HEALTH POLICY CENTER Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Publicly Insured and Uninsured Patients Are More Likely Than Other Patients to Be Treated Unfairly in Health Care Settings Because of Their Coverage Type Dulce Gonzalez, Genevieve M. Kenney, Claire O'Brien, Marla McDaniel, and Michael Karpman September 2022 In an ideal world, the type of health insurance people can or cannot afford should not determine how health care providers and their staff members behave toward patients when they seek care. Yet some patients who are uninsured or have public coverage, such as Medicaid, report experiencing unfair treatment because of their coverage type or ability to pay when seeking health care (Allen et al. 2017; Han et al. 2015; Martinez- Hume et al. 2017; McDaniel et al. 2021; Nong et al. 2020; Tajeu et al. 2015). Experiences of unfair treatment or judgment in health care settings due to insurance type have been associated with unmet health needs (Alcala et al. 2020; Han et al. 2015) that can result in poorer health care quality, undermine patient health and well-being, and contribute to health inequities by race and ethnicity (Institute of Medicine et al. 2003). Unfair treatment due to health insurance type could have many causes, including bias and discrimination on the part of providers and office staff members. Patients with Medicaid coverage or who are uninsured may encounter providers who have negative perceptions about uninsured and publicly insured people, resulting in providers and their staff shaming, ignoring, or otherwise disrespecting these patients (Arpey, Gaglioti, and Rosenbaum 2017; Hume et al. 2017). Providers may also alter their clinical decisions if they perceive, based on the patient's health insurance type or lack of insurance, that a patient may be unable to pay for services (Meyers et al. 2006). For the uninsured, provider attitudes could be related to concerns about a patient's ability to pay for care, the prospect of providing uncompensated care, or a patient's ability to afford follow-up visits, recommended tests, and prescription drugs (Allen et al. 2014; Allen et al. 2017; Han et al. 2015; Martinez-Hume et al. 2017; Tajeu et al. 2015). Provider perceptions of or experiences with structural aspects of the Medicaid program may also drive unfair treatment. These aspects include Medicaid's lower provider payment rates relative to those of private insurers and administrative hassles associated with billing and prior authorization that make serving a Medicaid-insured population more time consuming and costly (MACPAC 2021). Patients may also perceive difficulties with finding providers who will accept them as patients, scheduling appointments in a timely way, and requiring upfront payment as unfair treatment; these experiences are more common for publicly insured and uninsured patients than for those who are privately insured (Gotlieb, Rhodes, and Candon 2021; Hsiang et al. 2019; Kenney et al. 2014; Oostrom, Einav, and Finkelstein 2017). Understanding who is experiencing unfair treatment and patients' perceptions of why they are being treated unfairly is necessary so that policymakers and payers can implement effective policies to prevent such treatment. Our study provides a national picture of the extent to which privately insured, publicly insured, and uninsured patients perceive they are being treated unfairly because of their coverage type and other reasons when seeking care. Drawing on data from the 2021 Health Reform Monitoring Survey (see the Data and Methods section), we assess how the share of nonelderly adults experiencing unfair treatment or judgment because of their health insurance type at a doctor's office, clinic, or hospital (henceforth "health care settings") in the prior year varies by their coverage type (i.e., full-year private coverage, full-year public coverage, and full-year uninsurance). The highlights of our study include the following:  Adults with public coverage and those who were uninsured were more than twice as likely as adults with private coverage to report that they had experienced unfair treatment for one or more reasons (17.4 percent and 13.9 percent versus 6.4 percent).  Adults with public coverage and those who were uninsured were also more likely than adults with private coverage to report experiencing unfair treatment because of health insurance and another reason. » Among publicly insured adults who reported being treated unfairly because of their health insurance type and another reason, the most common other reasons were income, a disability or a health condition, and race or ethnicity.  Adults with public health insurance coverage and those who were uninsured were more than five times as likely as adults with private coverage to report that they had experienced unfair treatment or judgment in health care settings in the prior year because of their health insurance coverage type (9.6 percent and 7.4 percent versus 1.3 percent). » After adjusting for observed demographic, socioeconomic, health, and geographic characteristics of nonelderly adults in our sample, differences in the shares of people reporting unfair treatment due to health insurance coverage type remain between publicly insured and privately insured adults and between uninsured and privately insured adults. However, the differences do narrow. 1 2 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY  Having a disability, a physical health condition, or a behavioral health condition was also associated with a greater likelihood of reporting unfair treatment due to health insurance coverage both when adjusting and not adjusting for selected demographic and other characteristics.  Adults with public coverage were also more likely to report insurance-related hassles than those with private coverage (16.2 versus 11.0 percent), after adjusting for observed differences between privately and publicly insured adults. Our study finds that adults with public insurance coverage and those who are uninsured are more likely to experience unfair treatment in health care settings than those with private health insurance coverage, which they partly attribute to their health insurance type. Increasing provider payment in Medicaid and reducing administrative barriers that providers face with Medicaid could help reduce these differences. 2 But publicly insured and uninsured adults also indicate that they experience unfair treatment at higher rates than those with private insurance for other reasons, such as their income, disability status, and race and ethnicity. Thus, other factors beyond concerns about payment and administrative barriers appear to be eroding the quality of care Medicaid-covered and uninsured patients receive and their interactions with the health care system and providers. As such, addressing payment and administrative barriers is likely necessary but insufficient for reducing the treatment inequities these patients experience. More exploration is needed to assess the roles insurance-related hassles and differential access to care play in shaping people's perceptions of unfair treatment due to insurance type. Recognizing and addressing the discrimination and bias that underlie experiences of unfair treatment or judgment in health care settings will be important for improving health care services across all insurance types. Results Adults with public coverage and those who were uninsured were more than twice as likely as those with private coverage to report unfair treatment due to one or more reasons and to report unfair treatment due to health insurance and another reason. Overall, 9.8 percent of nonelderly adults reported that they experienced unfair treatment in a health care setting in the prior year because of one or more of the following reasons: racial or ethnic background, country of origin, primary language, a disability, a health condition, gender or gender identity, sexual orientation, health insurance coverage type, income level, or some other reason (figure 1). Adults with public coverage and those who were uninsured were more than twice as likely as adults with private coverage to report that they had experienced unfair treatment for one or more reasons (17.4 percent and 13.9 percent versus 6.4 percent). Among the 9.8 percent of adults who reported unfair treatment due to any reason, roughly one- third (3.6 percent) said they were treated unfairly because of their health insurance type, either alone or in combination with one or more other reasons. This includes 2.8 percent of adults who were treated unfairly because of their health insurance type and one or more other reasons and 0.8 percent who PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 3 were treated unfairly only because of their health insurance type. Adults with public coverage and those who were uninsured were more likely than those with private coverage to report unfair treatment due to their health insurance type in combination with one or more other reasons (7.8 percent and 5.7 percent versus 1.0 percent). FIGURE 1 Share of Adults Ages 18 to 64 Reporting Unfair Treatment or Judgment in Health Care Settings in the Past 12 Months, Overall and by Health Insurance Type, April 2021 Treated unfairly but not because of health insurance type Treated unfairly because of health insurance type and one or more other reasons Treated unfairly because of health insurance type only 17.4%*** 13.9%***^ 7.8%*** 9.8% 6.5% 6.4% 6.1% 7.8%*** 9.6% 5.7%*** 5.1% 7.4% 2.8% 3.6% 0.8% 1.0% 1.3% 1.8%*** 1.7%*** Private coverage Public coverage Uninsured All adults By health insurance type URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Notes: Estimates by health insurance type are based on adults with the same coverage type all year. The shares of adults reporting unfair treatment due to health insurance alone or in combination with another reason add up to the total share of adults reporting unfair treatment due to health insurance. The share of adults with private coverage who reported unfair treatment only because of health insurance is 0.3 percent. Adults could have reported unfair treatment due to one or more of the following: racial or ethnic background, country of origin, primary language, a disability, a health condition, gender or gender identity, sexual orientation, health insurance coverage type, income level, or some other reason. */**/*** Estimate differs significantly from that for adults with private coverage at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^ Estimate differs significantly from that for adults with public coverage at the 0.10/0.05/0.01 level, using two-tailed tests. Among publicly insured adults who reported being treated unfairly because of their health insurance type and another reason, the most common other reasons were income (5.9 percent), a disability or health condition (4.6 percent), and race or ethnicity (2.6 percent; table 1). Adults with public insurance were more likely than those with private insurance and those who were uninsured to report that they experienced unfair treatment because of their coverage type and income level (5.9 percent versus 0.7 percent and 3.7 percent), health insurance and a disability or health 4 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY condition (4.6 percent versus 0.5 percent and 1.7 percent), and health insurance and racial or ethnic background (2.6 percent versus 0.5 percent and 1.4 percent). Among adults with private health insurance coverage, those with family incomes below 250 percent of the federal poverty level (FPL) were more likely than those with higher incomes to report that they experienced unfair treatment because of their coverage type and income level (3.4 versus 0.5 percent), coverage type and a disability or health condition (2.7 versus 0.4 percent), and coverage type and racial or ethnic background (2.9 versus 0.4 percent; data not shown). TABLE 1 Share of Adults Ages 18 to 64 Reporting Unfair Treatment or Judgment in Health Care Settings Due to Health Insurance Type and One or More Other Reasons in the Past 12 Months, by Health Insurance Type, April 2021 Health Insurance Type Private Public coverage coverage Uninsured Treated unfairly for the following reasons (%) Health insurance and one or more other reasons 1.0 7.8*** 5.7*** Health insurance and income level 0.7 5.9*** 3.7***^ Health insurance and a disability or health condition 0.5 4.6*** 1.7***^^^ Health insurance and racial or ethnic background 0.5 2.6*** 1.4*^^ Health insurance and another reason 0.7 3.5*** 2.5*** Sample size 5,369 1,517 739 Source: Health Reform Monitoring Survey, April 2021. Notes: Estimates are based on adults with the same coverage type all year. "Another reason" includes respondents who reported being treated unfairly because of country of origin, primary language, gender or gender identity, sexual orientation, or some other reason. */**/*** Estimate differs significantly from that for adults with private coverage at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^ Estimate differs significantly from that for adults with public coverage at the 0.10/0.05/0.01 level, using two-tailed tests. Adults with public health insurance coverage and those who were uninsured were more than five times as likely as adults with private coverage to report that they had experienced unfair treatment or judgment in health care settings because of their coverage type. Overall, 3.6 percent of nonelderly adults reported that they experienced unfair treatment or judgment in health care settings in the prior 12 months because of their health insurance type (figure 2). Adults with public coverage and those who were uninsured were more than five times as likely as adults with private coverage to report that they had experienced unfair treatment for this reason (9.6 percent and 7.4 percent versus 1.3 percent). Adults who were uninsured for part of the year reported unfair treatment due to coverage type at a rate similar to that for adults uninsured all year (8.4 versus 7.4 percent; data not shown). Similarly, adults insured all year but with multiple coverage types reported a similar rate of unfair treatment due to health insurance type as adults with private coverage only (1.9 versus 1.3 percent; data not shown). 3 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 5 When considering only people who sought care for themselves in the past 12 months, we see similar patterns. About 3.8 percent of all adults, 1.4 percent of adults with full-year private coverage, 10.1 percent of adults with full-year public coverage, and 9.7 percent of adults uninsured all year reported unfair treatment due to their health insurance type (data not shown). 4 FIGURE 2 Share of Adults Ages 18 to 64 Reporting Unfair Treatment or Judgment in Health Care Settings Due to Health Insurance Type in the Past 12 Months, Overall and by Health Insurance Type, April 2021 9.6%*** 7.4%*** 3.6% 1.3% Private coverage Public coverage Uninsured All adults By health insurance type URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Notes: Estimates by health insurance type are based on adults with the same coverage type all year. */**/*** Estimate differs significantly from that for adults with private coverage at the 0.10/0.05/0.01 level, using two-tailed tests. After adjusting for observed demographic, socioeconomic, health, and geographic characteristics of nonelderly adults in our sample, differences in the shares of people reporting unfair treatment due to health insurance coverage type remain between publicly insured and privately insured adults and between uninsured and privately insured adults. However, the differences do narrow. People's coverage types were not the only factor determining whether they felt they had been treated or judged unfairly because of their coverage type. In unadjusted analyses, Black adults with private coverage were more likely than white adults with private coverage to report unfair treatment due to their health insurance type (3.2 versus 0.9 percent; table 2). Privately insured adults with family incomes at or below 138 percent of FPL were more likely to report unfair treatment due to health insurance type than those with higher incomes (4.8 versus 1.1 percent). 6 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY TABLE 2 Unadjusted Share of Adults Ages 18 to 64 Reporting Unfair Treatment or Judgment in Health Care Settings Due to Health Insurance Type in the Past 12 Months, by Health Insurance Type and Selected Characteristics, April 2021 Health Insurance Type Private coverage Public coverage Uninsured All adults (%) 1.3 9.6 7.4 Demographic characteristics (%) Gender Women^ 1.3 10.7 9.5 Men 1.3 7.8 5.1* Age 18–34^ 1.2 8.8 - 35–49 1.6 11.9 8.9 50–64 1.1 8.5 - Race/ethnicity White^ 0.9 9.8 9.1 Black 3.2** 10.0 - Hispanic/Latinx 1.8 9.4 7.2 Additional races 1.6* - - Socioeconomic characteristics (%) Family income At or below 138% of FPL^ 4.8 9.9 8.2 Above 138% of FPL 1.1*** 9.0 6.6 Educational attainment High school degree or less^ 1.8 8.1 7.1 Some college or more 1.1 12.3** 8.0 Geographic characteristics (%) Region Northeast^ 1.4 6.3 - Midwest 1.0 10.0* - South 1.3 10.5** 8.1 West 1.6 10.4 - Urban or rural residence Lives in urban area^ 1.3 10.2 7.4 Does not live in urban area 1.2 6.6* - Sample size 5,369 1,517 739 Source: Health Reform Monitoring Survey, April 2021. Notes: FPL is federal poverty level. - represents estimates suppressed because of sample size restrictions. Estimates are based on adults with the same coverage type all year. People who are Black, white, and additional races are not Hispanic/Latinx. */**/*** Estimate differs significantly from that for the reference group (^) at the 0.10/0.05/0.01 level, using two-tailed tests. Among adults with public coverage, those with some college education or a college degree were more likely than those with lower educational attainment to report unfair treatment (12.3 versus 8.1 percent). Adults with public coverage in the Midwest and the South were more likely than those in the Northeast to report unfair treatment due to insurance type (10.0 percent and 10.5 percent versus 6.3 percent). The distribution of Black and Hispanic/Latinx populations likely explains some of these geographic patterns. For example, Black adults, who constitute a disproportionate share of the PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 7 Medicaid population, are more likely to live in the South (Tamir 2021). 5 Among uninsured respondents, women reported unfair treatment due to health insurance type at higher rates than men (9.5 versus 5.1 percent). Among both publicly insured and privately insured adults, those with a disability, a physical health condition, or a behavioral health condition were much more likely than such adults without disabilities or who lacked these health conditions to report that they experienced unfair treatment because of their health insurance coverage type (table 3). Similarly, both publicly insured and privately insured adults in fair or poor health were more likely than such adults in excellent or very good health to report experiencing unfair treatment because of their coverage type. Uninsured adults with a physical health condition were four times as likely as those without a physical health condition to report experiencing unfair treatment because of their coverage type. TABLE 3 Unadjusted Share of Adults Ages 18 to 64 Reporting Unfair Treatment or Judgment in Health Care Settings Due to Health Insurance Type in the Past 12 Months, by Health Insurance Type and Selected Health Characteristics, April 2021 Health Insurance Type Private coverage Public coverage Uninsured All adults (%) 1.3 9.6 7.4 Disability status (%) Has a disability^ 6.6 14.8 - Does not have a disability 0.9*** 7.0*** 6.7 Presence of physical health condition (%) Has a physical health condition^ 1.7 12.4 15.4 Does not have a physical health condition 0.9** 4.9*** 3.8*** Presence of behavioral health condition (%) Has a behavioral health condition^ 2.5 14.3 - Does not have a behavioral health condition 0.9*** 5.1*** 4.6 Health status (%) Excellent or very good^ 1.1 6.2 3.4 Good 1.2 9.8 8.5* Fair or poor 3.1** 12.3*** - Sample size 5,369 1,517 739 Source: Health Reform Monitoring Survey, April 2021. Notes:- represents estimates suppressed because of sample size restrictions. Estimates are based on adults with the same coverage type all year. */**/*** Estimate differs significantly from that for the reference group (^) at the 0.10/0.05/0.01 level, using two-tailed tests. When we adjust for observed demographic, socioeconomic, health, and geographic characteristics of nonelderly adults in the sample, we still find that those with public coverage and those who were uninsured were more likely than those with private coverage to report unfair treatment due to their health insurance type in the prior 12 months. But the difference in this measure between those with public versus private coverage decreases from 8.3 to 4.8 percentage points, and the difference between 8 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY uninsured adults and those with private coverage decreases from 6.1 to 5.6 percentage points (table 4). This suggests that differences in the characteristics of privately insured, publicly insured, and uninsured adults partly explain the differences in reported unfair treatment due to health insurance type between these groups. However, that differences in reported unfair treatment remain significant even after adjusting for these characteristics suggests other factors may contribute to the discrepancies. TABLE 4 Regression Coefficients Associated with Unfair Treatment or Judgment in Health Care Settings Due to Health Insurance Type among Adults Ages 18 to 64 Who Were Publicly Insured, Privately Insured, or Uninsured, April 2021 Treated unfairly because of health insurance type in the past 12 months Health insurance coverage type Has public coverage 0.048*** Is uninsured 0.056*** Demographic characteristics Men -0.005 Ages 18 to 34 0.001 Ages 35 to 49 0.012* Black 0.011 Hispanic/Latinx -0.001 Additional races 0.004 Socioeconomic characteristics Family income at or below 138% of FPL 0.014* Less than high school degree 0.002 High school degree -0.008 Some college 0.003 Bilingual or speaks Spanish 0.009 Health characteristics Has a disability 0.050*** Has a physical health condition 0.018*** Has a behavioral health condition 0.029*** Good health status 0.001 Fair/poor health status 0.012 Geographic characteristics Midwest 0.003 South 0.005 West 0.009 Lives in an urban area 0.011* Constant -0.026 N 7,625 Source: Health Reform Monitoring Survey, April 2021. Notes: FPL is federal poverty level. Estimates are based on adults with the same coverage type all year. People who are Black, white, and additional races are not Hispanic/Latinx. Reference groups are adults with private coverage, women, adults ages 50 to 64, white adults, adults with incomes above 138 percent of FPL, adults with a college degree or higher, adults whose primary language is English, adults without a disability, adults without a physical health condition, adults without a behavioral health condition, adults in excellent or very good health, adults living in the Northeast, and adults not living in an urban area. */**/*** Estimated association differs significantly from zero at the 0.10/0.05/0.01 level. PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 9 Further, differences in reported unfair treatment between some populations, especially those who may have elevated health needs, remain significant after adjusting for insurance type and other characteristics. For example, people with disabilities were about 5.0 percentage points more likely than those without disabilities to report unfair treatment due to health insurance type. People with behavioral health conditions were about 2.9 percentage points more likely than those without behavioral health conditions to report unfair treatment due to health insurance type. The higher reports of unfair treatment among this population could also be related to the greater number of interactions people with disabilities and health conditions tend to have with the health care system. 6 Adults with public coverage were more likely than those with private coverage to report that they had an unmet health need because of an insurance-related hassle, even after adjusting for observed demographic, health, and socioeconomic characteristics. We find that 16.2 percent of adults with public coverage reported having an unmet need for care because of an insurance-related hassle, defined as difficulties getting authorization from a health insurer for care or prescription drugs, finding a doctor or health care provider who is accepting new patients, or finding a doctor or health care provider who would accept their health insurance coverage type, in the past 12 months (figure 3). This share is 11.0 percent among adults with private health insurance coverage. These patterns suggest that, on average, adults experience greater hassles associated with having Medicaid coverage relative to private insurance, which, in turn, could be interpreted by patients as unfair treatment. 7 FIGURE 3 Share of Adults Ages 18 to 64 Reporting an Unmet Need for Care Due to Insurance-Related Hassles in the Past 12 Months, by Health Insurance Type, April 2021 16.2%*** 11.0% Private coverage Public coverage URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Notes: Estimates are based on adults with the same coverage type all year. Insurance-related hassles include difficulties getting authorization from a health insurer for care or prescription drugs, finding a doctor or health care provider who is accepting new patients, and finding a doctor or health care provider who would accept the respondent's health insurance coverage type. 10 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY Estimates are adjusted for respondent gender, age, race and ethnicity, family income, educational attainment, primary language, disability status, presence of physical conditions, presence of behavioral health conditions, health status, census region, and urban or rural residence. */**/*** Estimate differs significantly from that for adults with private coverage at the 0.10/0.05/0.01 level. Discussion Our study finds that publicly insured and uninsured adults report experiencing unfair treatment or judgment because of their health insurance type at significantly higher rates than privately insured adults. These differences narrow but are not eliminated after adjusting for key health, demographic, and socioeconomic characteristics. Additionally, adults with public coverage or who were uninsured were more likely to report unfair treatment due to health insurance in combination with other reasons, such as race or ethnicity, showing that people with these insurance types are more likely to have other characteristics that place them at higher risk of being treated unfairly. Experiences of unfair treatment could be compounding for these adults, or they could be finding it hard to determine why they are being treated unfairly. Even when controlling for other characteristics, including health insurance type, people with a disability and people with health conditions were more likely to report unfair treatment due to their coverage type. These experiences may reflect negative provider or staff biases toward people with disabilities or particular health conditions, or they could reflect a lack of appropriate accommodations that meet these patients' needs. These populations often have elevated health care needs, but these negative experiences and the resulting lack of trust in the health care system could be deterring them from getting needed care. There is still much to learn about the nature of the unfair treatment patients experience because of their health insurance type, especially to distinguish between treatment that may be related to aspects of the Medicaid program (e.g., hassles associated with seeking authorization for care or prescriptions) and negative interpersonal treatment at the point of care or when speaking to front office staff. The types of solutions that would target unfair treatment due to insurance type in health care will depend on uncovering these distinctions. Reducing Administrative, Payment, and Other Barriers in Medicaid To the extent that administrative hassles, low reimbursement rates for providers who serve Medicaid patients, or patients' inabilities to find appointments in a timely way contribute to perceptions of unfair treatment, then steps that address these issues could reduce unfair treatment due to insurance type. Providers often do not accept Medicaid patients because of the low reimbursement rates associated with the program, the greater complexity required to navigate billing, or the greater cost associated with treating Medicaid patients, who often have more complex medical needs. 8 Physicians in states with greater administrative hurdles in billing for their Medicaid programs are significantly less likely to accept Medicaid patients, and reductions in administrative hassles for providers have been found to increase providers' acceptance of Medicaid patients (Dunn et al. 2021). Reducing administrative hassles and other insurance-related barriers by streamlining payment or other administrative processes and PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 11 increasing Medicaid reimbursement rates could help reduce unfair treatment stemming from these issues (Alexander and Schnell 2019; Dunn et al. 2021; Long 2013; Polsky et al. 2015). Mitigating Provider and Office Staff Bias and Discrimination To the extent that providers' and their staff members' implicit or explicit biases about publicly or uninsured patients drive unfair treatment due to insurance type, policies to reduce unfair treatment will require counteracting these biases and holding providers accountable for providing culturally competent care, regardless of their patients' identities and socioeconomic statuses. Steps policymakers and other stakeholders can take to make progress on this front include collecting patient satisfaction surveys that incorporate questions about unfair treatment and publishing these results, extending trainings around implicit and explicit biases and cultural competence to include not only health care providers but also their front office and billing staff members, incorporating criteria around providers' and office staff members' abilities to provide culturally competent care into performance evaluations, and being intentional about hiring providers and front office and billing staff members with track records of providing exceptional customer service and culturally competent care (Bleich, Zephyrin, and Blendon 2021). 9 Mitigating unfair treatment by providers and their staff members could help reduce disruptions to care stemming from these experiences (Gonzalez et al. 2022). Addressing Affordability Issues Facing Uninsured People Affordability, providers' perceptions of patients' abilities to pay for services, and requirements around upfront payment could be reasons why uninsured or privately insured adults with low incomes experience unfair treatment. For example, unfair treatment may stem from providers' responses to the challenges uninsured patients may experience in meeting their out-of-pocket costs, such as payments for office visits. Reducing the size of the uninsured population could be accomplished by expanding Medicaid eligibility in states that have yet to do so under the Affordable Care Act or expanding eligibility to additional groups of immigrants who are currently ineligible, enhancing subsidies for Marketplace coverage, and increasing enrollment and retention among people who are eligible for Medicaid or subsidized coverage but are not enrolled (Branham, Peters, and Sommers 2021; Buettgens 2021; Buettgens, Banthin, and Green 2022; Lacarte, Greenberg, and Capps 2021; Pollitz, Tolbert, and Orgera 2021). Broadening access to affordable care options by increasing capacity at federally qualified health centers could lower the out-of-pocket costs faced by the remaining uninsured population, which, in turn, could help reduce unfair treatment based on ability to pay (Behr et al. 2022; Lewis et al. 2021; Richards et al. 2014). Conclusion Though other studies have explored patients' perceptions of discrimination and unfair treatment by health insurance coverage type, our study is among few to assess these experiences nationally (Nong et al. 2020) and to quantify such experiences (Alcala et al. 2020; Allen et al. 2017; Han et al. 20175; Nong et al. 2020). Learning more about unfair treatment in health care settings and its adverse effects on 12 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY patients' care, health, and well-being-especially for populations who have elevated health needs or face systemic disadvantages-is important. Future work should continue exploring these issues to shed light on solutions that would expand patient receipt of high-quality health care regardless of ability to pay or health insurance type. Data and Methods Data We draw on the Urban Institute's Health Reform Monitoring Survey (HRMS), a nationally representative, internet-based survey of adults ages 18 to 64 launched in 2013 to provide timely information on the Affordable Care Act before data from federal surveys are available. HRMS samples are drawn from Ipsos's KnowledgePanel, the nation's largest probability-based online research panel, which includes households with and without internet access. If needed, panel members are given internet access and web-enabled devices to facilitate their participation. The HRMS is currently fielded annually, and 9,067 respondents participated in April 2021. Survey weights adjust for unequal selection probabilities and are poststratified to the characteristics of the national nonelderly adult population, based on benchmarks from the Current Population Survey and the American Community Survey. Participants can take the survey in English or Spanish. Measures We examine outcomes by the following health insurance coverage types: full-year private coverage, full-year public coverage, and full-year uninsurance. Public insurance includes Medicaid and Medicare, and about 90 percent of respondents with public insurance reported having Medicaid. Private insurance includes employer-sponsored insurance, Marketplace and other nongroup coverage, and TRICARE or other military coverage. Having a physical health condition is defined as having been diagnosed with one or more of the following: hypertension; high cholesterol; heart condition; stroke; cancer; diabetes; asthma; chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; arthritis; liver disease; or kidney disease. Having a behavioral health condition is defined as having been diagnosed with one of the following conditions: anxiety, depression, another type of mental health condition, or a problem with alcohol or drug use. We define unmet needs for care in the past 12 months due to insurance-related hassle as those attributable to difficulties getting authorization from a health insurance plan for health care, getting authorization from a health insurance plan for prescription drugs, finding a doctor or health care provider who was accepting new patients, or finding a doctor or health care provider who would accept the respondent's health insurance coverage type. PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 13 Our measure of unfair treatment in health care settings is based on questions that ask respondents whether there was a time in the past 12 months when they felt treated or judged unfairly at a doctor's office, clinic, or hospital because of one or more of the following reasons:  racial or ethnic background  gender or gender identity  sexual orientation  country of origin  primary language  health insurance coverage type  a disability  a health condition  income level  some other reason (specify) Approach We examine perceptions of unfair treatment or judgment due to one or more of the above listed reasons at a doctor's office, clinic, or hospital in the 12 months before April 2021. We first determine the unadjusted share of adults who reported unfair treatment or judgment due to their health insurance coverage type overall and by insurance coverage type. We do not report estimates based on sample sizes with fewer than 250 respondents. We also assess differences in reported unfair treatment or judgment in health care settings due to health insurance coverage type in a linear probability model that includes coverage type, gender, age, race and ethnicity, family income as a percentage of the FPL, educational attainment, primary language, disability status, presence of physical health conditions, presence of behavioral health conditions, self- reported health status, region, and urban or rural residence. Finally, we assess the share of privately and publicly insured respondents who reported facing insurance-related hassles in the past 12 months. Limitations Our study has several limitations. First, though the cumulative response rate for the HRMS is much lower than the response rates for federal surveys such as the National Health Interview Survey and the Current Population Survey, analyses have found that HRMS estimates benchmark well against those from the National Health Interview Survey and other surveys (Karpman and Long 2015; Long et al. 2014). Moreover, we are limited in our ability to characterize experiences of unfair treatment given that these are fully self-reported patient perceptions, and we cannot complement these with measures of provider behavior or intent. In addition, because people with public coverage or who are uninsured are 14 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY more likely to have other characteristics, such as a disability or low income, that place them at greater risk of experiencing unfair treatment in health care settings, some respondents may have attributed unfair treatment to health insurance type when they may have been treated unfairly because of a reason overlapping with insurance (e.g., income or disability). Additionally, we cannot determine whether respondents were seeking care for themselves or someone else (e.g., a child) when they were treated or judged unfairly. Further, though we report on key insurance-related hassles, such as providers not accepting a respondent's insurance coverage type, we cannot capture all the factors that could make interacting with public or private insurance difficult for patients. We also cannot determine whether and to what extent reported unfair treatment or judgment is related to administrative difficulties or interpersonal interactions beyond administrative failings. Additionally, our estimates are subject to underreporting because we asked respondents to report experiences of unfair treatment or judgment in the last 12 months, so we do not capture the experiences of people who may have experienced unfair treatment in a longer time frame or who did not see a provider in the past 12 months. We may also be underreporting experiences of unfair treatment or judgment in health care settings because respondents may not know the reason they were treated unfairly or may hesitate to classify their negative experience as discrimination without evidence (McDaniel et al. 2021). Further, some respondents, such as those with health care conditions and disabilities requiring frequent medical care, may have more encounters with the health care system. This could increase their chances of encountering unfair treatment relative to someone who interacts less frequently with health care settings. Sample sizes also do not permit us to assess the consequences to health care receipt for people who experienced unfair treatment because of their health insurance type. Further, some measurement error may be associated with reported health insurance coverage type. Finally, the HRMS is only conducted in English and Spanish, so we do not capture the experiences of respondents who do not speak these languages. Notes 1 See the Data and Methods section for more information. 2 Tiffany N. Ford and Jamila Michener, "Medicaid Reimbursement Rates Are a Racial Justice Issue," Commonwealth Fund blog, June 16, 2022, https://www.commonwealthfund.org/blog/2022/medicaid- reimbursement-rates-are-racial-justice-issue. 3 Because of sample size restrictions, we do not present analyses for people uninsured part of the year or with multiple insurance types throughout the year in later sections of this brief. 4 We base these estimates on all adults in our sample who sought care for themselves through one or more of the following: a routine checkup, an encounter with a provider or specialist to discuss health, a telehealth visit, or a visit to the emergency department. 5 "Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity, Timeframe: 2019," Kaiser Family Foundation, accessed August 9, 2022, https://www.kff.org/medicaid/state-indicator/nonelderly-medicaid-rate-by- PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 15 raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%2 2%7D. 6 In sensitivity analyses where we control for whether adults sought one or more types of care (see endnote 4 for definition) in the past 12 months, the results do not change. 7 Adults with private insurance face higher out-of-pocket-spending burdens than those with public coverage. This could introduce access barriers, particularly among adults with low incomes. 8 Kayla Holgash and Martha Heberlein, "Physician Acceptance of New Medicaid Patients: What Matters and What Doesn't," Health Affairs Forefront, April 10, 2019, https://www.healthaffairs.org/do/10.1377/forefront.20190401.678690/full/. 9 Rick Evans, Shari Berman, Esther Burlingame, and Stephanie Fishkin, "It's Time to Take Patient Experience Measurement and Reporting to a New Level: Next Steps for Modernizing and Democratizing National Patient Surveys," Health Affairs Forefront, March 16, 2020, https://www.healthaffairs.org/do/10.1377/forefront.20200309.359946/full/; and Vivek Garg, Amberly Molosky, Sandeep Palakodeti, and Sachin H. Jain, "Rethinking How Medicaid Patients Receive Care," Harvard Business Review, October 5, 2018, https://hbr.org/2018/10/rethinking-how-medicaid-patients-receive-care. References Alcala, Hector E., Amanda E. Ng, Sujoy Gayen, and Alexander N. Ortega. 2020. 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Baker, Hannah S. Bell, Isabel Montemayor, Kristan Elwell, and Linda M. Hunt. 2017. "'They Treat You a Different Way': Public Insurance, Stigma, and the Challenge to Quality Health Care." Culture, Medicine, and Psychiatry 41:161–80. https://doi.org/10.1007/s11013-016-9513-8. McDaniel, Marla, Audrey Richardson, Dulce Gonzalez, Clara Alvarez Caraveo, Laura Wagner, and Laura Skopec. 2021. "Black and African American Adults' Perspectives on Discrimination and Unfair Judgment in Health Care." Washington, DC: Urban Institute. Meyers, David S., Ranit Mishori, Jessica McCann, Jose Delgado, Ann S. O'Malley, and Ed Fryer. 2006. "Primary Care Physicians' Perceptions of the Effect of Insurance Status on Clinical Decision Making." Annals of Family Medicine 4 (5): 399–402. https://doi.org/10.1370/afm.574. Nong, Paige, Minakshi Raj, Melissa Creary, Sharon L. R. Kardia, and Jodyn E. Platt. 2020. "Patient-Reported Experiences of Discrimination in the US Health Care System." JAMA Network Open 3 (12): e2029650. https://doi.org/10.1001/jamanetworkopen.2020.29650. Oostrom, Tamar, Liran Einav, and Amy Finkelstein. 2017. "Outpatient Office Wait Times and Quality of Care for Medicaid Patients." Health Affairs 36 (5): 826–32. https://doi.org/10.1377/hlthaff.2016.1478. PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 17 Pollitz, Karen, Jennifer Tolbert, and Kendal Orgera. 2021. "Navigator Funding Restored in Federal Marketplace States for 2022." San Francisco: Kaiser Family Foundation. Polsky, Daniel, Michael Richards, Simon Basseyn, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman, and Karin V. Rhodes. 2015. "Appointment Availability after Increases in Medicaid Payments for Primary Care." New England Journal of Medicine 372:537–45. https://doi.org/10.1056/NEJMsa1413299. Richards, Michael R., Brendan Saloner, Genevieve M. Kenney, Karin Rhodes, and Daniel Polsky. 2014. "Access Points for the Underserved: Primary Care Appointment Availability at Federally Qualified Health Centers in 10 States." Medical Care 52 (9): 818–25. https://doi.org/10.1097/mlr.0000000000000184. Tajeu, Gabriel S., Andrea L. Cherrington, Lynn Andreae, Candice Prince, Cheryl L. Holt, and Jewell Halanych. 2015. "'We'll Get to You When We Get to You': Exploring Potential Contributions of Health Care Staff Behaviors to Patient Perceptions of Discrimination and Satisfaction." American Journal of Public Health 105 (10): 2076–82. https://doi.org/10.2105%2FAJPH.2015.302721. Tamir, Christine. 2021. The Growing Diversity of Black America. Washington, DC: Pew Research Center. About the Authors Dulce Gonzalez is a research associate in 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 health care access. Her work has also focused on the impacts of the COVID-19 pandemic on nonelderly adults and their families. Before joining Urban, 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. Genevieve M. Kenney is a vice president and senior fellow in the Health Policy Center. She is a nationally renowned expert on Medicaid, the Children's Health Insurance Program (CHIP), and health insurance coverage; health care access and quality; and health outcomes for low-income adults, children, and families. She has played a lead role in several Medicaid and CHIP evaluations, including multiple congressionally mandated CHIP evaluations, and has conducted state-level evaluations of the implementation of managed care and other service delivery reform initiatives and policy changes in Medicaid and CHIP. Currently, she is leading a project for the Robert Wood Johnson Foundation focused on health equity that involves working with a community advisory board. In other work, she is assessing Medicaid policies aimed at improving outcomes in the postpartum period and increasing receipt of evidence-based treatment for substance use disorder. Her prior work has used mixed methods to examine Medicaid expansions for pregnant women, parents, and children; Medicaid family planning waivers; and a range of policy choices related to Medicaid and CHIP. She received a master's degree in statistics and a doctoral degree in economics from the University of Michigan. Claire O'Brien is a quantitative research assistant in the Health Policy Center. She leverages Medicaid claims to study the relationship between racialized economic segregation and health outcomes and to evaluate integrated care plans for beneficiaries dually eligible for Medicare and Medicaid. Additionally, she takes part in the implementation and analysis of the Urban Institute's Health Reform Monitoring Survey, which she has used to study telehealth, unfair treatment, patient-provider racial concordance, 18 PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY and knowledge of insurance Marketplaces. She uses other national survey data to study family coverage and prescription drug affordability. Finally, she monitors changes in the Affordable Care Act's Marketplaces. She has a bachelor's degree in economics and applied math with a minor in poverty studies from the University of Notre Dame and is currently pursuing a master of public policy degree at the George Washington University. Marla McDaniel is a senior fellow in the Urban Institute's Center on Labor, Human Services, and Population at the Urban Institute whose research examines racial and ethnic disparities; low-income children, youth, and families; and the programs and policy environments that touch families' lives. She is interested in the relationships between inequities across multiple domains-including health, education, and employment-and their compounding effects on overall health and well-being. McDaniel holds a BA in psychology from Swarthmore College and a PhD in human development and social policy from Northwestern University. Michael Karpman is a senior research associate in the Health Policy Center. His work focuses on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. His work includes overseeing and analyzing data from the Urban Institute's Health Reform Monitoring Survey and Well-Being and Basic Needs Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University. PUBLICLY INSURED AND UNINSURED PATIENTS MORE LIKELY TO BE TREATED UNFAIRLY 19 Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. The authors would like to thank Heidi H. Allen and Stephen Zuckerman for their comments and suggestions on this brief. The authors are also grateful to members of a community advisory board organized and overseen by Myriam Hernandez-Jennings of Community Catalyst and Kimá Joy Taylor of the Urban Institute for their input on findings from this study. Finally, the authors thank Rachel Kenney for her editorial assistance. ABOUT THE ROBERT WOOD JOHNSON FOUNDATION The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity, that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people's lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness 500 L'Enfant Plaza SW and enhance the well-being of people and places. Washington, DC 20024 Copyright © September 2022. Urban Institute. 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