The Doctor will see you Now (For $160)

Although the Affordable Care Act sought to expand health insurance to near universal levels, this has not occurred. In the Supreme Court case National Federation of Independent Business v Sebelius, the court ruled Medicaid expansion to be optional. Subsequently, 20 states opted not to participate in expansion. What was left were significant questions regarding access to care for those left out of Medicaid expansion.

Source: Carol Von Canon (Flickr/CC)

Source: Carol Von Canon (Flickr/CC)

In an article recently published in Health Affairs, researchers used a secret shopper methodology to assess how difficult it would be to obtain a primary care appointment without health insurance. The research team made 1,613 phone calls as new patients to primary care offices seeking appointments. Nearly 80% of the uninsured callers were offered appointments, only slightly lower than the 83.2% of insured patients.

After securing an appointment, the trained callers asked the scheduler two important questions: “How much will this visit cost in total?” and “How much money do I need to bring to the appointment in order to be seen?” Overall, the callers were quoted a mean price of $160 (median $125). Only 18% were told they could bring partial payment to secure the appointment.

These results may not be surprising, but the implications are important. The federal poverty level for a single individual is listed as $981 monthly. A $160 charge represents 16% of monthly income for Americans in this income bracket. Additionally, the per visit fee doesn’t include any blood work, imaging or other costs that may be billed during the course of the visit.

However, this study did contain several small silver linings. First, prices at Federally Qualified Health Centers (FQHC) were lower cost options for the uninsured. Additionally, costs were lower in highly impoverished zip codes. Still, the cost at an FQHC was $109 and the average high-poverty zip code was $144, which would present enough sticker shock to prevent uninsured patients from seeking care.

Overall, this study serves as a stark reminder of the barriers of care the uninsured still face in the United States. For those living at the poverty level, items ranging from health care, housing, and food all compete for a place on a tight budget. Although the ACA expanded insurance access throughout the country, for the uninsured Americans in the 20 non-expansion states, access to care will remain a struggle.

commentary by Kyle Fisher

Abstract

Provisions of the Affordable Care Act (ACA) allow millions more Americans to obtain health insurance. However, a sizable number of people remain uninsured because they live in states that have not expanded Medicaid coverage or because they feel that Marketplace coverage is not affordable. Using data from a ten-state telephone survey in which callers posed as patients, we examined prices for primary care visits offered by physician offices to new uninsured patients in 2012–13, prior to ACA insurance expansions. Patients were quoted a mean price of $160. Significantly lower prices for the uninsured were offered by family practice offices compared to general internists, in offices participating in Medicaid managed care plans, and in federally qualified health centers. Prices were also lower for offices in ZIP codes with higher poverty rates. Only 18 percent of uninsured callers were told that they could bring less than the full amount to the visit and arrange to pay the rest later. ACA insurance expansions could greatly decrease out-of-pocket spending for low-income adults seeking primary care. However, benefits of health reform are likely to be greater in states expanding Medicaid eligibility. PMID: 25941278  Saloner et al. Health Affairs. 2015; 34 (5): 773-780.

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