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Uninsured struggle to obtain, afford doctor appointments

(Reuters Health) – Without some kind of health insurance, getting an appointment with a primary care doctor, and being able to pay in full or over time remains a challenge for millions in the U.S., a recent study suggests.

Although the number of uninsured is down from a high of 49 million people in 2010, to less than 30 million in 2017, barriers to their ability to access care have not changed much, the study team reports in Health Affairs.

In 2012-2013, and again in 2016, researchers found that only about 80 percent of uninsured callers willing to pay in full could get a primary care appointment, and just one in seven could get an appointment if they needed to pay over time.

“We’re just starting to learn how healthcare is changing as a result of the Affordable Care Act (ACA),” said lead author Brendan Saloner of the Johns Hopkins Bloomberg School of Public Health in Baltimore.

“We know that access to care has improved for people who got health insurance under the ACA. But we took a unique perspective with this study and looked at the population who still have no insurance – whether by choice or as a result of ineligibility,” he said in a telephone interview.

In both study periods, Saloner and colleagues had trained interviewers call both private primary care provider offices and federally qualified health centers in a diverse sample of ten states, including Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania and Texas.

The callers posed as prospective new patients seeking an appointment for either a routine check-up or complications related to suspected high blood pressure and made it clear that they did not have health insurance. In one scenario, the callers said they were able to bring full payment to the appointment. In another, the callers said they could bring less than half of the full price and asked about arranging a payment plan.

The quoted price for the office visit, regardless of the reason, averaged about $163 at both time points. During the 2016 arm of the experiment, callers also asked whether a price discount was available for lower-income individuals, and just over 22 percent were told there was.

Overall, the rate at which callers could get an appointment did not change between the two study periods, the study found.

The proportion who could get an appointment without paying in full at the time of the visit dropped from 14 percent in 2012-2013 to about 12 percent in 2016. However, certain states had sharper declines, for example, from 17 percent to 9 percent in Illinois and from 10 percent to 4 percent in Texas.

The state where callers were most likely to be offered low-income discounts in 2016 was Montana, at over 41 percent, and discounts were least common in Massachusetts, where just under 7 percent of callers were told a discount was available.

In states with a large uninsured population, like Montana, doctors may be more accustomed to working with these individuals in order to have a business, Saloner said, whereas Massachusetts residents are more likely to have insurance and therefore private offices might not be set up to attend to the needs of the uninsured patients.

The study also found that federally qualified health centers were four times as likely to offer low-income discounts compared with private physician offices.

Part of the reason for the disparity is that federally qualified health centers are required to be responsive to the needs of lower-income populations, said Dr. Jeffrey Kullgren a researcher with the VA Ann Arbor Healthcare System and the University of Michigan Medical School, who was not involved in the study.

“Essentially, federally qualified health centers are the pillars of our country’s healthcare safety net,” he said in a telephone interview.

“Even though the ACA has led to improvements, there is still a substantial (number) of individuals who don’t have health insurance,” Kullgren added. “And even for people who are insured, deductibles have climbed dramatically in recent years.”

“It’s important to know that there is not a one-size-fits-all policy solution for this challenge,” Saloner said. “There are a lot of ways to make things incrementally better. Getting a handle on the affordability of care is a good place to start.”

SOURCE: bit.ly/2EECd0J Health Affairs, online April 2, 2018.

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