Many previously uninsured Americans gained coverage following the implementation of the Affordable Care Act in 2010. However, many people still remain uninsured and University Medical School students wanted to learn why.

Brent Williams, an associate professor of internal medicine, and a team of medical students run a free clinic in Pinckney, Mich. Williams said they continue to encounter a large number of uninsured patients every week. In a recent paper, the students expanded on the reasons that might be.

“With the Affordable Care Act and the Healthy Michigan Plan, the number of uninsured patients in Michigan dropped significantly, but they found that they were still left with a steady flow of patients into the clinic for the uninsured,” Williams said. “They had a suspicion that there were reasons why some of those patients could be insured but were not and thought it was just time to ask them.”

Williams helped the Medical School students with their research. He said the students found many of their patients were unaware of how exactly the ACA could make health insurance an affordable option for them.

“Some patients weren’t aware of how the tax credits worked,” he said. “You can sign up if your income is above a certain level and still be eligible for tax credits and those come back at tax time. But calculating the actual effect on your annual budget is difficult.”

Based on this finding, Williams said students realized there are opportunities to help patients by providing guidance for calculating the impact of the ACA on their budgets.

Second-year Medical School student Brian Desmond is one of the students who works in the clinic and conducted the research. He said another reason people are not insured is that they don’t always know how to sign up for the insurance they qualify for.

“Most people know the Affordable Care Act happened and changed insurance coverage,” Desmond said. “Not as many people seem to know the details of how that affects them individually.”

As a result of these findings, the students thought it was necessary to provide insurance counseling as a feature of their free clinic. The government provides some of this training under the ACA. Desmond said a group of six students completed the training to provide counseling to patients.

“Essentially, our findings were strong enough that we thought our patients could benefit from one-on-one counseling about their insurance options,” he said.

Desmond said the students will mostly help patients with navigating the HealthCare.gov marketplace, as well as sign up for Medicaid.

Though the task of educating and providing all patients with insurance may seem easy for some people, Williams said, the prospect of a monthly payment and large deductibles can be daunting when coupled with an unstable income. Many patients, he said, have only intermittent work.

“So even though in a given year they might technically make enough to qualify for a tax subsidy, they’re less certain that the next year they’re going to make the same amount,” Williams said. “The unpredictability of it makes them hesitant to commit to something that has a monthly payment and a big copay.”

However, Williams said having insurance under the ACA could allow patients to save money in the long term. Under the ACA, insurance companies are required to cover preventative tests such as mammograms, which could prevent health issues down the road.

Williams listed three main problems that come from lack of insurance. The first is that if patients need to go to the emergency room, they have to pay the bill themselves. The second implication is that it’s harder to get care for chronic illnesses, including hypertension and diabetes, that, if untreated, can have more devastating impacts in the long run. The third issue is the lack of preventative care.

“We see patients all the time who just need the basic preventative care but can’t get it because they don’t have insurance,” he said.

Desmond agreed that health insurance is key for providing the best patient care and said though the free clinic will probably always be necessary, he hopes their research and current counseling services can help people achieve optimal insurance coverage.

“If you look at studies about health insurance, really it’s in people’s best interest to get health insurance and be a part of the formal healthcare network,” he said. “Our goal is to get as many people affordable health insurance so that they can see someone else and not rely on us.” 

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