and utilization management: three-quarters of those who reported at least one episode of non-adherence said they were subject to some form of utilization management.

Not surprisingly, Americans are interested in finding some relief. Given a choice, two-thirds, or 66%, said they would prefer lower out-of-pocket costs over lower premiums when it comes to prescription drug coverage.

Specific reforms backed by those surveyed include requiring hospitals and Medicare Part D plans to pass their discounts and rebates on prescription drugs directly to patients, as well as giving insurers more incentive to lower out-of-pocket costs.

The survey was conducted between Nov. 30 and Dec. 21. It included responses from 4,264 Americans with health insurance.