Adam texted me yesterday about a problem he was having with getting his COVID-19 booster. I’m transcribing a portion of the text-chain with his permission as it highlights administrative burdens:
“INSURANCE will not cover the new covid booster”
“The system has not processed the new code for the new booster”
“So I’m going to pay for it and then submit for reimbursement once it is added to the insurance company system….”
There were a couple of other things, including the mechanics of generating new CPT-4 codes and then implementing the benefit structure to activate payment for a new code, but I want to focus on administrative burden.
Adam (and many tens of thousands of others) has to do a lot to get a “free” shot. Everyone has to make the normal time and attention carve out an appointment. Normally, there is no transaction at the point of service. There might be a paper or a screen to sign/initial and then the insurer pays the bill.
Even in this fairly smooth system, my colleagues and I found substantial variation in the uptake of no cost-sharing preventive services by both actuarial metal level (higher implies more care seeking or risk averse behaviors) and income as lower income individuals with high CSR Silver plans had different uptake.
But it was not a smooth process for Adam and others. Instead they now have to figure out where to send a claim, get the right set of forms, fill them out, find a stamp and then get it in the mail. These steps are substantial burdens. Things fall through both known and unknown cracks. In the context of the ACA, we found that the process of setting up a payment account to pay a $1 or $2 monthly premium instead of nothing makes people lose about a month of insurance coverage on average per year. I would assume that over the long run, many people who have to get reimbursed will get reimbursed.
However, the cost of burdens are not evenly distributed. Kyle and Frakt found substantial gender, education and income disparities on burden. More marginalized populations faced higher costs and higher likelihoods of foregoing care. A little bit less concretely, I would speculate/hypothesize that the existence of these burdens likely acts as a deterrent from individuals seeking care as they know that they don’t have the time/ability/willingness to deal with this shit.
And that is bad. Especially when we’re dealing with infectious diseases.