Changes in Primary Care Access Between 2012 and 2016 for New Patients With Medicaid and Private Coverage

Millions of uninsured adults in the United States have gained health insurance under the Affordable Care Act since major coverage provisions of the act were implemented in 2014, including federal funding for an extension of Medicaid eligibility to nonelderly and low-income adults in some states.¹ Anticipating heightened demand, policymakers launched concurrent initiatives to strengthen primary care delivery, such as raising Medicaid reimbursement to Medicare levels for certain primary care providers in 2013 and 2014,² increasing funds for federally qualified health centers³ and expanding the penetration of Medicaid managed care.⁴

In this audit study, simulated patients requested new patient appointments from primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas. To assess the Affordable Care Act’s effect on primary care access, a baseline study⁵ from 2012-2013 was repeated in 2016 with an updated sample of practices. Eligible practices had at least 1 primary care physician who served nonelderly adults and participated in a provider network within a caller’s insurance type. A nondeceptive and pre-audit survey verified eligibility and identified a specific in-network plan. This study, performed from November 13, 2012, to April 3, 2013, and from February 8, 2016, to June 16, 2016, was approved by the institutional review board of the University of Pennsylvania. The requirement for informed consent was waived, and we have protected the confidentiality of individual practices.

Callers varied by age, sex, and race/ethnicity and were randomized to an insurance type (Medicaid or private coverage) and clinical scenario (hypertension or check-up). They requested the earliest appointment available with a randomly selected primary care physician within each practice but, if necessary, accepted appointments with another primary care physician or midlevel provider. Callers requested an appointment using an in-network plan, recorded whether an appointment was granted and what date it was scheduled, and then cancelled the appointment. More detail on our methodology is available elsewhere.^2,5

We analyzed changes between 2012-2013 and 2016 in appointment availability and the probability of short wait times (≤1 week) and long wait times (>30 days). We tested for significant differences in means using 2-tailed tests, weights, and county-clustered SEs.

Across the 10 states, for Medicaid callers, appointment availability increased 5.4 percentage points (95% CI, 2.1-8.6) (Table 1) and short wait times decreased 6.7 percentage points (95% CI, −10.1 to −3.3) (Table 2) between 2012-2013 and 2016. For privately insured callers, there was no significant change in appointment availability, although short wait times decreased 4.1 percentage points (95% CI, −6.3 to −1.9) and long wait times increased 3.3 percentage points (95% CI, 1.9-4.8). The gap in appointment availability between insurance types narrowed, but Medicaid rates still lagged behind private coverage in 2016.

Medicaid callers experienced increasing appointment availability in Illinois (20.0 percentage points; 95% CI, 11.4-28.5), Iowa (8.1 percentage points; 95% CI, 1.2-15.0), and Pennsylvania (7.2 percentage points; 95% CI, 0.0-14.5). Privately insured callers experienced increasing appointment availability in Pennsylvania (6.5 percentage points; 95% CI, 1.9-11.2) but faced decreases in Oregon (−8.9 percentage points; 95% CI, −16.4 to −1.5) and Arkansas (−5.1 percentage points; 95% CI, −9.4 to −0.8). There was no significant change in appointment availability for either insurance type in Georgia, Massachusetts, Montana, New Jersey, or Texas.

Between 2012-2013 and 2016, appointment availability increased for Medicaid callers and remained stable for privately insured callers. Short wait times (≤1 week) decreased for callers with both insurance types, and long wait times (>30 days) increased for callers with private coverage.

The appointment availability results should ease concerns that the Affordable Care Act would exacerbate the primary care shortage. The increase in appointment availability is particularly surprising given the expiration of the Medicaid rate increase in most states.² Primary care practices may be adapting to an influx of new patients with shorter visits and more rigorous management of no-shows. The absorption of patients can explain the longer wait times, which was similarly observed in Massachusetts after it expanded Medicaid in 2006.⁶ Beyond Affordable Care Act initiatives, changes that may have further expanded capacity include team-based practices, retail clinics, and data sharing.

Of note, this study considers only new patients calling in-network offices. We cannot measure access for established patients nor can we control for the myriad health system changes that occurred during the same period. While the 10 states were selected for diversity along a number of dimensions, our results may not be generalizable to other settings.

Corresponding Author: Daniel Polsky, PhD, Department of Health Care Management and the Division of General Internal Medicine, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104 (polsky@wharton.upenn.edu).

Published Online: February 27, 2017. doi:10.1001/jamainternmed.2016.9662

Author Contributions: Drs Polsky and Candon had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

Study concept and design: Polsky, Candon, Wissoker, Kenney, Rhodes.

Acquisition, analysis, or interpretation of data: Candon, Saloner, Wissoker, Hempstead, Kenney, Rhodes.

Drafting of the manuscript: Polsky, Candon, Saloner.

Critical revision of the manuscript for important intellectual content: Wissoker, Hempstead, Kenney, Rhodes.

Statistical analysis: Polsky, Candon, Wissoker.

Obtained funding: Polsky, Wissoker, Kenney, Rhodes.

Administrative, technical, or material support: Wissoker.

Study supervision: Polsky, Wissoker, Kenney, Rhodes.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by grant 72843 from the Robert Wood Johnson Foundation.

Role of the Funder/Sponsor: Although Dr Hempstead is employed by the Robert Wood Johnson Foundation, as a funding source the Robert Wood Johnson Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.