Navigating Healthcare for the Uninsured
Despite its bumpy initial launch, the health insurance Marketplace, established by the Affordable Care Act (ACA), completed enrollment of around 8.8 million U.S. citizens by December of 2017. This sweeping legislation had aimed to reform the American healthcare industry by making health insurance an affordable imperative, regardless of income. The power of informed choice – once the province of employers and insurance providers – now lies in the hands of the consumer.
Immediate Effects of the ACA
A key provision of the Act was directed at families who live at or below the Federal Poverty Level (FPL). Medicaid, a government-subsidized healthcare plan for these low-income families, has always been administered by individual states. Depending on the state, U.S. residents with income equal to or lower than the FPL will qualify for Medicaid. As of 2018, the ACA gave states the option of expanding Medicaid coverage to 138% of the FPL.
At the other end of the income spectrum, families earning higher incomes qualify for tax credits to offset the cost of purchasing health insurance plans through the ACA Marketplace. This tax incentive has allowed many families to opt into ACA-approved health plans as long as they meet minimum income requirements.
While all states were offered federal funding to expand Medicaid programs, not all of them chose to accept. This created a coverage gap between families that qualify for Medicaid and families that receive tax credits to help them afford private insurance. Families who make too much income to qualify for Medicaid, but not enough to qualify for tax credits, are often unable to shoulder the cost of insurance. These families remain uninsured, despite the ACA mandate. The number of people in this coverage gap varies by state, but totals 2.5 million U.S. residents.
As of January 2018, 18 states have chosen not to expand Medicaid eligibility. Within these states, more than a fourth of the population falls into the coverage gap, ranging across states from 9% to 27%. Some states limit Medicaid coverage to families with dependent children, leaving childless adults without coverage. Uninsured adults and children risk facing costs associated with catastrophic illness or injury; they are not subject to the cost-reduction benefits of preventive health care. The gravity of being uninsured cannot be overstated: A highly cited survey from the American Journal of Public Health found that up to 45,000 Americans die annually as a direct result of being uninsured, although this number is debated.
Understanding Your Options
Many U.S. citizens fall into this Medicaid coverage gap and remain uninsured. Fortunately, options are available for these citizens, both for catastrophic and preventive care. It’s important to note that preventive care is equally as important as care in the event of injury or illness. In fact, preventive care is much more likely to stave off sickness. If you fall into the coverage gap, read on to explore free or low-cost healthcare options for you and your family.
Community Health Centers (CHC): The U.S. Dept. of Health and Human Services (HRSA) operates care centers for uninsured Americans. These clinics can be found nationwide, spread across both urban and rural areas. Fees are charged on a sliding scale based on income. Available services at these centers include:
- Well visit checkups
- Illness and injury treatment
- Pregnancy care
- Well-baby care, including immunizations
- Dental care
- Prescription drugs
- Behavioral and substance abuse counseling
HealthFair: This organization takes a proactive approach to low-cost preventive healthcare. Trained medical professionals operate a fleet of buses fitted with state-of-the-art screening technology and miniature exam rooms. Screening exams are offered at much lower costs than at typical medical facilities, and results are often immediate. No prescription or physician’s order is necessary for an appointment.
HealthFair’s mobile labs are designed to detect cardiovascular disease, stroke, cancer and other life-threatening diagnoses. Available tests include:
- Cardiac Artery Ultrasound
- Bone Density testing
- Prostate Specific Antigen testing
- Abdominal Aortic Aneurysm testing
- Cholesterol testing
Because of the large volume of screenings HealthFair’s units can perform, the company is able to offer much lower pricing than a hospital or doctor’s office. While not technically inexpensive (cost may run as high as $2300), this may still be a much cheaper option for an uninsured patient who suspects severe illness.
Hill-Burton Obligated Facilities: Another program maintained by the U.S. Dept. of Health and Human Services, Hill-Burton Obligated Facilities, offer free or low-cost healthcare solutions to qualifying patients. Participating medical facilities, such as hospitals, clinics or nursing homes, are obligated to provide a designated amount of free healthcare or at greatly reduced cost each year.
Eligibility is based on income and family size; usually meeting up to 300% of the FPL can qualify a family for services, depending on individual facilities. Citizenship is not required, but you must have been living in the U.S. for at least 3 months. Patients must apply for Hill-Burton assistance at participating facilities’ business offices.
National Breast and Cervical Cancer Early Detection Program (NBCCEDP): Operated by the Centers for Disease Control and Prevention, this resource delivers free or low-cost mammograms and pap smears to low-income and uninsured women. All 50 states offer this program, providing early detection and treatment services for breast and cervical cancers. Patients receive:
- Clinical examinations
- Pap smears
- Pelvic examinations
- HPV testing
- Further diagnostic testing with abnormal results
- Referrals to treatment providers when necessary.
Women ages 21-64 are eligible for cervical cancer screening; ages 40-64 may qualify for breast cancer screening. To qualify, women must demonstrate an income at or below 250% of the FPL.
Planned Parenthood is a comprehensive healthcare resource for women. As the nation’s leading advocate of sexual and reproductive healthcare, this organization often makes the news in a political context. What’s often overlooked is the extensive range of general healthcare services offered to women, including:
- Preventive screening for anemia, thyroid, cholesterol, diabetes and high blood pressure
- Well checkups, including those required by an employer or for a sport
- Flu shots
- Tetanus shots
- Smoking cessation assistance
- Birth control
- Prenatal care
- Breast cancer screening
- Sexually transmitted disease (STD) testing and treatment
- Pelvic exams, including pap smears
In addition to these medical services, Planned Parenthood also offers support with ACA issues, such as determining whether you are eligible for Medicaid or assisting you with a health plan purchase on the Marketplace. A plain-language explanation of our healthcare reform may also be helpful. Fees will vary by location, though they can always be expected to be low-cost or nonexistent.
Mini-clinics: Sometimes referred to as Doc in a Box, these clinics are standalone facilities that operate outside of a typical hospital-affiliated or doctor’s office network. Frequently, they are located adjacent to pharmacies, such as the CVS Minute Clinic, Walgreens Take Care Clinic, or the Walmart Clinic. Staffed by a nurse practitioner, physician’s assistant, or doctor, these clinics offer basic healthcare services to adults and children. They accept private insurance, but also treat uninsured patients who can pay cash. Some clinics accept Medicaid.
Because they are often open on the evenings and weekends, their extended hours make them a popular destination, especially when an Emergency Room is not necessary. While walk-in patients are accepted, long waits are possible during off-peak hours; making an appointment can save you long wait times. Typical treatment options at these clinics include:
- Flu shots
- Sports and school physicals
- Basic illness diagnosis and treatment, such as for bacterial infections or minor injuries
- Smoking cessation assistance
- Minor dermatological diagnosis and treatment
- Wellness exams
- Screening for diabetes, tuberculosis, cholesterol, and high blood pressure
- Pregnancy evaluation
- Allergy care
Medical / Dental school clinics: Many medical and dental schools offer free or low-cost services in student-run clinics. While students do perform all diagnosis and treatment, mostly in their second- or third-year and prior to residencies, all work is supervised by a practicing physician or dentist. And the range of services provided is the same as one would expect from a professional’s office.
Typical treatment might be prenatal and well-baby checkups, immunizations, school physicals, standard preventive care in adults and children, diabetes and hypertension screening, or flu shots. Dental patients receive cleanings, x-rays, oral surgery, and periodontic and orthodontic treatment when necessary. Services may be free or at reduced cost, and Medicaid is often accepted along with cash payment.
Charity care: While it should not be considered a reliable means to fund healthcare, charity care programs in place at some medical facilities can help you pay your medical bills if you are uninsured. Generally, these funds are provided by philanthropic donors or private endowment trusts and may be applied for by patients after services have been received.
Depending on the individual facility, healthcare can be covered at 100% for patients earning up to 200% of the FPL, and discounted payments may be offered for patients who make up to 300% of the FPL. Many medical facilities do little to nothing to advertise these programs, preferring to attract paying customers. However, they can often be uncovered by asking questions in the billing and patient accounts departments.
Emergency Room visits should always be considered the healthcare solution of last resort. Due to the belt-tightening our entire economy has experienced, emergency rooms are often understaffed. This overworked group of individuals is meant to treat true emergencies, where injury or illness threatens a life and/or requires immediate treatment. Because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to accept all patients regardless of their insurance status, an emergency room cannot legally turn you away. However, if your medical condition is not a true emergency, consider another means of care before you occupy valuable space in an ER that’s designed to save lives.
How to Lower Your Costs
Preventive care is clearly proven to be the best way to lower overall healthcare costs. If you’re uninsured, it may be tempting to avoid a doctor’s office until you are in such dire condition that you have no choice. This strategy may make sense in the short term; however, the management of a chronic illness that develops in the absence of preventive care is far, far more costly. Seeing a primary care physician for checkups, testing and even treatment can be expensive, but there are ways to mitigate that expense.
Do your research: It’s one thing to diagnose oneself with Dr. Google, which is never advised and rarely appreciated by medical professionals. However, the right information in the right context can actually save you money and help you manage your medical care. If you are told you need an expensive test, for example, conduct some research before you schedule an appointment. As you research, ask questions like:
- What information is this test expected to provide?
- Is there another test that provides the same information, perhaps in a less invasive or less expensive manner?
- Is it possible to delay the testing by trying an inexpensive course of treatment first?
- Are the test results reliable, or are they prone to false responses?
- Must this test be performed at a particular facility?
- Is the cost in line with similar testing at other medical facilities?
- Should you happen to locate a less expensive testing location? Are you allowed to be tested elsewhere?
Perform due diligence: Regardless of your insurance status, it’s good practice to be informed about every step of the diagnostic and treatment process. Your medical file likely is handled by an enormous amount of people, and one unnoticed mistake can cost you hard-earned cash. Educate yourself about procedures, terminology, billing codes, and standard pricing. Be aware of the costs before you receive a nasty surprise from the billing department. Even better, take advantage of a service like New Choice Health that lets you choose among competing providers in your area.
If your research leads you to an expensive conclusion, or you experience a true emergency situation and are unable to control spending done on your behalf, all is not necessarily lost. Many doctors are willing to set up a payment plan, negotiate a lower fee, offer discounts for cash payments, or otherwise help you work out a solution that ensures your good health and not your bankruptcy.
The key is to communicate, as quickly as possible, with the billing facility. Silently panicking as incoming bills stack up may be your first inclination, but, by the time you land in the collections department, you already lost some negotiating power. All businesses, whether doctors in solo practice or enormous hospitals, appreciate advance notification that you are unable to pay your bills.
Consider external resources as well. For example, Medical Cost Advocate (MCA) is an online resource that benefits both patients and healthcare providers by helping ensure you are billed correctly. Any medical bill you receive can be submitted for analysis. MCA’s billing and coding experts, who claim to discover mistakes on up to 50% of submissions, make a determination about your bill.
If there are errors, MCA works with you and your provider to solve them. In other circumstances, expert attorneys and medical advisors can help you negotiate payment plans, resolve health insurance issues, and reduce the cost of some procedures.
The Patient Advocate Foundation (PAF) offers similar services in human form. Funded entirely by philanthropic donations, PAF accepts patients on a case-by-case basis. Each potential case is evaluated against PAF’s ability to help using its vast resources of attorneys, medical advisors and financial specialists. If your case is accepted by PAF, you are assigned a case manager who works closely with you and all concerned parties until the issue is resolved. PAF advocates for patient issues like:
- Medical debt management
- Legal issues relating to illness, including job retention and discrimination
- Negotiation and settlement
- Arbitration and mediation
Aside from case management, PAF also offers a co-pay relief program and financial aid grants to patients meeting certain guidelines. A special focus is given to the low-income, uninsured populace, where PAF conducts outreach and spreads healthcare awareness.
Crowdsourcing your medical costs is a relatively new trend, and it can work in some circumstances. Many Americans who are or who anticipate being overwhelmed with medical debt use services like KickStarter, You Caring, and Fundly to raise money. Though it isn’t exactly solid business practice, with enough publicity and the attention of the right donors, it can be possible to rely on the kindness of strangers.
It’s no argument that healthcare in the U.S. is astronomically expensive. Navigating the behemoth structure of our healthcare system is intimidating enough; for uninsured patients, it may seem too daunting to attempt. There are solutions, though, if you are willing to put in the time and effort that it requires to uncover new options.
Medical facilities and physician’s offices sometimes acquire a reputation as heartless patient factories that are focused on profit. Most of time, the opposite is true: your medical team entered their professions because they want to improve the lives of their patients. Asking questions, speaking up about discrepancies and having awkward conversations about finances may be difficult, but it often produces good results.