Improving Health Equity Across Coverage Types

American health insurance generally falls into one of two categories: public and private. Public insurance is run by and at least partially paid for by the government, while private insurance is often run by for-profit companies and paid for by employers and individuals. While all insurance types vary in how much they cost and what they cover, fairness in treatment shouldn’t vary simply based on who is or isn’t picking up the bill. Unfortunately, it sometimes does.

In September 2022, the Urban Institute’s Health Policy Center published a report which found that publicly insured and uninsured patients were more likely than other patients to believe they were treated unfairly in healthcare settings. Some believed they were treated unfairly specifically because they had Medicaid or were uninsured. While the contributing biases for that unfairness are varied, healthcare administrators and other healthcare leaders can take purposeful steps to address them.

To learn more about the importance of public health insurance, and what can be done to ensure fair treatment for publicly insured patients, read on.

Dulce Gonzalez

Dulce Gonzalez is a research associate at the Health Policy Center at the Urban Institute. She forms part of a team working on the Urban Institute’s Well-Being and Basic Needs Survey. Gonzalez conducts quantitative and qualitative research focused primarily on the social safety net, immigration, and barriers to healthcare access. Her work has also focused on the impacts of the Covid-19 pandemic on nonelderly adults and their families.

Before joining the Urban Institute, Gonzalez worked at the Georgetown University Center for Children and Families and at the nonprofit organization Maternal and Child Health Access. Gonzalez holds a BA in economics from California State University, Long Beach, and a master’s degree in public policy from Georgetown University.

Leighton Ku, PhD

Dr. Leighton Ku is a professor and director of the Center for Health Policy Research at the George Washington University School of Public Health. As a health policy researcher, public policy analyst, and advocate, his career has been built around understanding and improving access to affordable healthcare for vulnerable populations.

Among his areas of expertise are national and state health reforms, Medicaid, the Children’s Health Insurance Program (CHIP), immigrant health, and healthcare financing and budgets, emphasizing strengthening the healthcare safety net.

Dr. Ku has authored or co-authored more than 100 peer-reviewed articles and 200 other policy and translational health policy research reports. As a member of the community, he has helped develop and guide the District of Columbia’s health insurance marketplace since 2012 as a member of its Executive Board. He has also served as a senior fellow at the Center on Budget and Policy Priorities, which focuses on improving policies for low- and moderate-income Americans; as a principal researcher at the Urban Institute; and as a policy and budget analyst for the federal Women, Infants, and Children (WIC) nutrition program.

Public insurance serves a crucial role in the American healthcare system. While it comes in many varieties, the two largest forms of public insurance are Medicaid and Medicare: the former focuses on low-income people and people with disabilities, while the latter primarily covers people over the age of 65.

Health insurance coverage, whether public or private, improves access to care, supports positive health outcomes, and reduces financial strain on individuals, families, and communities (AHA). Expansion of Medicaid in various states has been associated with decreases in mortality, lower rates of depression, and reduced rates of violent crime and property crime.

Medicaid is particularly important as it largely insures people who may not be insured otherwise. Private insurance, which comes in many forms, often has substantial cost barriers, including premiums to purchase insurance and high deductibles or copayments once they are insured. Those costs can lead private patients to incur medical debts. Notably, medical debt contributes to 66.5 percent of bankruptcies in the US (AJPH 2018).

“Medicaid has very little cost-sharing for patients and relatively broad benefits, including medications and long-term care,” Dr. Ku says. “But patients sometimes encounter problems finding a doctor on a timely basis. And doctors are somewhat less likely to serve Medicaid patients, because of low fees and because Medicaid patients are often in low-income neighborhoods where fewer doctors practice.”

Dr. Ku notes that meaningfully assessing the difference in patient outcomes between publicly insured and privately insured patients can be difficult, primarily due to underlying differences in patient populations. Since Medicaid patients have lower income levels, they generally have more embedded underlying health risks, such as poverty, limited education, and poor nutrition.

Moreover, research conducted by Dr. Ku indicates that the average level of care—such as the length of a medical visit and type of care offered—is almost identical for Medicaid and privately insured patients and is very similar for uninsured patients (Health Affairs 2013).

But patients may nonetheless feel differently about the care they receive, and these feelings matter. A recent study by the Urban Institute’s Health Policy Center has found that a significant number of patients reported unfair treatment that they believed to be based on their publicly insured, or uninsured, status. It presents an opportunity to look at how healthcare leaders, providers, and administrators can improve patient care.

“Research shows unfair treatment in healthcare disproportionately affects publicly insured and uninsured patients,” Gonzalez says. “Efforts to mitigate such treatment could be beneficial for patients’ health.”

The Urban Institute study found that adults covered by public insurance, or without any insurance, were more likely to believe that they received unfair treatment in healthcare settings than those with private health insurance. On first glance, “unfair treatment” may seem like a nebulous category, but it has concrete impacts.

“We know from past research that experiencing unfair treatment in healthcare can lead to disruptions to care, such as delaying or forgoing healthcare or not following recommended treatment after experiencing negative treatment,” Gonzalez says. “Patients could also miss out on care to the extent that unfair treatment stems from providers ignoring patient concerns or altering their decisions to provide certain types of care based on perceptions that patients will not be able to afford it. Those unmet health needs could potentially lead to adverse effects to health for patients who report unfair treatment.”

Addressing unfair treatment requires understanding the underlying reasons for it. Issues germane to public health insurance, such as administrative barriers or issues with repayment and reimbursement, could explain part of it: if a provider feels they are less likely to be paid, or that it will be more difficult to get reimbursed, then that may affect the type and the quality of the care they provide. But adults in the study indicated they felt they received unfair treatment due to other reasons, such as their income, disability state, and/or race and ethnicity.

“People with public coverage or who are uninsured are disproportionately likely to be People of Color, have low-incomes, or have disabilities, among other characteristics placing them at structural disadvantage, so it is possible that people with these types of coverage are facing unfair treatment along multiple dimensions,” Gonzalez says. “Some potential strategies to mitigate provider biases could include collecting patient satisfaction surveys that include questions about unfair treatment, making those results public, and holding providers and their staff accountable for providing culturally competent care and quality customer service to patients regardless of their background.”

Unfair treatment is not limited to the publicly insured and uninsured. New and aspiring healthcare leaders can play an important role in improving health equity for people of all coverage types.

“Providers and administrators need to be respectful of patients and to try to see things from the patients’ perspectives,” Dr. Ku says. “But this can be tough in our complex healthcare systems, which are so focused on standards of efficiency. Healthcare can learn from other service industries about how to be more customer-centric.”

In March 2023, North Carolina became the 40th state to adopt Medicaid expansion (AP). As more people come under the umbrella of public insurance, it’s up to providers and administrators to provide them with the same care and fairness of treatment they afford all other patients. Each newly insured patient brings America one step closer to greater health equity by improving access and reducing disparities (KFF 2021).

“I am heartened that the state of North Carolina has come up with a bipartisan compromise to expand Medicaid,” Dr. Ku says. “But my home state of Texas still refuses to expand Medicaid, even though it has the highest percentage of people without health insurance. One thing we know for sure is that having health insurance, whether Medicaid or private insurance, is better for the patient than being uninsured.”