Addressing Financial Barriers to Health Care Among People Who are Low-Income and Insured in New York City, 2014–2017

While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW–HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities. Supplementary Information The online version contains supplementary material available at 10.1007/s10900-022-01173-6.


Introduction
Largely due to economic exploitation and trauma inflicted systematically over centuries in the United States, [1] Black people and other people of color have been prevented from accumulating wealth and entering higher-income occupations in the same ways as white Americans. These inequitable systems persist in the form of social, economic, and cultural barriers to accessing health and social services. [2][3][4][5] The health care delivery and financing systems are particularly suboptimal, even punitive, for those with low household incomes. [6] While some research has assessed financial barriers for uninsured individuals with low household incomes, [7][8][9] financial barriers to health care among insured people with low household incomes, and the strategies to ameliorate them, have not been as well characterized. A limited number of studies have shown that insured families ineligible for Medicaid but still considered to have low household incomes struggle disproportionately with unaffordable co-pays, deductibles, and prescription drug costs. [10][11][12][13][14][15][16][17][18][19][20][21][22] However, it is often the case that communities where a high proportion of households live below the federal poverty level (herein, "low-income communities"), and in which a majority of members have Medicaid or other health insurance, have limited access to information about how to obtain free or discounted medical care and other support to help with out-of-pocket medical expenses. [23] These factors contribute to underutilization of medical care

Intervention
Led by the NYC Health Department, HHAP was developed as a multi-stakeholder partnership with the New York University-City University of New York Prevention Research Center (NYU-CUNY PRC), the Community Service Society of New York (CSS), and the New York City Housing Authority (NYCHA). [24] HHAP is guided by a health equity framework and the evidence supporting the use of community-based CHWs to improve health outcomes. [4 25-28] HHAP CHWs engage residents with asthma, diabetes, hypertension, and other health conditions, to improve disease management and achieve health goals. CHWs provide health coaching activities, community events, and advocacy training. [24] HHAP strives to hire CHWs who live in public housing and/or the East and Central Harlem neighborhoods to create authentic connections to the community served and a workforce development pipeline through fulltime employment.
A novel feature of the HHAP model combines CHW assistance with that of HAs, who have technical expertise in health insurance and health system navigation. [24] This component was conceived in response to feedback from the community and evidence in the published literature that many insured residents in low-income communities face health care navigation challenges. [29 30] The HA component allows CHWs to refer residents to HAs when there are insurance-related obstacles to achieving their health goals. HAs use their knowledge of both public and private insurance systems and the local health care provision landscape to help residents understand their insurance options, obtain affordable health care, resolve billing issues, and overcome other barriers to getting the health care they need (Fig. 1). [24] CHWs work one-on-one with residents to achieve their health goals and HAs use their specialized training in health system navigation and insurance policy to mitigate barriers to achieving those goals. [24].
At HHAP's inception, CSS was contracted to provide HA services to the program. The history of CSS's Health Advocates can be traced back to 1998 when the NYC Council provided funding to CSS to establish the Managed Care Consumer Assistance Program in partnership with 26 community-based organizations (CBOs). This program was New York's first health care Consumer Assistance Program (CAP) and a precursor to federal CAPs, which were authorized in Sect. 1002 of the Patient Protection and Affordable Care Act. CAPs educate consumers about coverage options, enroll consumers into coverage, inform consumers of their rights and responsibilities, file grievances with insurance plans and regulators, and report back to policy makers about problems with existing programs and regulations. CSS has operated New York State's (NYS's) CAP, Community Health Advocates (CHA), since 2010. CHA, currently funded by the NYS State Legislature and the NYS Department of Health, is one of the largest CAPs in the country with a live-answer Helpline and a network of 27 CBOs. The inclusion of HA services provides assistance to clients whose health goals are hampered by financial barriers related to their health care and coverage, particularly in light of the subsequent reductions in federal funding for state-based CAPs, which began in 2017. [31].
Because HHAP is place-based, it eliminates the burden of traveling to receive health insurance enrollment or other post-enrollment assistance for clients. HHAP participants can meet with an HA in their homes, a community center, or neighborhood health action center. Unlike other place-based initiatives that train CHWs to identify a client's issue and refer them to other services for resolution, HAs focus on sustaining relationships with CHWs and clients through advocacy and addressing barriers to health care, while also expanding health insurance literacy. [32][33][34][35][36][37] Specifically, HAs help residents understand their insurance options, obtain affordable health care, resolve billing issues, and overcome other barriers to getting needed health services (Fig. 2). [24] Some insurance navigation issues can be addressed in a single visit. Other issues require multiple conversations with residents and additional action by HAs.

Data Sources
Data for this analysis were drawn from two data sources used to conduct formative and program evaluations for HHAP: focus groups done in the planning phase of HHAP and administrative data record review from the first four years of HHAP. At the outset of the project, the NYU-CUNY PRC team conducted focus groups in December 2014 among HHAP-eligible NYCHA residents. [38] Focus group participants were required to meet the following criteria: (1) speak English or Spanish; (2) be aged 35 to 65 years; (3) have a self-reported diagnosis or family history of diabetes, asthma, and/or hypertension; and (4) reside in one of five intervention housing developments. Focus groups lasted approximately 1.5 to 2 h; six focus groups were completed with a total of 55 residents. [38] Discussion topics included barriers and facilitators to disease management, engaging in healthy behaviors, preferred methods of health education  and promotion, and acceptability of and motivation to participate in a CHW intervention. [38]. The second data source focused specifically on HHAP participants who were referred to CSS for HA assistance. We reviewed CSS administrative case record notes and compiled case studies from September 1, 2014 through September 30, 2017 to provide further context for problems faced by CSS clients reporting financial barriers to care and the process by which HAs resolved these problems. Within this timeframe, HHAP HAs assisted 591 public housing clients, with 150 individuals (25%) who had insurance reporting financial barriers to care. We identified 244 financial barriers among the 150 clients, with clients having the option to report multiple barriers.

Data Analysis
Recorded focus group sessions were transcribed, and a codebook was developed using the moderator guide as an initial outline of primary codes, followed by secondary and tertiary codes. Three independent coders reviewed and analyzed transcripts through thematic analysis, following a constant comparative approach, discussing and resolving discrepancies until an acceptable level of inter-coder reliability had been established. [39] Atlas.ti 6 was used to code and analyze the data. [39 40] Findings related to barriers and facilitators to access to care were highlighted for this paper.
Data analysis from the CSS administrative record review was conducted on client cases reporting financial barriers to care. Each CSS client case was coded into one of six categories of financial barriers: (1) Affordability; (2) Outstanding Bills; (3) Non-covered Benefits; (4) Billing Errors; (5) Service Denials; and (6) Eligibility. These codes were created based on major themes presented in the data. Affordability barriers involve cost-sharing, such as deductibles, co-insurance, co-pays, or premiums that prohibit individuals from accessing care. Outstanding Bills include medical bills indicating a balance that clients are responsible for paying. Non-Covered Benefits include services not covered by insurance and cases in which plan benefits were exhausted. Billing Errors include bills sent to clients erroneously, either due to health insurance system or provider error. Service Denials include cases in which clients sought to appeal or otherwise contest pre-authorization or service coverage denials from their health insurer. Eligibility includes the inability to enroll into supplemental health insurance.
Resolutions for each financial barrier were coded into one of four categories: (1) Resolved with HA assistance, indicating that an HA directly resolved the issue or provided information towards resolution); (2) Resolved without HA assistance, indicating cases resolved by the client or an administrative body without HA advocacy; (3) Unresolved due to issues outside the scope of HAs, such as an unmet eligibility requirement or a plan contract; and (4) Unresolved due to loss to follow up. HAs participate in weekly case review sessions, and upon closure, cases undergo a quality assurance process to ensure all options available to address the client's needs were explored.
Descriptive analysis was conducted of the codes generated from the CSS database to characterize the proportion and type of barrier experienced by clients as well as the proportion and type of resolutions. In addition to this descriptive analysis, we conducted a content analysis of CSS case files to generate case studies of financial barriers to care and resolution processes and strategies.

Characterization of Barriers to Health Care Among East and Central Harlem NYCHA Residents
During focus groups to explore barriers and facilitators to disease management, residents were asked questions about care management and financial barriers to care. Participants were mostly female (82%), with an average age of 58 years. Participants described affordability issues related to their insurance coverage as a significant barrier to chronic disease management and quality of life. Many participants with low or fixed incomes cited outstanding bills and difficulty covering premiums, co-pays, and other out-of-pocket expenses.

Sometimes the [insurance] doesn't cover the diabetic medication. So, some people can't get the medication because they are on a fixed income.
Participants also expressed frustration with navigating health coverage policies and lack of coordination or consistency among providers, insurers, and pharmacies.

Financial Barriers to Care Experienced by CSS Clients
Of the 591 HHAP clients served between November 2014 and January 2017, 150 individuals (25%) reported experiencing a financial barrier to care. Although the provision of demographic information was not required to receive HA services, 96% (n = 144) of the 150 individuals who reported experiencing a financial barrier also reported some demographic information. Of those who reported demographic information, 74% (n = 106) were female, 50% (n = 58) identified as Hispanic, and 48% (n = 56) identified as African American (Table 1). 63% (n = 90) and 35% (n = 51) reported speaking English and Spanish at home, respectively. Clients who experienced financial barriers to accessing care (n = 150) were more likely to be African American (48% vs. 33%) or Hispanic (50% vs. 40%) compared to those who did not experience financial barriers (n = 441; see Supplement).
65% (n = 97) of clients who experienced financial barriers were enrolled in Medicare through original Medicare or a Medicare Managed Care plan. Of the Medicare enrollees, 26% (n = 39) were dual-eligible, with Medicaid as their secondary insurance. A total of 23% (n = 34) of clients had Medicaid as their primary insurance (17% enrolled in a Medicaid Managed Care plan and 6% enrolled in fee-forservice Medicaid). 6% of clients (n = 9) had employer-sponsored insurance, 2% (n = 3) were enrolled in the Essential Plan, the NYS Basic Health Program serving lower income and immigrant populations), and 4% (n = 6) did not report insurance type.
Clients who reported financial barriers experienced a total of 244 financial barriers (ranging from one to three barriers per client). Affordability barriers were the most common and were experienced by 48% of the 150 clients with barriers. This was followed by outstanding bills (37%), non-covered benefit barriers (27%), billing errors (24%), service denials (15%), and eligibility issues (12%). A total of 73% of the 244 financial barriers were resolved by HAs, with at least one barrier (clients often experience more than one) resolved for 79% (n = 118) of clients. For the remaining barriers, 13% were unresolved due to issues outside the scope of HAs, 10% were unresolved due to client loss to follow up, and 4% were resolved without HA intervention (Fig. 2).

Affordability
Forty-eight percentage of clients experienced affordability barriers, which accounted for 72 of the 244 barriers experienced. Many insured clients had difficulty affording their monthly premiums and cost-sharing responsibilities, such as deductibles and co-pays. These affordability barriers were most often related to Medicare.
HAs were able to resolve 49 of the 72 affordability barriers using various strategies. Premiums and cost-sharing were reduced for some Medicare enrollees through supplemental insurance programs like the Medicare Savings Program (MSP). [41] HAs also assisted residents who were ineligible for supplemental insurance. HAs often directed clients to HHC Options, which provides care on a sliding fee scale through NYC's public hospital system or through alternative private philanthropy resources, like The New York Times (NYT) Neediest Cases Fund, as demonstrated through the case below. [42][43][44] A 72-year-old client with advanced stage periodontitis needed assistance from an HA to secure coverage for her procedures. The client's Medicare only covered preventive dental services and her supplemental dental coverage only offered a 20% discount on services. The client is the primary caregiver for her grandchildren and could not afford to pay the remaining costs. The HA helped her find a dentist who would treat her at a lower cost than any standalone dental insurance on the market could offer and helped her secure a NYT Neediest grant of $930 to pay for the procedure. .

Outstanding Bills
Thirty-seven percentage of clients experienced unexpected medical bills, which accounted for 56 of the 244 barriers experienced. Most bills experienced by residents could be categorized as cost-sharing bills, balance bills, hospital out-of-network emergency service bills, surprise bills (unexpected bills for out-of-network care received unbeknownst to patients), bills for non-covered services, bills for services denied on the basis of medical necessity, and bills for failure to request a prior authorization. HAs had to be well-versed in operational and legal intricacies of the health care and insurance systems and apply a multifaceted approach to solving outstanding bill issues. Because of the fragmented nature of health care coverage in the U.S., the HA's decision on which strategy to use to achieve a positive outcome depended not only on the type of bill but also on the resident's insurance type. An example of strategies used to resolve unexpected medical bills experienced by a client is described below.
A client had over $14,000 in outstanding medical bills. The client had not worked since 2014 due to a work-related injury and had a pending workers' compensation case. The coverage from the client's former employer was still active, but the plan had unaffordable co-pays and a high deductible. The HA helped the client apply for Medicaid as secondary insurance through the NYS of Health Marketplace and resolved many of the bills through the retroactive approval of coverage.
In Table 2, we summarized common billing issues experienced by HHAP clients, the strategies employed by HAs to address them, and broader policy recommendations to resolve underlying structural drivers of the recurring billing issues consumers encounter. Medical billing can be challenging for consumers to navigate without an understanding of the specific billing protections for the type of plan in which they are enrolled and that plan's contract details. Robust consumer assistance programs are needed to ensure that plans adhere to billing protections and provide any mandated coverage to their members. A recent report indicated that "[e]ighteen percent of payment denials were for claims that met Medicare coverage rules and [Medicare Advantage Organization] billing rules." [45] Several of the issues identified in Table 2 are discussed in turn below.

Non-Covered Benefits
Twenty seven percentage of clients experienced non-covered benefits, accounting for 40 of the 244 barriers. HAs resolved 58% of these barriers. The HAs educated clients about their rights when benefits were exhausted and helped them explore secondary and tertiary insurance options. For instance, HAs helped clients enroll in the NYS Elderly Pharmaceutical Insurance Coverage (EPIC) program, a supplemental insurance option for NYS residents who are 65 and older, enrolled in Medicare Part D drug coverage, and are unable to afford the cost of a necessary prescription medication or are caught in the annual Medicare "doughnut hole." [46] A client questioned why several of her medications were not covered by her insurance. Each prescription was either a Tier 2 or 3 drug, for a total monthly cost of $145. None of the prescriptions had cheaper generic alternatives, which the client preferred. The HA introduced the client to the EPIC program as an option. In EPIC, members may pay an annual fee ranging from $8 to $300 based on their income. After any Part D deductible is met, members then only pay the EPIC co-payment for drugs. Co-payments range from $3 to $20 based on the drug cost not covered by Part D. This client was eligible to pay $230 annually or $52.50 quarterly, allowing her to receive her prescriptions at a more affordable rate. .

Billing Errors
Billing errors were common among clients enrolled in both Medicare and Medicaid. They were experienced by 24% of the clients in our sample and accounted for 36 of the 244 barriers reported. HAs resolved 94% of these barriers, often by advocating with billing offices to correct errors by citing the Medicaid law that protects dual-eligible clients from balance billing and ensuring that claims are properly resubmitted. Billing errors also occurred when a client with a Medicaid spend-down was hospitalized; Medicaid limits the amount that hospitals can charge these patients. HAs advocated to ensure that clients were only held responsible for the allowable amount and negotiated that amount down further based on the client's ability to pay.
HHAP clients with Medicaid coverage often had billing errors related to out-of-state emergency medical care. Medicaid covers emergency care in all 50 states, but it can be difficult to get out-of-state providers to honor this provision. Through advocacy, HAs helped Medicaid clients resolve these out-of-state emergency bills.
HAs also advocated on behalf of clients confronted with out-of-network surprise bills by using their knowledge of recently passed consumer protection laws, like NYS's 2015 Surprise Bill Law. Trained to navigate complex and unique health insurance issues, HAs held billing offices accountable, while also educating clients about their rights, as demonstrated by the case described below.
A client received a denial from his health insurance company claiming he had gone to an out-of-network provider for cataract surgery and would need to pay the out-of-network rate of $3,500. However, this provider was listed on his Explanation of Benefits as being in-network. The client worked with the HA to inquire into this discrepancy and request that the health insurance company review the determination, before filing an appeal of the decision. The insurance company resubmitted the claim, and the bill was ultimately covered as in-network.

Service Denials
Service denials for medically necessary treatments and procedures were experienced by 15% of clients in our sample and accounted for 22 of the 244 barriers. These denials can significantly delay or derail medical care when a client does not have the technical expertise or advocacy support to appeal. HAs resolved 81% of these denials. To resolve these types of issues, HAs identified errors in billing codes, submitted appeals in disputes over medically necessary procedures/services, and discovered administrative errors or unnecessary delays. Through appropriate channels and Create an independent dispute resolution process for plans and providers, and prohibit all balance billing for emergency services • Bill is from an OON provider at an innetwork hospital and either: • in-network doctor was not available; • client did not know an in-network physician provided services; or • unforeseen medical circumstance arose at time services were provided • A client is referred by an in-network provider to an OON provider and client is not aware the provider they were referred to was OON. Only applicable if plan requires referrals If client has a fully-insured commercial plan, HAs help the client complete and submit an assignment of benefits (AOB) form to be held harmless for the bill Extend balance billing protections to patients who receive false information about a provider's inclusion in a network from either the provider or the plan.
If the plan does not honor the AOB or mistakenly process the AOB as an appeal, file a complaint with DFS Apply these protections in all instances when patients unknowingly receive care from an out-of-network provider If client has a self-insured commercial plan or is uninsured, use same approach as Hospital out-of-network emergency services bills Hospital/provider bills for non-covered services All health insurance plans can deny coverage and bill for a service on the grounds that it is "not a covered benefit", meaning that the service is excluded from the plan's contract Verify that the plan is not violating any applicable federal or state laws by failing to cover the service.
Expand coverage for preventative care services to include ultrasounds in lieu of mammograms for women with dense breast tissue.
Review the plan contract. If the plan is not responsible to cover the service, help client apply for hospital financial assistance or negotiate the bill Expand coverage of IVF and fertility services and improve dental coverage and benefits

Discussion
In this paper, we contribute to a limited body of literature to gain a more in-depth understanding of health care-associated financial barriers faced by insured individuals with low household incomes using qualitative and administrative data. [4 17 47] We also describe an innovative, placebased model to ameliorate these barriers. Focus group data revealed residents to be deeply frustrated with the lack of Many insurance plans require prior authorization before they will cover certain medical services or medications. Clients who fail to request prior authorization may be billed for services Verify the medical service requires prior authorization. A client may be held harmless when an in-network provider fails to obtain prior authorization Limit the types of care that require pre-authorization. For example, New York State recently prohibited prior authorization for pediatric mental health hospitalizations Request that the provider submit prior authorization retroactively. If that is unsuccessful, help the client apply for hospital financial assistance or negotiate the bill States must provide independent consumer assistance programs to aid patients in navigating prior authorization requirements for care coordination in the health care system and often unable to afford cost-sharing for health care services. [38] Our analysis of administrative data identified several categories of financial barriers faced by HHAP clients in accessing care and outlined strategies HAs used to resolve the majority of the most frequently reported financial barriers to health care. Clients whose issues could not be resolved were informed of the reasons why their barrier could not be addressed. HAs educate patients about both their rights and the limitations of those rights in the health care system, a key component of health care literacy.
In the HHAP initiative, HAs employed direct navigation and advocacy methods while also addressing health care literacy, rather than using passive referral methods. [48][49][50] HAs must be highly trained on the complexities of the health care system and its programs, as well as resources and tools to resolve clients' financial barriers. Their core strategies included helping residents apply for hospital financial assistance or supplemental insurance programs, enforcing consumer protection laws, and appealing service denials. For certain financial barriers, such as outstanding medical bills, HAs had to resort to a wider arsenal of advocacy tools to help clients eliminate or reduce the amount they owed.
HA decisions on which advocacy tool to use and outcomes of HA intervention depended heavily on the resident's insurance type. This was common across nearly all financial barriers cases and highlights one of the major challenges faced by broad-based health care literacy initiatives. For instance, residents enrolled in public programs like Medicaid, Child Health Plus, and the Essential Plan were less likely to face affordability barriers and cost-sharing bills because these types of insurance do not charge deductibles or high co-payments for services. In general, Medicaid enrollees were more protected from financial barriers such as balance billing than residents enrolled in Medicare or commercial health insurance products because providers are not allowed to charge a difference between the amount paid by a Medicaid plan and the amount charged by the provider. [10][11][12][13][14][15][16][17][18][19][20][21][22] Lack of financial consumer protections and affordable cost-sharing options were the main reasons residents enrolled in Medicare reported more financial barriers. HAs thus tried to help senior residents reduce their Medicare premiums and cost-sharing by enrolling them in Medicaid or the Medicare Saving Program. However, income limits for some of these programs are so low that even clients at 101% of the Federal Poverty Level were not eligible to enroll.
While this study demonstrates the valuable role that HAs can play in ameliorating financial barriers, some financial barriers remained intractable. Medicare enrollees ineligible for supplemental insurance plans and other cost-sharing reductions such as the pharmaceutical discount can have significant out-of-pocket expenses associated with their health care. Several benefits are not covered by Medicare-for example, dental and homecare-and raise additional affordability concerns. Many clients eligible for Medicaid with a surplus are often unable to pay the amount required to activate their Medicaid coverage. Facility fees are another health care cost imposed by providers, but sometimes not covered by insurance carriers, resulting in unexpected and unresolvable costs for consumers. Additionally, generations of economic injustice have created and perpetuated a cycle of financial disadvantage that underpins many poor health outcomes. These are reproduced and reinforced by interconnected discriminatory policies and systems of power. HAs advocate for their clients within the confines of the existing health care infrastructure where gaps in coverage persist in areas such as dental and vision care, homecare, and prescription drugs. [17] High deductible health insurance plans and other significant cost-sharing also prohibit many insured people from accessing care, especially when they are ineligible for affordable supplemental insurance options. [8 17].
This study has some limitations. The administrative data were based on clients' self-reported financial barriers to health care. Due to the lack of a controlled comparison group, it was not feasible to compare the resolution of financial barriers for clients assisted by HAs to those who did not receive any outside assistance or those who were assisted by other means. However, during our observation period, we observed a modest percentage of resolutions achieved without HA intervention (4% of all identified financial barriers).

Conclusion
This study describes the financial barriers to health care faced by insured public housing residents in East Harlem, but these barriers are experienced more broadly by Black people and other people of color throughout the United States. We highlight the role that HAs play in ensuring that individuals not only have health insurance, but that they understand and are able to use their health insurance to get the care they need. Based on our experience, we recommend that CHW models incorporate HAs to ensure that health system navigation can be seamlessly integrated and that participants can effectively utilize all aspects of their insurance. In addition to addressing financial barriers, HAs help bridge community-clinical linkages, and reduce health disparities experienced by public housing residents, all of which have implications toward achieving health equity. Experimental or quasi-experimental models to test this partnership model against CHW-only service provision would provide valuable empirical evidence.