Shaking the Self-Pay Patient Stigma: Keep Calm and Carry Cash

Michael Hamilton | August 2, 2016 | 3:40pm EDT
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Some physicians advertise cash prices for health care procedures. (AP Photo/Jeff Barnard)

Anyone who has sought health care services while uninsured may be acquainted with a phenomenon I call the “self-pay stigma.”

The self-pay stigma is a voodoo emitted by patients who inadvertently intimidate licensed health care professionals or their staff simply by lacking health insurance.

One sees it in the furrowed brows and in the stammering larynxes of hapless front-desk workers at medical practices.

Even though self-pay patients save practices time and money that would otherwise be diverted to tracking down partial payments from insurance companies, self-payers frequently elicit knee-jerk reactions to their uninsured status.

My wife and I—proud self-payers since 2014, the second year of the Affordable Care Act’s implementation—pass no judgment on these staffers, whom we regard as lambs beguiled by mainstream partisan rhetoric common to Democrats and Republicans. They have been coerced into wrongly assuming insurance as we know it is the health care solution patients and doctors crave.

Here are four of our favorite misguided, yet well-intentioned, statements our self-pay status has elicited from health care providers and staffers during their fleeting moments of panic—and why the statements and panic are unfounded.

1. ‘You’re being illegal.’

This encounter escalated quickly. In a rookie move, I introduced myself as an uninsured patient to the young, possibly post-collegiate woman who said this. How foolish I was to brandish a detail wise self-payers never lead with. Her gist was President Barack Obama outlawed the sordid practice of going uninsured, except for the poor, whom Obama elevated to elite status.

The outlawing bit is false. ACA includes a “waiver of criminal penalties” and absolute “limitations on liens and levies” for taxpayers who fail to pay the penalty for going uninsured. Plus, where the IRS is concerned, Obamacare includes several exceptions to the individual mandate. For instance, members of a health care sharing ministry, a category my wife and I fall into, are exempt. So are people who lacked insurance for less than three months and people whose lowest-priced available coverage exceeded 8 percent of their household income.

A lone Google search uncovers a cottage industry of writers hell-bent on helping 130 million taxpayers dodge the ACA tax penalty—or, as I call it, “going Capone.”

2. ‘Paying cash is going to cost you 25 percent more.’

This line from a blood-lab receptionist stoked my ire, but after a deep breath, I realized this staffer was just stalling until she could remember her training. Fortunately, she never did, so I helped.

I explained to her that by paying her cash right before allowing her to take my blood, I would save the lab 100 percent of the administrative expenses of processing my insurance claim, plus the time and money lost chasing down an insurer’s reimbursement. Thanks to my cutting out the middle-man insurer, the lab could charge me less than usual and make an equal or greater profit. This is why providers typically post a cash discount price somewhere in the office, or at least buried in a forgotten folder.

A few clicks later, the worker rang me up for 50 percent of an insured patient’s price.

3. ‘Our hospital assistance program is not funded by the government.’

To get to this part of the script, I have to decline to apply for my state’s Hospital Care Assurance Program (HCAP). When pressed why, I say my free-market capitalist friends might shun me if they found out, and besides, as a health care policy journalist, I need to preserve impartiality toward government programs.

Instead of dismissing my patently absurd reasons, the two X-ray technicians assisting me assured me the “H” in HCAP, stands for “Hospital,” thereby clearing me of my government conspiracy. Seeing through this, I urged them to Google “HCAP,” whereupon we three agreed the program is “a state and federal program administered by the [state’s] Department of Medicaid,” according to our state’s hospital association.

4. ‘We can’t serve patients without insurance unless they fill out the HCAP form.’

If I placed a bet every time I heard this before disproving it, I could almost afford an Obamacare premium.

As a rule, cash is better than a form asking the government to give you cash. That some health care staff will instinctively reject the cash shows how Americans have brainwashed each other into mistaking health insurance for health care.

Fortunately, the cash vs. form conundrum is easily flipped: If you don’t take my cash without the form, I will take my cash elsewhere. Soon, all is well, even if not everyone fully understands why.

Although self-pay patients are driving untold numbers of doctors to gravitate toward payment models centered on patients—as opposed to models centered on insurers, lobbyists, and governments—the self-pay stigma will probably stick around awhile.

Self-pay patients will keep calm and carry cash.

Michael T. Hamilton ( is The Heartland Institute’s research fellow for health care policy, managing editor of Health Care News, and author of the weekly Consumer Power Report.

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