Survivors of sexual assault often find themselves billed over $3,600 for emergency room medical treatment they receive because of those attacks, according to an analysis of ED visits.
Only about one-fifth of survivors seek medical care after sexual assault, and many other survivors likely avoid seeking essential medical care because they fear being billed for high out-of-pocket costs, public health researchers wrote in a letter to the editor of the New England Journal of Medicine (NEJM).
One of the authors of the letter—Steffie Woolhandler, M.D., a distinguished professor of public health and health policy in the CUNY School of Public Health at Hunter College—tells Fierce Healthcare that the U.S. healthcare system in effect re-traumatizes victims of violent sexual assault by billing them for care that should be free.
Though Woolhandler knew this was a problem, the findings in her study still surprised her.
“I think the size of the bills people are getting are shocking,” Woolhandler said. “We’re talking nearly $3,600 for the emergency room visit, and that’s a lot of money for low-income people. No victims of sexual assault should have to pay out-of-pocket for their follow-up care.”
The researchers analyzed nationwide data on 35 million ED visits in 2019, focusing on visits for which physicians included specific billing codes for care after sexual assault. The study, published in NEJM, states that 17,842 individuals who went to ERs for sexual assault in 2019 paid “often substantial costs themselves.”
Another co-author, Samuel Dickman, M.D., a physician with Planned Parenthood of Montana, tells Fierce Healthcare that the magnitude surprised him. “More than 17,000 uninsured survivors of sexual violence were expected to pay thousands of dollars out-of-pocket. It’s hard even to imagine what that experience is like, to experience a sexual assault and then to get a huge bill afterward.”
Lower-income individuals aren’t the only demographic forced to pay for their care. Victims with employer-sponsored healthcare insurance paid, on average, 14% of the cost for ER visits out-of-pocket. Woolhandler says that these costs, combined with the stigmatization of sexual assault, could prevent individuals from getting care for what might result from the attacks such as HIV or unwanted pregnancies.
In theory, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy of patients. But does it?
“People think that HIPAA does a lot of things that it doesn’t do,” says Woolhandler. For instance, 64% of U.S. employees who get healthcare benefits from their employer work for companies that are self-insured, according to the Kaiser Family Foundation. In businesses with 200 or more employees, 82% of workers are in self-insured plans.
This creates privacy problems, because the payer of insurance has a right to know what they are paying for, says Woolhandler. “If we want victims of violent sexual assault to get the care they need, we can’t take money out of their pockets, and they need to know that their employer won’t know what happened to them.”
Dickman notes that under the Violence Against Women Act (VAWA) of 1994, hospitals and insurers are “not allowed to bill victims for evidence collection, but to actually protect survivors means that they need to stop sending bills for things like emergency contraception, medications to prevent transmission of sexually transmitted infections like HIV, mental health care and treatment of physical injuries. It’s brutal and inhumane to bill survivors for that kind of treatment.”
Woolhandler has long pushed for the U.S. to adopt a single-payer system for healthcare, similar to the one in Canada. Victims of violent sexual assault in Canada will be cared for free of charge without their employer ever having to know.
The NEJM letter states that “emergency department charges may discourage the reporting of rape and seeking of medical care for both short-term and long-term sequelae of sexual assault. Incurring such charges may further harm survivors—even those with full insurance coverage—by serving to disclose a potentially stigmatizing event to parents, partners, or employers.”
The authors looked at diagnosis codes from 112,844 emergency department visits. Most of the victims were female (88.3%), with 52.7% between the ages of 18 and 44. Children 17 or younger comprised 38.2%.
Woolhandler and co-authors urge lawmakers to strengthen the provisions of VAWA to include coverage for therapeutic services for survivors and not just the collection of evidence. However, “I’m not aware of any movement in that direction,” she tells Fierce Healthcare. “Hopefully, some people will read this study and do something.”
She says that the only payer who will sometimes foot the entire bill for ER services for victims is Medicaid, but not in all cases nor in all states.
Dickman argues that “all states should expand Medicaid."
"Legislators and governors in Texas, Florida, Georgia, Wisconsin, North and South Carolina, and many other states—they refuse to accept federal dollars that would protect survivors of sexual violence. Even states with Medicaid expansion leave many victims vulnerable to catastrophically high out-of-pocket costs since insurance coverage often doesn’t cover the full cost of emergency care," he said.
The letter to the editor states that Medicaid was the expected payer for 36.2% of ER visits and private insurance, 22.1%. Sixteen percent of the victims were expected to pay out-of-pocket.
“Emergency department charges averaged $3,551; victims of sexual abuse during pregnancy incurred the highest charges ($4,553),” the authors note. “Charges for self-pay patients (which some hospitals may discount) averaged $3,673.”
Even examining victims with rape kits—that are fully covered by the VAWA—could possibly come with a price tag, as a Kaiser Family Foundation study in March found. The rape kit exam should be administered by sexual assault nurse examiners (SANEs).
“Finding a place to get a rape kit from a certified SANE can be difficult,” the KFF study noted. But many hospitals do not have such nurses on staff, and there’s no national database listing such providers. This makes it “difficult for victims who do not interact with law enforcement or a rape crisis center to know where to go,” said the KFF study. “Many survivors would likely not know that only specific providers are required to perform sexual assault forensic exams without cost-sharing.”
Woolhandler says that, “in some cases, victims who are subsequently hospitalized because of the assault will not have to pay the out-of-pocket deductible.” But that’s usually a moot point, because “most victims aren’t hospitalized.”