Although the Affordable Care Act (ACA) made preventive healthcare free for most Americans, claims for these services nonetheless get denied for various reasons by insurance plans, leaving patients with unexpected bills or without access to important health screenings and other recommended preventive care.
A new study published in JAMA Network Open by a team of scientists, including a University of Massachusetts Amherst health services researcher, also shows that insurers are more likely to deny claims from racial and ethnic minorities, as well as other marginalized groups, for such preventive care as cancer, diabetes, cholesterol and depression screenings, as well as contraception administration and wellness visits.
In addition, when claims were denied, healthcare providers charged a higher amount for preventive services to disadvantaged groups, the study found.
"Preventive care provides a lot of value to patients and healthcare systems and population health overall," says co-author Michal Horný, assistant professor of health policy and management in the UMass Amherst School of Public Health and Health Sciences, who collaborated with lead author Alex Hoagland, a health economist at the University of Toronto, to examine claims from 2.5 million preventive care visits by 1.5 million patients between 2017 and 2020. "That's why the Affordable Care Act mandated health insurers to provide recommended preventive services to their beneficiaries at no cost. What we document is that there are inequities at the starting line."
For example, Asian, Hispanic and non-Hispanic Black patients were about twice as likely as non-Hispanic white patients to have claims denied, and low-income patients were 43% more likely than high-income patients to have their claims denied.
The inequitable pattern continued when researchers looked at the amount healthcare providers billed to patients for denied claims. For example, the median charge for a denied claim for patients with a household income of under $30,000 was $412, compared to a $354 median charge for patients with a household income of between $50,000 and $74,000 and a $365 charge for patients with an income over $100,000.
Non-Hispanic white patients were charged less than any other ethnic group when preventive service claims were denied. "These findings suggest that experiences of patients seeking free preventive care differ on the basis of their demographics, leading to inequities in accessing basic preventive care," the paper concludes.
A second, related study published in the American Journal of Preventive Medicine
found that privately insured patients faced charges in 40% of preventive care visits that should have been fully covered for free. These unexpected out-of-pocket costs may deter patients from pursuing preventive care services in the future, Horný says.
For both studies, the team looked at national claims data for seven preventive services recommended by the U.S. Preventive Services Task Force, which triggers the ACA requirement for Marketplace insurance, as well as private health plans, to cover them fully, at no cost to the patient: wellness visits, contraception administration and screenings for breast cancer, colorectal cancer, cholesterol, depression and diabetes.
In addition, the researchers had access to demographic details of the patients. "It's a highly novel and innovative data set because it combines the richness of the claims data that span the entire nation, and also includes the demographic information which is typically lacking in these data sources," Horný says.
In the study about patients' shared expenses, the research team found the "likelihood and size of [out-of-pocket] costs for preventive care varied considerably by patient demographics; this may contribute to inequitable access to high-value care."
For example, lower-educated patients had 9.4% higher odds of incurring out-of-pocket costs than patients with college degrees. On the other hand, patients with a lower household income ($49,999 or less) had 10.7% lower odds of being charged than high-income patients. However, when incurring costs, lower educated patients paid $15 less than higher educated patients, and low-income patients paid $12 more than high-income patients.
"Some protections for individuals with lower incomes seem to be kicking in, so they do not get billed for preventive care as often as those with higher incomes," Horný says. He hypothesizes that lower income people incurred higher expenses when they are billed because of multiple cracks in a complex healthcare system.
Both studies highlight how the lack of both uniform coverage of preventive care by insurers and standardized billing practices for physicians contribute to inequitable access to preventive healthcare in the U.S., the researchers note.
"We want to prevent preventable diseases," Horný says. "It saves money down the road if we don't have to treat the diseases that could have been prevented in the first place. And the key reason is we want to have a healthy population."
