By Kristen Ukeomah

As we splashed into summer, CHIR soaked up the latest health policy research along with some rays. In June, we read about trends in coverage and access for LGBT adults, the rise of facility fees, and the out-of-pocket cost burden of mental health care.

Andrew Bolibol, Thomas C. Buchmueller, Benjamin Lewis, and Sarah Miller, Health Insurance Coverage and Access to Care Among LGBT Adults, 2013–19, Health Affairs. Using data from the Urban Institute’s Health Reform Monitoring Survey from 2013–2019, researchers assessed how health coverage changed for LGBT Americans after Affordable Care Act (ACA) implementation in 2014 and the Supreme Court’s 2015 ruling in Obergefell v. Hodges, which expanded access to employer-sponsored insurance by recognizing a constitutional right to marriage for same-sex couples.

What it Finds

• Seven percent of survey respondents identified as lesbian, gay, bisexual, or transgender (LGBT), comparable to a 2022 Gallup poll finding that 7.1 percent of U.S. adults identify as LGBT.
  • Among the study sample, LGBT adults tended to be younger, were less likely to be White, were less educated, and were less likely to be U.S. citizens in comparison to non-LGBT adults.
    • LGBT adults in the study sample were more likely to identify as having “fair” or “poor” health (as opposed to “good,” “very good,” or “excellent” health), despite being younger on average than non-LGBT adults.
• During the study period, the largest disparity in health insurance coverage between LGBT and non-LGBT adults was in 2013, prior full implementation of the ACA and Obergefell.
  • In 2013, approximately 84 percent of non-LGBT adults reported having health insurance coverage, compared to about 76 percent of LGBT adults.
• By 2019, the insured rates of partnered LGBT and partnered non-LGBT adults were almost identical, with both reaching 92 percent.
  • Although single LGBT adults were less likely to have coverage in 2013, by 2019, their insured rate surpassed that of single non-LGBT adults.
• In 2013, approximately 70 percent of non-LGBT adults and 64 percent of LGBT adults reported having a consistent source of care. By 2017–2019, both groups saw improvements and this disparity had narrowed, with 76.7 percent of non-LGBT adults and 75.2 percent of LGBT adults reporting a usual source of care.
• Disparities persisted in some measures of access to care. In 2017–2019, due to affordability issues, 15.7 percent of LGBT adults went without mental health care (versus 7.4% of non-LGBT adults), 20.2 percent went without prescription drugs (versus 14.3 percent of non-LGBT adults), and 16.9 percent went without medical care (versus 12.1 percent of non-LGBT adults).

Why it Matters

Prior to the ACA, insurers could deny people coverage based on their sexual orientation, and the uninsured rate among the LGBT community was high. Pre-Obergefell, same-sex partners frequently could not get covered as an employee’s dependent. This study shows that policies expanding access to health insurance—namely the ACA’s reforms and the increased access to employer-sponsored insurance after Obergefell—helped to narrow coverage disparities. However, gaps remain; in addition to the disparities highlighted in this study, transgender individuals still lack access to gender-affirming care, and ongoing litigation threatens access to HIV prevention medication without cost sharing. Evidence of these continuing barriers to care show that the fight for equality is far from over, including among the privately insured.

HCCI Staff, Facility Fees and How They Affect Health Care Prices: Policy Explainer 

Health Care Cost Institute. Researchers at the Health Care Cost Institute (HCCI) published data looking at the impact of facility fees on health care costs as well as a primer on facility fees and how policymakers are responding to this cost driver.

What it Finds

• A facility fee is a component of the bill a patient receives from the hospital—separate from the bill received from the provider—that supports the emergency room and other hospital services beyond the care the patient received.
  • Facility fees are increasingly charged when a patient visits a hospital-owned outpatient health center for non-hospital services, leading patients to pay more for the service than they would have paid at an independent physician’s office.
• HCCI data from 2021 shows that facility fees dramatically increase the cost of care for patients:
  • Facility fees raised the average cost of an ultrasound from $164 to $339, the average cost of a physician office visit from $118 to $186, and the average cost of a biopsy from $146 to $791.
  • Average prices and discrepancies vary by state. For example, in Arkansas, facility fees raised the average cost of an ultrasound from $144 to $179, while in California, facility fees raised the average cost of an ultrasound from $165 to $564.
• Hospital advocates argue that these fees help cover rising hospital administrative costs, that acquiring physician practices benefits patients, and that hospitals, at large, provide a community benefit.
• Facility fee opponents point out that patients can receive the same care in an independent physician’s office that they do in hospital-owned outpatient settings, and the ability to charge facility fees incentivizes hospitals to acquire physician groups, which often increases the cost of care for patients without a corresponding increase in clinical quality or outcomes.
• Some states, including Connecticut, Minnesota, Texas, and Washington, require physicians’ offices to notify patients of hospital affiliation and that they may be billed a facility fee and subsequently owe more in out-of-pocket costs.
• “Site neutrality” policies prohibit providers from charging a different amount for services based on the care setting. For example, Connecticut bans facility fees for certain services that can be safely performed in a non-hospital setting.

Why it Matters

As discussed in a forthcoming report from CHIR, facility fees are increasing the cost of routine health care services. American health spending is already higher than spending in all other high-income countries, and a majority of Americans report difficulties affording health care. Additionally, cost disparities created by facility fees encourage further provider consolidation, exacerbating health systems’ negotiating power to extract more out of commercial payers, which pass on these costs to consumers through higher premiums and cost-sharing obligations. State and federal policymakers are considering action to slow this trend through transparency and site neutrality requirements.

Hope Schwartz, Nirmita Panchal, Gary Claxton, and Cynthia Cox, Privately Insured People with Depression and Anxiety Face High Out-of-pocket Costs, Peterson-KFF Health System Tracker. Using claims data from the 2021 Merative MarketScan Commercial Database, researchers evaluated trends in private health plan enrollees’ expenditures on mental health services.

What it Finds

• Privately insured individuals treated for either depression or anxiety in 2021 spent almost twice as much out of pocket on health care than enrollees without a mental health diagnosis.
• Enrollees treated for either depression or anxiety shouldered a larger share of costs for mental health services (20 percent) than other health services (13 percent), with health plans picking up a smaller portion of the tab for mental health services. 
• Overall health spending and out-of-pocket costs incurred by enrollees with severe depression exceeded comparable amounts incurred by enrollees with mild depression.
• Among enrollees with anxiety or depression, psychotherapy was the most commonly used mental health service—and the most expensive in the context of both total care costs (averaging $1,507) and enrollees’ out-of-pocket spending (averaging ($557).
• Telemedicine was the most common mental health care setting for enrollees with depression or anxiety.
• The costs of seeking mental health services without insurance coverage, such as enrollees who self-pay for out-of-network care, were not included in this analysis, suggesting even higher enrollee costs for mental health treatment.

Why it Matters

Americans face significant barriers to mental health care. This study shows that obstacles extend to privately insured individuals with a mental health diagnosis, who on average incur nearly twice as much out-of-pocket spending than enrollees without such a diagnosis. This disparity does not even account for enrollees who self-pay for mental health services due to network adequacy issues. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity between mental health benefits and medical benefits, but enforcement remains a challenge, particularly for non-quantitative treatment limitations. The growing body of research about the unmet need for mental health care should sound the alarm for policymakers.