Insurance Status May Affect How Well Patients Are Treated, Study Finds

WASHINGTON — People on Medicaid and those who are uninsured reported experiencing more unfair treatment from healthcare providers and office staff members than those with private insurance, survey data showed.

Nearly 10% of adults with public health coverage such as Medicaid said they experienced unfair treatment or judgment in a clinical setting because of their insurance status compared with 1.3% of adults with private insurance, according to a study by Dulce Gonzalez, MPP, and colleagues at the Urban Institute, a left-leaning think tank here.

“Experiences of unfair treatment or judgment in healthcare settings due to insurance type have been associated with unmet health needs that can result in poorer healthcare quality, that can undermine patient health and well-being, and contribute to health inequities by race and ethnicity,” the authors noted in their introduction.

“Provider perceptions of or experiences with structural aspects of the Medicaid program” — including low Medicaid payment rates — may also drive unfair treatment, they added.

The researchers analyzed April 2021 data from the Urban Institute’s Health Reform Monitoring Survey (HRMS), a nationally representative, internet-based study of adults ages 18 to 64 which started in 2013 to provide timely information on the Affordable Care Act (ACA). The data included households with and without internet access. The HRMS is conducted annually and 9,067 respondents participated in April 2021.

Gonzalez and colleagues looked at outcomes by the following health insurance coverage types: full-year private coverage, full-year public coverage, and full-year uninsurance. Public insurance included Medicaid and Medicare, and about 90% of respondents with public insurance reported having Medicaid. Private insurance included employer-sponsored insurance, ACA marketplace and other non-group coverage, and TRICARE or other military coverage.

Respondents were asked whether, within the past 12 months, they felt they were unfairly treated in a doctor’s office, hospital, or clinic due to one or more of the following factors: racial or ethnic background, gender or gender identity, sexual orientation, country of origin, primary language, health insurance coverage type, a disability, a health condition, income level, or some other reason.

As to what “unfairly treated” means for patients, the authors weren’t able to look at that for this study, Gonzales said in a phone interview, adding that “we do have a follow-up where we try to get more information on that.”

For this survey, “patients self-reported unfair treatment … [instances where] they had felt they were treated or judged unfairly within the past year in a healthcare setting, so people could have defined that in any number of ways,” she added.

Overall, 9.8% of non-elderly adults reported that they experienced unfair treatment in a healthcare setting in the prior year because of one or more of the above factors, and adults with public coverage and those who were uninsured were more than twice as likely as adults with private coverage to report they had experienced unfair treatment for one or more reasons (17.4% and 13.9% vs 6.4%), the researchers found.

Among the 9.8% of adults who reported unfair treatment due to any reason, roughly one-third (3.6%) said they were treated unfairly because of their health insurance type, either alone or in combination with one or more other reasons. This included 2.8% of adults who were treated unfairly because of their health insurance type and other reasons, and 0.8% who were treated unfairly because of their health insurance type alone.

“Adults with public coverage and those who were uninsured were more likely than those with private coverage to report unfair treatment due to their health insurance type in combination with one or more other reasons (7.8% and 5.7% vs 1.0%),” the authors wrote.

And although “after adjusting for observed demographic, socioeconomic, health, and geographic characteristics of non-elderly adults in our sample, differences in the shares of people reporting unfair treatment due to health insurance coverage type remain between publicly insured and privately insured adults and between uninsured and privately insured adults, the differences do narrow,” they added.

As to why people were treated unfairly due to their insurance status, Gonzales said the researchers’ past work has found that patients attributed the maltreatment to the fact that “people don’t accept their insurance type, or they’re turned away because they don’t have insurance. Other potential reasons could be related to sort of the hassle of having public insurance versus private insurance — for example, having greater sorts of challenges getting authorization for specific treatments or specific medications. There’s just so many different reasons.”

People’s coverage types were not the only factor determining whether they felt they had been treated or judged unfairly, the investigators found. In unadjusted analyses, Black adults with private coverage were more likely than white adults with private coverage to report unfair treatment due to their health insurance type (3.2% vs 0.9%). Privately insured adults with family incomes at or below 138% of the federal poverty level also were more likely to report unfair treatment due to health insurance type than those with higher incomes (4.8% vs 1.1%).