Medicaid Access Increased Under ACA

Under the Affordable Care Act (ACA), millions of previously uninsured Americans gained access to primary care. Specifically, a newly released study by Daniel Polsky, PhD, a professor of medicine at the Perelman School of Medicine, Philadelphia, Pa., looked at who exactly that included when it came to insurance plans. The study simulated patients using field workers who called up physicians' offices, differing in age, sex, race, ethnicity and, insurance type (Medicaid or private coverage). The study's authors looked at two clinical scenarios, hypertension or check-up, and had participants called in-network primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas. What they found is Medicaid patients had increased access to primary care, while private insurance holders were not affected by the uptick.

Physicians Practice recently sat down with Dr. Polsky to discuss his findings.  Below are excerpts from this conversation.

Talk about your study and its findings?

The study started in 2012 and we've been tracking the ability to get a new patient appointment [at a primary-care practice]….The way we [analyzed] [patients] access is to have field workers call up physician offices and ask for an appointment, we did it the exact same way in 2012, 2014, and then again in 2016. We varied the insurance that the caller had, sometimes they had private insurance and sometimes they had Medicaid. The main finding is that the ability to get a new patient appointment went up for Medicaid [patients] between 2012 and 2016 by 5.4 percentage points.

As an economist, my prediction was that the probability of getting an appointment in Medicaid would go down. [This is because] there would be more people trying to seek care from the same number of doctors. For it to go up means something must have changed on the supply side for doctors and physician practices. With more Medicaid patients out there, physician practices must have made some adjustments to how they organize their practices to be able to give appointments to a greater fraction [of Medicaid patients].

Why did you use those metrics to study patient access?

The primary reason was that the new patient appointment is the most experimentally valid for an [this type of] study. You can't ask about existing patient relationships, because if you called up as a field worker, it wouldn't make sense if you're already in that practice. The other reason is we really wanted to focus like a laser on the issues of access for the people who are just getting insurance and developing a new relationship with a primary-care provider. Finding one that is willing to see you and knowing you have a choice over providers, that relationship was the main focus here in terms of the dimension of access we were interested in exploring.

The other thing we explored was wait times. We found there was a slight uptick [from 2012 to 2016] in the number of days until you got to see a doctor. The probability that you can call up and get an appointment in seven days went down by six percentage points [over that same period of time]. What we found is that instead of waiting one week, you wait two. For primary-care access, we weren't too alarmed by the increase in wait times from 2012 to 2016. Practices had to make room for more Medicaid patients, increasing wait times.

What should physicians take away from your study?

I think there's a lot of chatter out there, I don't see it so much in the evidence, but a concern [is] there are not enough primary-care physicians. This work suggests that there is sufficient capacity to handle more patients, it just requires a reorganization of physicians practices. I'm not denying that there might be pockets of the country that have insufficient access, but I think there are opportunities for primary- care practices to adapt to handle increased demand.

In terms of what physicians can do when they get busy is find ways to organize their practice to be able to meet patient demand. We've seen that practices have done that and they should take pride in their ability to adapt to the changing environment that they face.

Did anything along the way lead you to believe the results would differ for established patients?

I think the results would be about the same. I think one reason there are a lot of physicians that are in Medicaid managed-care networks but not accepting new patients is that they are dedicated to their existing patients. These patients may have transitioned into Medicaid and they want to make sure they are in those networks. Clearly there's a dedication with those stable patients across their insurance transitions, and I've seen an increase in the amount of physicians that are part of Medicaid managed networks.

We have looked at the correlation between the states with Medicaid expansion and found that there's more access in Medicaid…The states that have Medicaid expansion have a greater breathe of physicians who are willing and able to make appointments for Medicaid.…From a policy perspective, it suggests to me any notion that the Medicaid expansion might have eroded access, our results are moving completely in the opposite direction. This [research] suggests that physician practices have been able to meet the demand and then some, they have been there for the expansion and embraced it.