Your annual doctor’s appointment is supposed to cost nothing. So why are people being accused?

After moving to West Virginia last year, Steve Kuo signed up for a new insurance plan that would cost him $500 a month. But there was an advantage: he knew he was entitled to a free preventive visit. He wanted to take advantage of it, so he made an appointment at a clinic near his new home.

But then when he got there, they asked him about his medical history and he mentioned previous kidney problems. When he received a bill a few weeks later, he had been billed twice for the same appointment: once for this free preventative visit, once for an “office sick visit” due to a kidney conversation. He was baffled – and very annoyed, as he shared on social media. “No co-pay means no co-pay, exactly as stated in the insurance guidelines,” Kuo explained to me via email. “What is written and agreed must be honored. »

He is far from alone. On Reddit, I easily found more than a dozen examples over the past year of people receiving a surprise bill for what they thought was a free tour.

A woman posted a nearly $1,000 bill she received for what she thought was a preventative gynecology visit. Another woman said she ended up having to pay about $3,000 because she had an ultrasound (which she said she didn’t ask for) during a preventative visit and then had her blood work sent to an out-of-network lab. Another person lamented that she was charged $170 for an office visit because she briefly mentioned back stiffness.

It’s not supposed to be like this. Americans don’t have much in the way of health care, but most of us are supposed to be entitled to at least one thing: Once a year, regardless of your health insurance, you can see a doctor with the goal of preventing future health problems by discussing important vaccinations, cancer screenings, and cardiovascular health checkups. The Affordable Care Act made it law in 2010.

But more than 15 years later, people across the country walk into their doctor’s office thinking they’re entitled to that free visit every year, only to walk out being charged for a sick visit, blood tests and more. Researchers estimate that Americans spend tens or even hundreds of millions of dollars each year on services that are supposed to be free under the ACA.

Dr. Yalda Jabbarpour, a family physician in the Washington, D.C., area and medical director of the Robert Graham Center for Policy Studies, told me that she still encounters people’s confusion about what a preventive visit really means.

“Every time I’m in the clinic, this problem comes up with a patient. And it’s sad that it comes up again,” Jabbarpour told me. “In my mind, the blame should not be placed on the patient. The blame should not be placed on the doctor. In reality, this points to a larger systemic problem that we need to address.”

How could a seemingly simple promise of a free annual checkup result in a situation so complicated that patients and doctors are still struggling with nearly two decades later? And how could we fix it?

Patients receive surprise bills from their doctors – and they’re pissed

The goal of the ACA was to expand coverage and ensure that health insurance would be comprehensive to actually help people stay healthy. As part of the plan, the bill’s authors added a mandate for insurers to cover these services, including an annual wellness exam. The problem is that they didn’t define what the parameters of this preventive visit actually were, said Alex Hoagland, a health economist at the University of Toronto.

“It hasn’t established a clear definition of … all the diagnostic and procedure codes, or how often you get that combination over the course of a year,” he said. “They don’t define what actually constitutes preventative care and what doesn’t.”

This left each insurer defining a preventive visit themselves – and that’s where the perverse incentives that leave patients in the lurch begin. Preventative visits are supposed to be reserved strictly for screenings and other preventive measures you can take to protect your long-term health, but you may be charged for an “office visit” or “sick visit” if you talk about a specific symptom you’re experiencing, such as if you came in because you had the flu.

Health insurers have an incentive to maintain as narrow a definition of preventive care as possible, so they must pay fewer claims without any patient contributions. At the same time, doctors want to be paid for the services they provide. If someone brings up a more serious health issue during a preventative visit, the doctor reasonably wants to be paid accordingly.

“I know, especially in health care, it’s very common to blame one party or the other, and here I don’t think it’s a matter of corporate greed or doctor incompetence or anything,” Hoagland said. “It’s just a natural mismatch of incentives.”

So the reality is that “a free visit to the doctor” sounds simple, but in practice it is much more complicated. As a patient, you might think of this as a single visit, but in our fee-for-service health care system, where providers charge based on each specific thing they do, that’s not the case. Talking about your vaccination may be free, but asking about your back pain is not. If you are asked for blood tests, that’s another post. The list is long. “It’s not like you walk into a doctor’s office and it’s just a thing that happens, right?” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “There are multiple different things that happen when you walk into a doctor’s office.”

Part of the problem may be that A free visit. We Americans are consumers at heart: tell us we’re going to get something for free and we want to take advantage of it. But having only one free visit can also lead people to bring a long list of questions to that preventative visit because they view it as their only chance to ask their doctor everything.

This makes it easy for the discussion to veer into a sick visit — and not only does it lead to a surprise bill, but it can also crowd out the prevention conversation that the visit is supposed to focus on.

“What ends up happening a lot…is a patient comes in for their annual visit, and in their mind, this is the time for them to bring up everything that happened during the year, because they view it as a free visit to bring up everything that happened during the year. For some patients, that takes up the entire visit,” Jabbarpour told me. “They leave and they’re like, ‘Oh my God, we forgot to do all the screening things: vaccinations, cancer screenings and cardiovascular risk screenings.’ And then something ultimately happens because you never address those controls.

A 2021 study by Hoagland and Paul Shafer, both of Boston University at the time, estimated that Americans with employer-sponsored insurance paid between $75 million and $219 million in medical bills in 2018 alone that should have been free. They were more likely to be charged for things like birth control or cholesterol and diabetes screenings, with individuals sometimes paying hundreds of dollars for these services.

Hoagland told me he was billed for preventative visits because he had Type 1 diabetes and the system automatically classified his appointment as a diabetic visit. Earlier this year, he co-authored a study that found people with chronic illnesses were more likely to be billed for preventative care. Corlette said she, too, was recently charged with what was supposed to be a preventative visit after she raised an issue on the sidelines. And these are people who study health care for a living.

“It was literally a 10-second conversation where I asked the doctor a question about something,” she said. “And that’s what started it.”

Colonoscopies are another dramatic example of how this problem plays out in real life; Corlette told me the procedure was one of the first services where this blurred line between prevention and treatment under the ACA became evident. People undergo what is supposed to be a preventive colonoscopy. But then their doctor discovers a polyp and decides to remove it – good clinical practice, but as a result their patient could be billed thousands of dollars because the colonoscopy was no longer preventative once the polyp was cut out.

“All of a sudden it would trigger what the patient thought was a preventative service into a cost-sharing obligation,” Corlette said. “Colonoscopies can cost thousands of dollars. That’s when we first said, ‘Oh, yeah, this is a more complicated area than the legislators who wrote this provision initially envisioned.'”

How the United States Could Solve Our Preventative Visitation Problems

The ACA’s preventive visitation promise was clearly well-intentioned, and it’s worth remembering that, looking overall, more Americans are receiving more free preventative care than before the law was passed. The problem, above all, is expectations: people think they are entitled to a free visit and are understandably frustrated when they are charged for it.

“The difference is that before the Affordable Care Act, maybe they had some sort of cost sharing,” Hoagland said. “But then they…