What if “free” preventive care wasn’t really free for everyone?

by Jon Scaccia January 29, 2025

For many Americans, the Affordable Care Act (ACA) promised cost-free preventive services, from cancer screenings to routine check-ups. Yet, a groundbreaking study reveals that 40% of these encounters still result in out-of-pocket (OOP) costs for patients, often in unexpected and inequitable ways. This issue is more than an inconvenience—it has profound implications for public health and equity.

The ACA’s Promise and Reality

The ACA aimed to remove financial barriers to preventive care by exempting these services from cost-sharing. The idea was simple: by reducing the upfront costs, more people would seek preventive care, leading to better health outcomes and lower long-term health costs.

However, administrative complexities and insurance practices have undermined this vision. Between 2017 and 2020, researchers examined over 1.7 million preventive care encounters among privately insured adults. Their findings? Nearly half of these services led to unexpected OOP costs, with significant disparities tied to income, education, and race.

Breaking Down the Numbers: Who Pays, and How Much?

Let’s start with the overall picture. Among those who incurred costs, the average bill was $113, though half of patients paid $36 or less. But these averages obscure deeper inequities.

• Income Disparities: Patients in the lowest income brackets were less likely to receive a bill than wealthier patients, but when they did, the amounts were disproportionately higher—up to 33% more.
• Educational Differences: Patients with only a high school diploma were 9.4% more likely to face OOP costs than those with college degrees. However, their bills were typically smaller, reflecting differences in the types of services accessed.
• Racial Inequities: Non-Hispanic Black patients were both more likely to be billed and to pay higher amounts than their non-Hispanic White counterparts. Meanwhile, Hispanic patients saw fewer and smaller bills, though these findings varied depending on how the data was analyzed.

Why Do These Disparities Exist?

The study points to several possible explanations:

1. Insurance Plan Quality: Lower-income and less-educated patients may enroll in less generous insurance plans with stricter limits on preventive care coverage. These plans are more likely to misprocess claims or exclude services that should be covered under the ACA.
2. Provider Practices: Patients from marginalized groups may disproportionately visit providers with billing practices that result in more frequent or higher OOP costs.
3. Systemic Barriers: Language differences, health literacy gaps, and even algorithmic biases in claims processing could exacerbate these inequities.
4. Positive Test Results: While preventive screenings are typically covered, follow-up procedures after a positive test may not be, leading to unexpected costs. For instance, a free colorectal cancer screening can result in significant bills if additional diagnostic procedures are required.

The Real-World Impact: Why This Matters

These financial barriers don’t just affect bank accounts—they deter future care. Imagine being a low-income patient who receives an unexpected $200 bill for a routine screening. The likelihood of scheduling another preventive service drops dramatically. Over time, this avoidance contributes to worse health outcomes and perpetuates cycles of inequity.

Moreover, the study highlights the erosion of trust in the healthcare system. When patients feel blindsided by unexpected bills, they’re less likely to believe that providers and insurers have their best interests at heart.

What Can Be Done?

The findings underscore an urgent need for action:

• Policy Revisions: Policymakers should tighten enforcement of the ACA’s cost-sharing exemptions, ensuring consistency across insurance plans and providers.
• Transparency in Billing: Clearer communication between providers, insurers, and patients about what is and isn’t covered could help reduce surprises.
• Targeted Interventions: Efforts to improve health insurance literacy, particularly among at-risk groups, could empower patients to navigate the system more effectively.
• Equity Audits: Healthcare systems and insurers should regularly audit their practices to identify and address disparities in OOP costs.

What’s Next?

This study lays the groundwork for future research and policy change. Key questions remain: How do these disparities differ between employer-sponsored and ACA Marketplace plans? To what extent do provider-level factors versus systemic biases drive these inequities? Addressing these gaps will be critical to promoting equitable access to preventive care.

Join the Conversation

What do you think about these findings? Have you or someone you know faced unexpected bills for preventive care? How can policymakers, providers, and insurers work together to create a more equitable system? Share your thoughts in the comments below or join the discussion on social media using #PreventiveCareEquity.

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