Health care reform’s unexpected victims by Shelley DuBois @FortuneMagazine May 24, 2013, 9:01 AM EDT E-mail Tweet Facebook Google Plus Linkedin Share icons Health insurance companies are hectic places these days — they’re preparing for key pieces of the Affordable Care Act (ACA) to go into effect next year. Given the frenzy, certain parts of the act could have unintended consequences. Specifically, a new report suggests, Americans without bank accounts could get left behind, unable to pay their insurance premiums. Here’s why: Health care companies face many pressures before the ACA kicks in, but perhaps one of the most universal is to cut costs. The ACA will force many insurers to change their operations. After the act is fully in effect, insurers will need to allocate a set portion of insurance premiums toward the cost of care instead of overhead costs such as marketing and profits. Part of that overhead cost, for many insurance companies, pays for credit and debit card transaction fees. To reduce overhead costs, some companies are looking to cut those credit and debit card transaction fees by forbidding patients to pay their premiums with their cards. BlueCross BlueShield of Tennessee, for example, no longer accepts premium payments via credit or debit card. Health insurance company Health Net implemented similar measures last year. At press time, Health Net did not offer comment. MORE: What tummy tucks can teach us about health care reform More and more insurance companies are scrapping debit and credit card payment options, says Ryan McCostlin, team member at Nashville-based health care consulting firm Bernard Health: “Since I’ve been thinking about how to help individuals and families figure out what to do about health insurance, more than half the carriers, while they may allow you to pay the first month’s premium with a debit or credit card, quite often, the only options after that are to get direct-billed with a paper statement or to set up an electronic funds transfer (EFT).” The change doesn’t affect his clients much, he says, because the majority of Bernard Health customers have bank accounts and can switch to alternative premium payment methods. But the real problem, argues a new report out of tax services firm Jackson Hewitt, is that a significant number of Americans don’t have bank accounts and will be left without a method to pay for insurance. One out of every 12 households in America are unbanked, according to a 2011 study by the Federal Deposit Insurance Corporation, meaning that they don’t participate in the banking system at all. The Jackson Hewitt report focuses those numbers further: “Among the uninsured, non-elderly population with household incomes in the tax credit eligible range, 27% are effectively ‘unbanked,’” it says. Those “unbanked” Americans could use prepaid debit cards to pay for premiums if companies let them, the report says, but as of now, there’s no language that would require health insurance companies to accept those types of payments. To be clear, “Jackson Hewitt does have a limited commercial interest with prepaid debit cards,” the report disclosed, because the firm allows certain customers to receive tax refunds on prepaid debit cards. As of now, the issue of unbanked Americans paying premiums is not on the government’s radar. The National Association of Insurance Commissioners told Fortune that, so far, “this issue hasn’t been raised. Also, [there] is not anything in the federal register or in the state implementation efforts that would address insured’s being required to use EFTs for payments.” MORE: Watch out. The mortgage securities market is at it again. This issue should be raised, the report argues along with suggesting that government officials press insurance companies to accept debit and credit card payments from patients without bank accounts before the Health Insurance Marketplace opens in October 2013. “Since we’re still working through the regulations, it is too early to know what payment methods will be required for products purchased on the new Health Insurance Marketplace,” says Mary Danielson, a spokesperson for Blue Cross Blue Shield in Tennessee. Coincidentally, the population that could benefit most from universal health care tends to overlap with the population that doesn’t have a formal bank account. It’s a group that could get stuck, thanks to a glitch in the system, unable to pay premiums for the health care that the White House, via the Affordable Care Act, so desperately wants to make available to all.