The Affordable Care Act has led to historically low rates of uninsured. Over 750,000 Ohioans have enrolled since it went into effect. However, in Ohio, health care still looks different for people with low to moderate incomes (and especially for people of color) than it does for those with more money to pay for services. This is the first in a series of articles written by UHCAN Ohio’s Health Equity Director, Nita Carter, to help us understand how our current system of health care helps to create disparities in health care that lead to disparities in health outcomes.

As a health care advocate, an African American woman, and a member of the middle class, I want to begin by sharing my own story about my recent trip to my primary care doctor for my free annual exam, to illustrate continuing barriers to health care based on income and race.

In March, I went to the doctor for my annual exam, which included a pap exam and a colonoscopy.  When I arrived, my doctor, who I have been seeing for years, starts to talk about what has been going on with me since my last visit and over the year. I talk about the fact that I gained some weight this year and share other things about what I think has changed. She does her exam and orders a number of tests – the usual things, like checking my cholesterol levels and my “sugar” levels (in my community, we say “sugar,” not technical terms like “A1C”). She includes a test to check my thyroid to make sure I am having no thyroid problems, as thyroid problems run in my family and weight gain is an indicator. She also checks my vitamin levels as mine have been low in the past.  She gives me a pap exam, and on another day in March I have a colonoscopy – one of the free preventive screenings under the ACA.  From these 2 visits, my free colonoscopy, and my free annual exam, I received bills totaling over $500.00. 

When I called to ask my provider and the insurance company about these bills, I was told that the test for my thyroid and the Vitamin D were not covered. In addition, the biopsy on the polyp (to rule out cancer) removed during the colonoscopy and some of the tests on the tissue taken during the pap exam were not covered. 

Here is where money counts. If I have money none of this is a problem. I might try and appeal, but ultimately, I’m going to pay for the tests if the appeal does not work. Of course I want my thyroid checked, and I want my polyp tested to make sure it is not cancer, and I want to know if there is anything abnormal about my pap exam. But if I have no money for these extra costs, I am most likely only going to do the things that are free, even though the doctors recommends the tests that cost money. And if I am not told these tests will bear significant costs ahead of time and I get bills for them – as happened to me – I am going to be more than upset. If I have to pay these bills, I may have to skip some other important expense, like a utility bill or a prescription, or set up a payment plan using money I do not have, because I only budgeted for my monthly premium. This one visit teaches me I can’t afford “free” preventive and routine care from my primary care doctor. Next year and the years after, I am going to think twice about scheduling an annual exam, the pap exam, or any other free preventive screening that might cost me money.  I may avoid routine care until I have a problem I can’t ignore – and that’s why we see big inequities in health, based on income, which disproportionately impacts people in my community. 

Affordability is the main reason many currently uninsured people cite for not enrolling in coverage under the ACA.  And we know that many of the uninsured are from some of our most at-risk populations, living in communities where health disparities are high. So how do we change this and create access to more affordable, quality health care? We have our work cut out for us. There is more than one answer to this question.  For example, we could:

• Work with insurance companies to change their benefit structures to reduce cost sharing for recommended screenings and tests;
• Focus on educating people on how to use the Marketplace to choose plans that have less out of pocket cost, how to budget for extra costs in addition to premiums (cost sharing), how to choose providers whose services might have lower out-of-pocket costs, and how to use their coverage more effectively;
• Work with providers on billing in ways that create less out-of-pocket cost and ensure that patients know what they are being charged before they get services; and
• Teach people how to file appeals.

Most of all, we need to understand the problems people are having getting and paying for health care. Then we need to figure out what policy changes we should advocate for so that health insurance makes needed health care more affordable. These are the questions UHCAN Ohio struggles with every day and the questions I am going to explore in the next articles in this series on creating health equity in our health care system.