Publicly insured and uninsured patients more often report unfair treatment during care, Urban Institute finds

Adult patients with public or no insurance more often said they were treated unfairly by healthcare providers than those with private insurance, according to a recent research report from the Urban Institute.

Pulling on survey data from more than 9,000 nationwide respondents, the think tank found that public coverage and uninsured patients who more frequently reported unfair treatment said it stemmed directly from their coverage type as well as for other reasons including race or ethnicity.  

“Understanding who is experiencing unfair treatment and patients’ perceptions of why they are being treated unfairly is necessary so that policymakers and payers can implement effective policies to prevent such treatment,” Urban Institute researchers wrote in their report, which was supported by the Robert Wood Johnson Foundation.

The differences in these patients’ unfair treatment reports were “narrow” but persisted after adjustment for demographic, socioeconomic, health and geographic characteristics, researchers wrote.

At the same time, the team found reports of unfair treatment due to health coverage were even greater among respondents who had a disability, a physical health condition or a behavioral health condition.

“These populations often have elevated health care needs, but these negative experiences and the resulting lack of trust in the health care system could be deterring them from getting needed care,” researchers wrote.

Coverage-based unfair treatment could be a result of negative perceptions, “resulting in providers and their staff shaming, ignoring or otherwise disrespecting these patients,” the researchers explained.

It could also affect clinical decisions if a provider believes a patient wouldn’t be able to pay for care, including follow-up visits or test recommendations, they wrote, or lead to scheduling or payment hassles from providers who don’t want to deal with certain structural aspects of the Medicaid program such as lower reimbursement rates or additional administrative hurdles.

Addressing these drivers of unfair treatment would require increased attention toward addressing Medicaid barriers, care affordability and the delivery of culturally competent care, researchers wrote.  

“Identifying policy solutions to address unfair treatment will depend on further work to understand the extent to which such treatment is related to these reasons,” the Urban Institute wrote in a brief accompanying the report.

The Urban Institute’s report reviewed responses from 9,067 adults aged 18 to 64 years who participated in the think tank’s annual Health Reform Monitoring Survey in April 2021, which it weights to match national demographic characteristics.

Researchers grouped respondents who had a full year of private, public or no health insurance coverage and asked them to describe any unfair treatment they received at a doctor’s office, clinic or hospital. Overall, 9.8% of respondents reported unfair treatment or judgment in the preceding year.

The team found those with public coverage (17.4%) or the uninsured (13.9%) were more than twice as likely as those with private coverage (6.4%) to say they experienced any unfair treatment. Those two groups were also more than five times as likely to report unfair treatment attributed to coverage type (9.6% and 7.4% compared to 1.3%).

Unfair treatment due to coverage as well as another reason was most common among those with public coverage (7.8%) followed by the uninsured (5.7%), both of which were significantly higher than those with private coverage (1%), according to the study. Income (5.9%), disability/health condition (4.6%) and race/ethnicity (2.6%) were the most common additional reasons cited by respondents.

Additionally, the researchers found that adults with public coverage (16.2%) were significantly more likely to say they had an unmet care need due to insurance-related hassles than those with private coverage (11%).

“These patterns suggest that, on average, adults experience greater hassles associated with having Medicaid coverage relative to private insurance, which, in turn, could be interpreted by patients as unfair treatment,” researchers wrote.

The researchers acknowledged the reliance on self-reported experiences as a potential limitation, as patients could attribute their unfair treatment to insurance type rather than other overlapping factors. The focus on unfair treatment within the previous 12 months could also lead to underreporting among those who hadn’t seen a provider within the past year, they wrote.