Many uninsured patients get primary care for free

  | October 17, 2016

Healthcare reform has helped reduce the number of uninsured American adults by 20 million people, but roughly 24 million adults ages 19 to 64 are still uninsured. Why don't they have coverage?
There are a host of reasons why people remain uninsured, from the absence of Medicaid expansion in many states to a poor understanding of subsidies and exchanges. For many, the cost of coverage is a barrier. On the flip side, some people with relatively high incomes choose to pay penalties rather than pay for full insurance coverage.
But there's another factor that may, for some, contribute to the decision to remain uninsured: access to free or low-cost primary care.

A wide range of charges

The Affordable Care Act mandates that some types of preventive care cost nothing for patients with insurance. But physicians are free to make their own decisions about how much to charge uninsured patients who pay out of pocket for all types of visits. As part of ACAView, our ongoing project to assess the impact of the Affordable Care Act on the healthcare delivery system, we analyzed how much those uninsured people actually pay for primary care.

Uninsured payments for primary care, athenaInsight

Our analysis is based on visits from 400,000 uninsured adult patients to 19,000 primary care physicians on the athenahealth network in 2015. We measured payments either during the visit or after, including payments through July of 2016.

This is the first time, to our knowledge, that actual patient payments for uninsured patients have been measured; other studies have looked what practices report that they would charge uninsured patients, but do not measure what these patients actually pay.

We found that individual physicians take very different approaches to collecting from patients for primary care services. Some do not collect at all from uninsured patients, while others collect substantial amounts.
For 41 percent of the 800,000 visits we considered, uninsured patients paid nothing. On the other hand, physicians collected $60 or more for 37 percent of visits and $100 or more for 17 percent. acaviewfree_primary_care_2
That wide distribution in patient payments also persists for specific types of primary care visits.
For instance, the most common kind of visit recorded — accounting for roughly 28 percent of all visits — is for “level 3 evaluation and management services," which often includes a basic examination and treatment recommendation for one or more specific complaints.
More than a quarter of those visits were free for uninsured patients, while 20 percent cost $100 or more.
Uninsured people may skimp on primary care, or avoid the doctor's office completely, because of the substantial costs they often must pay. So we were surprised to find that so many primary care visits were free, and that others cost $20 or less. Could that fact decrease patients' motivation to purchase insurance?

The implications of free and low-cost primary care

It's possible that some proportion of these people can't access insurance at all, either because they're undocumented immigrants who aren't eligible for Medicaid, or because they're poor and live in non-expansion states — and thus can't qualify for either Medicaid or subsidies on healthcare exchanges.

Still, it's clear that many uninsured patients qualify for Medicaid and other subsidies, or could afford unsubsidized commercial coverage. And if those patients believe they're unlikely to need specialty, emergency, or hospital care, then the availability of free or low-cost primary care might make them feel more comfortable remaining uninsured — and thus less likely to get routine or preventive care, with potential consequences for their health and financial well-being.

Physicians can play a key role here in counteracting this tendency, by taking the time to stress the health benefits of remaining insured even if primary care is easily available.

Analysis for this report was performed by Anna Zink. Photography by David McLain.

Many uninsured patients get primary care for free