Managing Patients Who Are Uninsured-by-Choice

While one in 10 individuals living in the United States do not qualify for health insurance by way of the Affordable Care Act, there is a large number of Americans who, by choice, have elected to forgo health insurance even though it is available to them.

For healthcare providers, the uninsured-by-choice represent a missed opportunity, but while the door is closed to 2014, the time is now to educate their self-pay population in preparation for the 2015 enrollment period.

According to polling data and anecdotal evidence, the main reasons the uninsured-by-choice did not get coverage are:

• Perceived too expensive. For many, the cost of insurance outstrips their budget or their desire to pay, and the penalty for not signing up ($95 or 1 percent of income, whichever is greater) is a price this group is willing to pay. A New York Times/CBS News poll of uninsured individuals who already had decided to not get coverage found that half made their decision because they believed the cost for insurance was too high.
• Inability/unwilling to navigate signup process.  Many became frustrated with the online registration process, the problems of which had been well documented. While the problems with the federal exchange were eventually resolved, exchanges in many states, such as Oregon and Maryland, have never worked. Many became frustrated and gave up, even though they could have purchased insurance over the phone or in person.
• Politically opposed to the ACA. The aforementioned New York Times/CBS News poll found that three in 10 individuals who elected not to get insurance did so on political grounds.
• Believe they do not need it. One of the groups targeted by states and the federal government was young people ages 26-34. The objective was to get one-third of the eligibles in this group to sign up for insurance, and when the counting was done, the actual figure was less than 28 percent. Anecdotal evidence suggests that those who elected not to get insurance did so because they perceived they would not need it.

In addition, there are those who qualify for Medicaid, but have yet to be officially enrolled, and will be required to wait several months to process their application and enter the program.

Providers Need to Maintain Education Efforts

For healthcare providers, every contact point with an uninsured-by-choice patient represents an opportunity to correct that behavior for a lifetime. The key to getting a patient to change and purchase insurance requires that you first know exactly why they have elected not to obtain coverage.

For patient financial services and patient access staff, once the reason for lacking insurance is identified, an appropriate course of action can be determined. For example, for those individuals who were stymied or frustrated with the application process, one option would be to extend the offer to guide them through it during the next open enrollment period. For those who perceive it as too expensive, walk them through their insurance options to make certain they have not overlooked subsidies or have reviewed all the possible plans and their corresponding prices.

The most difficult patients to educate are those politically opposed to purchasing insurance and those who believe they don’t need it. In the latter case, if a provider is in contact with them, it is usually because they are seeking medicare services, so a compelling case can be made at that time how having insurance would have benefitted them. For the former group, it may be impossible to change their mind, but by at least presenting the facts of the benefits of having health insurance may prove useful.