Why Are One in Four Pennsylvanians Paying Out of Pocket for Annual Checkups?

When patients schedule an annual physical examination, they generally expect the visit to come at no additional cost. However, recent research highlights a surprising reality for many individuals seeking routine preventive care. According to a study published in August 2026 in the peer-reviewed journal Prevention Science, nearly one in four insured adults reported paying out of pocket for their most recent annual checkup.

Understanding the Gap in Preventive Coverage

Under the Affordable Care Act (ACA), most health insurance plans are required to cover specific recommended preventive services without cost-sharing, such as copayments or deductibles. These mandated services include blood pressure screenings, certain cancer screenings, routine vaccinations, and tobacco cessation counseling, provided patients see doctors within their insurance network.

Despite these federal regulations, unexpected bills frequently occur during routine doctor visits. Researchers emphasize several reasons why a preventive appointment might result in charges:

• Discussing a new symptom or asking a clinician to manage an existing chronic condition during the visit can trigger a separate office-visit charge.
• Certain diagnostic tests may be billed differently than preventive screenings, depending on the specifics of the plan and provider.
• Administrative and billing errors, such as incorrect medical coding submitted by a clinic, can mistakenly result in patient fees.
• Coverage policies and interpretations can vary significantly across different insurance plans and medical providers.

Insights From the Penn State Lion Poll

To examine how frequently patients encounter unexpected costs, researchers analyzed data from the 2024 Penn State Lion Poll, an online survey of Pennsylvania adults. The analysis focused on 912 insured individuals who reported attending an annual checkup within the preceding decade, with the majority having completed a visit in the past year.

Among those surveyed, 23.5% reported paying out of pocket for their latest checkup, with an average reported payment of $68.50. The authors noted that the study demonstrated statistical associations rather than direct causation, and the nonrandom sample cannot provide a definitive statewide estimate. Furthermore, because the findings relied on patient recall rather than official billing records, researchers could not independently verify why individual charges were applied.

However, the survey identified notable demographic and psychological associations. Respondents who were unfamiliar with ACA preventive-care protections were about 12 percentage points more likely to report paying out of pocket compared to those who understood the protections. Additionally, individuals who viewed healthcare as unaffordable were roughly 13 percentage points more likely to report out-of-pocket expenses.

Navigating Medical Bills and Protecting Your Coverage

While the study did not find a direct statistical link between paying for a previous checkup and skipping future appointments, health experts caution that financial uncertainty can create psychological barriers to seeking necessary medical attention. Delaying preventive services can ultimately hinder the early detection of health conditions when treatments are typically most effective.

To minimize the risk of surprise medical bills, researchers recommend taking proactive steps before and after appointments:

• Contact your insurance provider prior to your visit to verify which preventive services are fully covered and confirm that your physician is in-network.
• Ask your healthcare provider’s office whether addressing additional health concerns or receiving specific tests during your checkup will alter how the visit is billed.
• Review your insurance explanation of benefits documents after your appointment to ensure charges align with your expectations.
• Contact your provider’s billing department to request a code review or correction if a mistake appears on your statement.

Experts emphasize that patients should not need specialized knowledge in medical billing to access standard preventive healthcare, pointing to a need for clearer coverage details and enhanced billing transparency.