What sorts of challenges do uninsured and underinsured patients pose to physicians and other caregivers? Thanks to a raft of studies, we have an unusually clear idea of how the uninsured approach their healthcare. In comparison, we have far less information on the underinsured, but we can surmise that they behave in many similar ways because they too struggle with having to pay healthcare bills.

The list of challenges is lengthy, but a few basic points can be made initially. Compared with privately insured patients, uninsured patients are more likely to forgo needed medical care, be sicker, be nonadherent, and receive abbreviated treatment — but are less likely to sue for malpractice.

The uninsured typically don't have a regular doctor so they may put off screenings and treatment until their symptoms become advanced. In one study, 41.5% of uninsured adults reported not seeing a doctor or any healthcare professional in the past 12 months, and 40.8% said that they did not have a regular place to go when they were sick or needed medical advice.

Even years after the implementation of the Affordable Care Act, which was supposed to make coverage more affordable, many people were still doing without or postponing medical care because of cost. In an online survey in February 2020, 32% of US residents said they had avoided some sort of medical care over the past year owing to cost.

This problem was exacerbated with the onset of COVID-19 in March 2020. By June 30, 2020, an estimated 41% of US adults had delayed or avoided medical care for fear of contracting the virus.

The successful treatment and management of cancer, cardiovascular diseases, and diabetes depends heavily on the early detection of these diseases, but the uninsured are less likely to receive a screening.

When cancer is diagnosed in uninsured patients, it is more likely to be at an advanced stage that is more likely to be fatal. Uninsured patients also tend to have progressed to severe renal disease before they begin dialysis. And when admitted to the hospital, uninsured patients have a more serious mix of diseases and conditions than privately insured patients.

Patients who put off care are not only more acutely sick but may also have more complex diagnoses than other patients. Several studies have shown that uninsured patients with acute or chronic conditions have worse health outcomes than insured patients.

Because most of the uninsured and many underinsured have low incomes, study findings on low-income patients may be applied to this population. A 2020 study found that middle- and low-income earners are one third to one half more likely to have cardiovascular disease than high-income people.

Simply maintaining a healthy diet may be too expensive for low-income, uninsured persons. For example, fresh fruits and vegetables may be too expensive for low-income patients or simply not available in nearby grocery stores.

Getting insurance coverage, such as when uninsured patients qualify for Medicare, can change outcomes quite quickly. Uninsured patients who are aged 60-64 are nearly twice as likely to present with late-stage cancer than Medicare beneficiaries who are aged 66-69, even though the latter group is older. The uninsured group is also significantly less likely to receive surgery, chemotherapy, or radiation therapy, and their survival rate was 5%-17% lower than their counterparts with Medicare.

High healthcare costs affect more than just the 1 in 5 of US residents who are uninsured or underinsured. In a survey of patients in general, half said costs had forced them or a close family member to delay a doctor's appointment, not fill a prescription, or postpone some other medical care in the previous year.

Nonadherence to medications is common among low-income, uninsured patients who are initiating therapy for chronic conditions. Also, patients with diabetes who have no coverage for medications may just choose to eat cheaper, high-sugar foods rather than pay $300 per month for a diabetes medication that doesn't change how they feel.

Low-income patients may also miss appointments. Some missed appointments are because of financial considerations, and low-income patients may not understand that preventive visits are free.

High deductibles make it harder for patients to control chronic conditions. Studies have shown that when patients are required to pay more out of pocket, those with cancer, epilepsy, arthritis, multiple sclerosis, and other serious diseases often delay care or skimp on vital medications.

Low-income people who work have reported that taking time off from work was a problem for them, according to the Commonwealth Fund. They often do not get paid sick leave so they lose income when they take time off to go to the doctor.

Even when patients don't take their prescribed medications and don't follow treatment regimens, doctors aren't off the hook. Doctors are expected to take basic steps to assure adherence. If a doctor is sued for malpractice by a nonadherent patient, courts often determine the degree of fault of both the patient and the doctor and set the doctor's payment accordingly.

Many doctors believe that poor people are more likely to sue for malpractice, but in fact, the opposite is often true. This was the finding of a 1993 study of hospitals in New York State as well as a 1992 investigation by the federal Office of Technology Assessment (OTA).

The OTA study found that although Medicaid patients comprised 10% of the population at the time, they filed less than 5% of medical malpractice lawsuits. Furthermore, monetary settlements for non-Medicaid patients were 5-10 times greater than those received by Medicaid patients.

Why would low-income people sue less often? "Poor people may not recognize that the bad outcome was the result of a medical error," a  malpractice attorney explained. "They may not have the educational background or familiarity with the healthcare system to be able to comprehend that their injuries are the result of malpractice."

Furthermore, lawyers are less likely to accept cases on behalf of low-income patients because the economic damages that would be paid are based on the plaintiff's income.

Uninsured and underinsured patients may have received abbreviated treatment from past caregivers, which may affect how they deal with their current caregivers. For example, uninsured patients are more than twice as likely to be transferred to another hospital than people who have private insurance and are also 66% more likely to be discharged outright.

The uninsured often face the same treatment as Medicaid patients who, like many of the uninsured, have low incomes. In a 2019 study, many primary care physicians acknowledged that limited visit time with Medicaid patients, owing to low Medicaid reimbursement and fewer providers, got in the way of high-quality primary care.

Low-income patients may also get less respect from staff. In one study, these patients noted that clinicians avoided eye contact, spoke condescendingly, and even showed physical disgust when touching them. They said that they took these events very seriously and that these incidences affected how they subsequently chose clinicians.

The treatment that the uninsured get may leave them more suspicious of caregivers. In a survey by the Commonwealth Fund, many low-income patients said they did not trust the healthcare system, in large part because it had failed or even harmed them in the past.

However, most uninsured patients can still get an appointment, as long as they are prepared to pay for it. In 2016, about 80% of callers identifying themselves as uninsured received appointments at primary care offices if they agreed to pay at the time of service. When callers said they would need to go on a payment plan, less than 1 in 7 got appointments.

Some uninsured and underinsured patients have bills that go to collections agents, or they may go into bankruptcy.

According to a 2020 study, 17.8% of US residents had medical debt in collections. Medical debt was highest in the South and was more concentrated in lower-income communities in states that did not expand Medicaid.

Medical bills caused 1 million adults to declare bankruptcy in 2015, and 62.1% of all bankruptcies were caused by medical bills in 2009.

Low-income patients must make financial tradeoffs. Paying for a doctor's visit may mean not having money for some other basic need. In 2007, more than half of working-age adults earning less than $40,000 a year reported problems paying medical bills or being in debt from medical expenses, according to the Commonwealth Fund reports.

Like many patients, low-income patients often use credit cards to pay their medical bills, and then they may not be able to pay off the credit card, forcing them to pay hundreds a month just in interest. One study found that medical expenses contribute to 29% of the credit card debt of low- and middle-income households.

Aside from malpractice lawsuits, uninsured and underinsured patients have been identified with just about every major patient challenge. However, these patients are still very rewarding to treat, and most of the challenges can be addressed by taking measures within your own practice. These measures will be the focus of the final three chapters.