Preventive Care, Hidden Costs: Unearthing Disparities

by Jon Scaccia January 31, 2025

Imagine this scenario: you go for a routine health screening, assured by your health plan that it’s covered under the Affordable Care Act (ACA). Then, weeks later, a bill arrives—unexpected and unwelcome. For many Americans, this isn’t just a frustrating surprise; it’s a barrier that keeps them from seeking future care. New research reveals how these hidden out-of-pocket (OOP) costs for preventive services are not just a financial nuisance but a driver of inequity in healthcare access.

In this blog, we’ll explore a recent study that shines a light on how demographics—such as income, education, and race—play a significant role in determining who pays for preventive care and how much they pay. The findings reveal a complex web of disparities that policymakers and practitioners must address to ensure equitable access to essential healthcare.

The Promise and Pitfalls of Preventive Care

The ACA was heralded for its promise to make preventive care more accessible by eliminating cost-sharing for insured individuals. Screenings for breast cancer, diabetes, and depression, as well as contraceptive services, are among the many preventive measures that should come at no cost to patients. Yet, administrative inefficiencies and insurer policies mean that more than 40% of preventive care encounters still result in OOP costs.

This reality has significant consequences: unexpected bills can discourage people—especially those from marginalized groups—from seeking future care. The research we’ll examine dives deep into who bears these costs and why the burden falls unevenly across populations.

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

The study analyzed over 1.7 million preventive care encounters involving more than a million privately insured individuals across the U.S. between 2017 and 2020. Here are the key takeaways:

1. Income Inequities
   • Households earning less than $30,000 annually were less likely to incur OOP costs compared to high-income households. However, when these lower-income households did face bills, they paid significantly more—an average of $11.76 higher per service.
   • This disparity may reflect differences in insurance plan generosity, with lower-income individuals potentially opting for plans with lower premiums but higher OOP expenses.
2. Educational Gaps
   • Patients with lower education levels (high school diploma or less) were 9.4% more likely to receive a bill than those with college degrees. However, their bills tended to be smaller, possibly due to receiving less comprehensive care.
   • This pattern underscores how health literacy and familiarity with navigating insurance systems influence both healthcare access and financial outcomes.
3. Racial and Ethnic Disparities
   • Non-Hispanic Black patients were 2.2% more likely to incur OOP costs than non-Hispanic White patients and faced larger bills when they did.
   • Hispanic patients, in contrast, were less likely to incur costs and paid smaller amounts. This variability suggests systemic factors, such as provider billing practices or insurance coverage differences, may be at play.
4. Service-Specific Variations
   • The average OOP cost across all preventive services was $113, but certain services, like colorectal cancer screening, carried significantly higher price tags. The cost of necessary equipment, such as surgical trays, often contributes to these unexpected bills.

What’s Driving These Disparities?

The study points to several potential culprits for these inequities:

• Insurance Plan Design: At-risk populations often enroll in plans with restrictive coverage, increasing the likelihood of bills for services that should be covered.
• Provider Practices: Some providers may miscode preventive services as diagnostic, leading to unexpected charges.
• Systemic Barriers: Language barriers, health literacy gaps, and even algorithmic biases in claims processing may exacerbate disparities.
• Trust Erosion: Receiving unexpected bills can undermine patients’ trust in the healthcare system, discouraging them from seeking preventive care in the future.

The Real-World Impact: A Case Study

Consider Maria, a 35-year-old Latina woman earning $28,000 a year. Encouraged by her health plan’s promise of free preventive care, she schedules a mammogram. Weeks later, she’s hit with a $150 bill for what was supposed to be a covered service. Confused and frustrated, Maria decides to skip her follow-up appointment.

Maria’s story illustrates how financial barriers and systemic inefficiencies disproportionately affect marginalized groups. Her decision to forego future care could have serious implications for her health outcomes.

What’s Next? Toward Equitable Preventive Care

Addressing these disparities requires a multi-faceted approach:

1. Policy Interventions: Policymakers should enforce stricter guidelines to ensure preventive services are truly cost-sharing exempt. Additional safeguards are needed to standardize billing practices and prevent insurers from passing unexpected costs onto patients.
2. Health Literacy Programs: Educating patients about their insurance benefits and empowering them to advocate for cost-free preventive care can help reduce inequities.
3. Provider Accountability: Healthcare providers must receive training to accurately code and bill preventive services. Transparency in billing practices is essential to restoring patient trust.
4. Data-Informed Solutions: Future research should explore the root causes of these disparities, particularly the role of insurance plan differences and systemic biases. Comprehensive data collection and analysis can guide more effective interventions.

Join the Conversation

Preventive care is a cornerstone of public health, but its promise is undermined when financial barriers persist. How can we ensure that all patients—regardless of income, education, or race—can access the care they need without fear of unexpected costs?

• Have you or someone you know faced unexpected medical bills for preventive care?
• What steps should insurers and policymakers take to eliminate these inequities?
• How can public health practitioners advocate for more equitable healthcare systems?

Share your thoughts in the comments or join the conversation on social media using #HealthEquity and #PreventiveCare. Together, we can work toward a future where preventive care is accessible, affordable, and equitable for all.

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