What happens to primary care physicians when patients don’t have health insurance?

As health insurance becomes more expensive for some patients and unaffordable for others, primary care practices could see a reduction in volume of patients.

Downstream effects on health could grow worse for patients who skip their regularly scheduled check-ups and screenings, said an analyst at the Johns Hopkins Bloomberg School of Public Health.

On Jan. 22, Professor Gerard Anderson, PhD, and distinguished scholar Elizabeth Fowler, PhD, met online with media to discuss their latest analyses of health insurance policy at the federal level. During the COVID-19 pandemic, the federal government approved premium subsidies that made health insurance more available through the Affordable Care Act Marketplaces. Those subsidies were extended after the pandemic but expired this year, and the sector has been watching Washington, D.C., to see if lawmakers might pass them again, or adopt other ways to help people pay for medical services.

“It is a real problem that if people don't have insurance, or if they have very high deductible health plans, they're going to say, do I really need to make that physician visit, especially to a primary care physician? Maybe I can put off that primary care visit for another year and not get the checkup, do all sorts of things like that,” said Anderson, a researcher of health care spending, Medicare and Medicaid policy, and management of chronic conditions. He used the example of a woman skipping a screening.

“I mean, if I'm a woman and I don't get the breast exam, it's another year that potentially the cancer grows, so you need to go see your primary care physician,” he said.

As for physicians, they likely will continue to see sick patients because sick patients need the care, Anderson said. Routine services are more likely to drop in volume, but those are not particularly well-paid services to the physician, so doctors “will do generally OK,” he said.

Financial effects on patients

There’s a financial effect as well, Fowler said, because medical debt is one of the most frequent causes of bankruptcy in the nation. Up to 65% of personal bankruptcies are tied to unpaid medical bills, and the medical debt also hurts patient credit ratings.

“So I think there are very real impacts that could happen for people who are unable to pay their health care bills,” she said.

Where’s the preventive care?

Anderson repeated the importance of preventive services and the role that primary care physicians and other clinicians play in patient health, and thus the health of the nation. When patients skip mammograms or prostate cancer screenings, they may face a worse diagnosis in a year’s time or five years later. Those medical conditions could have been treated earlier, but the later treatment is likely to leave the patient with a greater expenditure, he said.

The United States spends an estimated 2% to 3% of the health care dollar on prevention. Other developed nations spend more and have longer life expectancy and better health, Anderson said.

“If we have a system where we really don't provide emphasis on primary care, we're going to see a continued decline in life expectancy, as we've seen recently,” he said. “And so we need to do something to deal with that particular issue.”

Federal payments to patients for health care

Fowler served as Medicare deputy administrator and director of the Innovation Center of the Centers for Medicare & Medicaid Services under President Joe Biden. She critiqued the proposal by President Donald J. Trump to offer money for patients to put in health care savings accounts.

“The president's proposal takes a different approach to addressing affordability, to give money directly to people rather than reducing the rate or the cost of insurance itself,” Fowler said. “Giving people money through a health savings account, a health reimbursement account or a flexible spending account is really not the same as providing health coverage. These approaches might work for people with higher means, or people who are relatively healthy and don't incur any health costs in the near term.”

But for patients with cancer, anticipating surgery, with a child with special medical needs, or managing a chronic condition, payments of $1,000 or $5,000 won’t come close to covering costs, she said. Even one visit to the emergency department could wipe out the account.

Show us the details

There are many unanswered questions about the president’s plan. There are no details about who qualifies and if amounts would be adjusted based on geography, because health care has different prices in different parts of the country, Fowler said. Financial awards to patients could vary based on age, family size, income, employment status, she said, and it’s unclear how the money would be distributed. Any financial program will draw a potential level of fraud and abuse, Fowler said. She noted asking questions about health care costs, and searching for ways to address fraud, abuse and waste, is the right approach.