Primary care visits available to most uninsured, but at a high price

And payment options are not very flexible, with only one in five people told they could be seen without paying the whole cost up front, suggests the new study published in the May issue of the journal Health Affairs.

"There's a discouragement factor for uninsured people when it comes to seeing a doctor when they are sick," says study leader Brendan Saloner, PhD, an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. "If you pick up the phone and the cost is high, you may stop looking -- even if you are really sick. For a lot of people it's bewildering to navigate the primary care market without health insurance."

Saloner's research is based on data from a 10-state telephone survey in which callers posed as patients from November 2012 to March 2013 to find out whether they could get a new patient appointment with a primary care doctor and, if so, how much a basic visit would cost. Callers only revealed their uninsured status after being offered an appointment. The audit, which included 1,613 completed calls, was conducted before the implementation of the Affordable Care Act in late 2013, which not only has given more patients private insurance but also has increased the number of people with Medicaid in many states.

While there are fewer uninsured people now and the number is expected to drop again in 2015, Saloner says, there is still a sizable uninsured population in the United States, particularly those who live in states that have not expanded Medicaid and who still believe that coverage on the ACA marketplace is unaffordable.

In total, roughly 79 percent of uninsured callers in the study were offered an appointment, while only about six percent who were denied an appointment were told that the denial was due to insurance status (other reasons included that the practice wasn't taking new patients). The average price of a new uninsured patient appointment was quoted as $160, with some variation among states (a low of $128 in Pennsylvania and a high of $188 in Oregon). The price was significantly lower at federally qualified health centers ($109). Prices were also lower for offices in zip codes with higher poverty rates. The price was for a basic new patient appointment, and the callers did not request price quotes for any additional blood work, imaging or other testing.

Still, Saloner points out, a medical bill of $100 would represent about one-tenth of the monthly income of a single adult living at the poverty level.

The average price quoted to callers in the study was lower than actual total amounts paid for privately insured new patient primary care visits in the same states (an average of $200), as reported in previously reported research. Of those visits, the average out of pocket cost for privately insured patients was $49.

Only 18 percent of uninsured callers were told they could bring less than the full amount to the visit and pay the rest later. On average, those told they could arrange a payment plan were told to bring 61 percent of the cost of the appointment to be seen.

Saloner says expanding Medicaid beyond the 29 states and the District of Columbia that have already done so, would enable more people to afford basic health care.

"Even with improvements coming with implementation of the Affordable Care Act, the system will make an uninsured person really think twice about whether he or she needs to go to the doctor," Saloner says.