Appointment Availability after Increases in Medicaid Payments for Primary Care

Abstract

Background:
Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects.

Methods:
We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state.

Results:
The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups.

Conclusions:
Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

Full text

The
new england journal
of
medicine
n engl j med 372;6 nejm.org february 5, 2015
537
Special article
Appointment Availability after Increases
in Medicaid Payments for Primary Care
Daniel Polsky, Ph.D., Michael Richards, M.D., Ph.D., Simon Basseyn, B.A.,
Douglas Wissoker, Ph.D., Genevieve M. Kenney, Ph.D., Stephen Zuckerman, Ph.D.,
and Karin V. Rhodes, M.D.
From the Perelman School of Medicine
(D.P., S.B., K.V.R.) and the Leonard Davis
Institute of Health Economics (D.P.,
M.R., K.V.R.), University of Pennsylvania,
Philadelphia; and the Urban Institute,
Washington, DC (D.W., G.M.K., S.Z.).
Address reprint requests to Dr. Polsky at
the Leonard Davis Institute of Health
Economics, University of Pennsylvania,
3641 Locust Walk, Suite 210, Philadel-
phia, PA 19104, or at polsky@wharton
.upenn.edu.
This article was published on January 21,
2015, at NEJM.org.
N Engl J Med 2015;372:537-45.
DOI: 10.1056/NEJMsa1413299
Copyright © 2015 Massachusetts Medical Society.
Abstract
Background
Providing increases in Medicaid reimbursements for primary care, a key provision
of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in
2013 and 2014 for selected services and providers. The federally funded increase in
reimbursements was aimed at expanding access to primary care for the growing
number of Medicaid enrollees. The reimbursement increase expired at the end of
2014 in most states before policymakers had much empirical evidence about its
effects.
Methods
We measured the availability of and waiting times for appointments in 10 states
during two periods: from November 2012 through March 2013 and from May 2014
through July 2014. Trained field staff posed as either Medicaid enrollees or pri-
vately insured enrollees seeking new-patient primary care appointments. We esti-
mated state-level changes over time in a stable cohort of primary care practices that
participated in Medicaid to assess whether willingness to provide appointments for
new Medicaid enrollees was related to the size of increases in Medicaid reimburse-
ments in each state.
Results
The availability of primary care appointments in the Medicaid group increased by
7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The
states with the largest increases in availability tended to be those with the largest
increases in reimbursements, with an estimated increase of 1.25 percentage points
in availability per 10% increase in Medicaid reimbursements (P = 0.03). No such as-
sociation was observed in the private-insurance group. During the same periods,
waiting times to a scheduled new-patient appointment remained stable over time in
the two study groups.
Conclusions
Our study provides early evidence that increased Medicaid reimbursement to pri-
mary care providers, as mandated in the ACA, was associated with improved ap-
pointment availability for Medicaid enrollees among participating providers without
generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.)
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A
primary goal of the Affordable
Care Act (ACA) was to improve access to
quality health care for uninsured Ameri-
cans, largely through public and private insur-
ance expansions.
1
At the same time, the architects
of the law recognized the need to increase the
availability of primary care providers to meet the
increased demand for health care. Provider access
is of particular concern for the Medicaid program,
which is set to absorb the bulk of newly insured
persons in many states, because Medicaid typi-
cally reimburses providers at much lower pay-
ment rates than those of Medicare and commer-
cial insurers for the sa me services. Lower payments
have been cited as a critical barrier to access for
primary care among Medicaid enrollees
2-7
and
are associated with lower provider availability for
Medicaid patients.
5
To address these concerns,
the ACA included a 2-year federally financed in-
crease in Medicaid reimbursement.
8,9
The ACA directed Medicaid agencies in each
state to raise Medicaid reimbursements up to
Medicare rates for primary care services in 2013
and 2014.
8,9
The size of this increase varied
widely according to state, since some states were
already paying at least Medicare rates, whereas
others were paying less than half those rates.
10
Providers who were eligible to receive increased
reimbursements included family physicians, in-
ternists, pediatricians, and certain subspecialists
who had a minimum of 60% Medicaid billings
for primary care services during the previous year.
Nurse practitioners and physician assistants work-
ing under the supervision of eligible physicians
also qualified. Because federally qualified health
centers receive payment on a facility basis rather
than on the basis of specific physician services,
such centers were excluded from the study.
8,11
The
reimbursement increase applied both to providers
who practiced in fee-for-service programs and to
those in capitated Medicaid programs.
8,12
The final federal regulations were released late
(in November 2012),
8,13
and there were substantial
challenges in translating fee-for-service Medicare
rates to capitated Medicaid managed care set-
tings.
13,14
As a result, it was well into 2013 before
states had their plans approved by the Centers
for Medicare and Medicaid Services.
14,15
All de-
layed reimbursements were paid retroactively to
January 1, 2013.
16
These considerable implemen-
tation challenges, along with the temporary nature
of the policy, has left even supporters question-
ing the ultimate effect of the policy.
14,17,18
In this study, we examined the association
between the increase in Medicaid payments and
appointment availability for Medicaid enrollees
seeking new-patient primary care appointments
at physician offices that participated in Medic-
aid. Our goal was to provide an empirical evalu-
ation of the effectiveness of the policy, which can
inform future state and federal legislative action
with respect to reinstating these payment increases
or allowing them to continue at lower levels in
2015.
19
We estimated appointment availability in
late 2012 to early 2013 and again in mid-2014, us-
ing an audit design in which primary care offices
would make real-world decisions in response to
appointment requests by simulated patients who
were randomly assigned an insurance type. We
then compared state-level changes in appointment
availability in the Medicaid group to the size of
the payment increase in that state and used the
private-insurance group as an experimental control.
Methods
Data Collection
Trained field staff members, simulating patients
seeking a new-patient appointment, called pri-
mary care offices in 10 states — Arkansas, Geor-
gia, Illinois, Iowa, Massachusetts, Montana, New
Jersey, Oregon, Pennsylvania, and Texas — dur-
ing two time periods: from November 2012 through
March 2013 and from May 2014 through July 2014.
Offices receiving audit calls were selected at ran-
dom, within insurance type and time period,
from the constructed sample frame, which was
defined as a physician office staffed with at least
one primary care physician who treated adults and
participated in at least one insurance plan includ-
ed in the relevant insurance type.
We constructed a sample frame of confirmed
qualified offices in three steps. First, we drew a
sample of potentially qualified offices in 2012
from the SK&A Office-Based Physician Database,
20
a commercial database that is estimated to in-
clude nearly 90% of physician practices.
21
Second,
we removed closed, out-of-scope, or unreachable
practices identified by a preaudit survey of the
potentially qualified offices that we conducted
before both audit periods. Third, for each insur-
ance group, we removed offices that did not par-
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Appointment Availability after Medicaid Payment Increases
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539
ticipate in that insurance type. We used the pre-
audit survey, supplemented by online resources,
to confirm insurance participation for both private
insurance and Medicaid and to obtain the name
of an insurance carrier accepted by each practice.
Because all the selected states mandated managed
care for adult Medicaid enrollees, the office had to
participate in some form of Medicaid managed
care (MMC), either capitated managed care or pri-
mary care case management (PCCM). The screen-
ing of offices and their inclusion in the sample
frame are shown in Figure S1 in the Supplemen-
tary Appendix, available with the full text of this
article at NEJM.org.
Offices were chosen randomly, within insur-
ance type and time period, according to the pro-
portion of the population with the relevant insur-
ance type in the county. The 13 callers
conducting the audit were selected on the basis
of having voices that matched particular roles
with respect to age, sex, and race or ethnic
group. They were randomly assigned to a script
requesting a new-patient appointment for either
routine care or an urgent health care concern
(e.g., “I think I might have high blood pres-
sure”)
21
(Fig. S2 in the Supplementary Appendix).
Since results did not differ substantially across
clinical scenarios, they were combined in all
analyses. Callers requested the earliest appoint-
ment with a specific physician in the office but
would accept appointments with any other avail-
able provider, including a nurse practitioner or a
physician assistant. The callers provided the
type of insurance, along with the name of the
plan identified during the preaudit survey, if they
were asked or when they confirmed the appoint-
ment. All appointments were canceled before the
call was ended or immediately thereafter.
We defined an appointment as being available
if the patient was offered a specific date and time
or was told that the specific appointment would
be scheduled on receipt of an insurance number.
Appointments were considered to be denied if
the caller was told that there was no appointment
available. In 11.4% of the calls (11.1% in the pri-
vate-insurance group and 11.8% in the Medicaid
group), we could not determine whether an ap-
pointment would be scheduled or denied, be-
cause of insurmountable scheduling barriers
that were typically tied to a lack of a valid insur-
ance number. We excluded these cases. Com-
pleted audit calls totaled 9737 during the first
period and 4898 during the second period.
Study Oversight
The study was funded by the Robert Wood John-
son Foundation. The protocol was approved by
the institutional review board at the University of
Pennsylvania; the requirement for informed con-
sent was waived, because we are studying the sys-
tem, rather than the providers, and have protect-
ed the confidentiality of individual practices. All
the authors vouch for the completeness and ac-
curacy of the data and analyses presented. The
manuscript was written, reviewed, modified, and
approved in its final version by all the authors.
The sponsor was not involved in the design or
conduct of the study, the preparation of the man-
uscript, or the decision to submit the manuscript
for publication.
Office Cohort
We analyzed a stable cohort of offices — those
that were eligible for audit calls during the two
time periods — in order to isolate changes over
time that were independent of a changing mix of
physician offices. For this stable cohort, we ex-
cluded audit calls during the first period if prac-
tices became ineligible during the second period.
In the Medicaid group, we also excluded audit
calls to offices that changed Medicaid eligibility.
Federally qualified health centers were excluded
because the Medicaid reimbursement increase
did not apply to those facilities.
Study Outcomes
Our primary outcome was the availability of ap-
pointments for new patients, according to state,
insurance type, and audit period. As a secondary
outcome, we estimated the median waiting time
for appointments as the number of days between
the call and the appointment date. For the esti-
mates, we used weights representing the propor-
tion of the population with each insurance type
in the county in which the office was located.
Weights were scaled so that each state contrib-
uted equally to an aggregate 10-state estimate.
Statistical Analysis
We assessed whether rates of appointment avail-
ability changed over time by testing whether the
percentage-point change between the two audit
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periods in the private-insurance group and the
Medicaid group was different from zero within
each state and for the 10-state average. We then
tested whether the change in the appointment-
availability rate in the Medicaid group was signifi-
cantly different from that in the private-insurance
group. In all cases, we use t-tests with robust esti-
mates of standard errors, clustered according to
county. In our main analysis, we did not adjust
for caller characteristics, since such adjustment
had no influence on the results (Table S1 in the
Supplementary Appendix). We used estimates of
the increase in Medicaid reimbursement (accord-
ing to state) that represent the average percent-
age increase in Medicaid reimbursement for the
affected primary care services that was required
to achieve parity with Medicare fees from 2012
through 2013. These estimates were based on a
sample of the affected primary care services.10 We
categorized states as having a high increase in
reimbursements or a low increase in reimburse-
ments on the basis of whether the size of the in-
crease was above or below the 10-state average.
(See Table S2 in the Supplementary Appendix for
details regarding Medicaid reimbursements for
one example of affected service.)
We displayed the relationship between the
change in appointment availability and the size
of the reimbursement increase for each type of
insurance in a scatter plot and summarized the
observed pattern using a 10-observation linear
regression of the state-level change in appointment
availability on the state-level amount of the reim-
bursement increase. We also explored nonlinear
associations using locally weighted scatterplot
smoothing (LOWESS) and assessed the sensitiv-
ity of the estimated association to the removal of
states with the highest leverage. We used a Pearson
chi-square test for comparisons of median wait-
ing times between the two insurance groups and
over time.
Results
Characteristics of Calls
By design, the characteristics of the calls within
each time period were balanced in terms of the mix
of age group, sex, race or ethnic group, and hyper-
tension scenario that was used. The audit calls
were conducted by a significantly different demo-
Table 1. Call Characteristics, According to Time Period and Insurance Type.*
Variable Period 1 (2012–2013) Period 2 (2014)
Medicaid Private
Insurance Medicaid Private
Insurance
number of calls
All states 3319 4434 1923 2302
New Jersey 374 532 234 271
Pennsylvania 413 478 218 248
Illinois 468 543 217 249
Texas 355 561 205 263
Georgia 382 536 200 252
Arkansas 185 321 153 222
Massachusetts 512 679 197 217
Oregon 205 337 166 232
Iowa 340 350 250 245
Montana 85 97 83 103
Month of call
January 1162 1467 0 0
February 560 751 0 0
March 86 177 0 0
April 0 4 0 0
May 0 0 496 1727
June 0 0 1246 556
July 0 0 181 19
November 513 707 0 0
December 998 1328 0 0
percentage of calls
Hypertension scenario 50.0 50.2 50.4 50.4
Female sex of caller 49.4 49.8 54.7 51.7
Race or ethnic group
of caller†
Black 38.3 37.8 40.6 42.2
Hispanic 24.5 22.6 12.2 14.8
White 37.1 39.5 47.2 43.1
Age of caller
18–29 yr 22.3 21.2 24.1 24.7
30–44 yr 51.3 51.8 45.0 48.0
45–64 yr 26.3 26.9 30.9 27.3
* Data are based on audit calls that were placed to a stable cohort of physician
offices that were practicing adult primary care and participating in the insur-
ance type during the two study periods.
† Race or ethnic group was self-reported.
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Appointment Availability after Medicaid Payment Increases
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541
graphic mix of callers between the two periods
(Table 1). A total of 7753 calls were made during
period 1, and 4225 calls during period 2, with at
least 150 calls in every state except Montana.
Appointment Availability and Waiting Times
Appointment availability and median waiting times
for all key groups are provided in Tables 2 and 3,
respectively. States are ordered according to the
size of the Medicaid reimbursement increase.
Waiting times showed very little change over time,
and the pattern of changes did not correspond to
the changes in reimbursements. For appointment
availability, however, we found changes that were
associated with the size of the Medicaid reimburse-
ment increase.
Although the appointment availability for pri-
vate-insurance callers stayed approximately the
same at 86%, the 10-state average of overall ap-
pointment availability for Medicaid callers in-
creased from 58.7% before the reimbursement
increase to 66.4% during the second period. De-
tails regarding these changes, including differ-
ences between periods within the Medicaid group
and the private-insurance group and between-
group difference-in-differences, are provided in
Table 4
.
In the Medicaid group, the 10-state difference
of 7.7 percentage points between periods was
significant (P<0.001). The states with the largest
increases in Medicaid appointment availability
also tended to be the states with the largest in-
creases in Medicaid reimbursements: New Jersey,
Pennsylvania, Illinois, and Texas. An exception
was Montana, which had the smallest change in
Medicaid reimbursements of the 10 states but still
had an increase of 6.8 percentage points in Medic-
aid appointment availability. There was no cor-
responding pattern of change for private-insur-
ance enrollees, although 2 states, Pennsylvania and
Massachusetts, had increased appointment avail-
ability for private-insurance enrollees. The result-
ing overall net difference in the change in ap-
pointment availability for Medicaid enrollees, as
compared with private insurance enrollees, was
8.3 percentage points for the 10 states (P<0.001).
Table 2. Availability of Appointments for New Patients, According to the State, Insurance Type, and Time Period.*
State
Appointment
Availability in
Medicaid Group
Appointment
Availability in Private-
Insurance Group
Increase
in Medicaid
Reimbursement†
Period 1 Period 2 Period 1 Period 2
percent
All 10 states 58.7 66.4 86.1 85.5 57.0
States with larger increases in payments
New Jersey 70.6 81.5 92.7 88.0 109.0
Pennsylvania 50.8 63.6 79.0 86.2 96.0
Illinois 47.4 65.7 90.7 89.8 93.0
Texas 63.5 75.4 90.4 87.6 66.0
States with smaller increases in payments
Georgia 73.3 77.2 89.4 90.9 48.0
Arkansas 46.4 51.8 89.2 83.3 47.0
Massachusetts 55.0 59.2 69.0 77.6 47.0
Oregon 37.7 34.9 77.4 69.0 39.0
Iowa 67.9 73.8 89.2 90.4 34.0
Montana 74.5 81.3 93.7 92.1 7.0
* States are ordered according to the amount of the increase in Medicaid reimbursement.
† The increase in Medicaid reimbursement is the average percentage increase in Medicaid reimbursement for the affected
primary care services that was required to achieve parity with Medicare fees from 2012 through 2013. These estimates
were based on a sample of the affected primary care services.
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Patterns across States
The patterns across states are shown in Figure 1,
where the differences in appointment availability
are plotted against the Medicaid reimbursement
increase in each state. In the Medicaid group, the
estimated slope of this line is 0.125 (P = 0.03),
and in the private-insurance group, the slope is
0.017 (P = 0.78). The positive Medicaid slope (Fig.
1A) implies that a 10% increase in Medicaid re-
imbursements, as compared with the Medicaid
reimbursement at baseline, was associated with
an increase in appointment availability of ap-
proximately 1.25 percentage points. (The effect
of a 10% change in the reimbursement ratio is
derived by multiplying the estimated 0.125
change in appointment availability for a 1%
change in reimbursements by 10.) This finding
was consistent with the pattern of findings in
Table 4 and suggests a pattern of increasing Med-
icaid appointment availability with increasing re-
imbursement level, although the true relationship
does not need to be linear, as indicated in Figure
1A. Whereas the linear relationship was not sen-
sitive to the removal of states with the highest
leverage, the LOWESS version of Figure 1A sug-
gests a possible threshold relationship (Fig. S3 in
the Supplementary Appendix).
Discussion
The mean increase of more than 50% in Medic-
aid reimbursement for primary care services was
associated with an increase from 58.7% to 66.4%
in the availability of new-patient appointments
among participating primary care physician of-
fices in the Medicaid group in the 10 study states.
This increase in availability was positively related
to the size of the increase in Medicaid reimburse-
ments for primary care across the 10 states. In
contrast, we did not see corresponding changes
in the availability of new-patient appointments in
the private-insurance group, which suggests that
the changes in the availability of appointments
for Medicaid enrollees were unlikely to have been
driven by general changes in the health delivery
system.
Increases in appointment availability were
similar in states that expanded Medicaid coverage
(e.g., New Jersey and Illinois) and those that did
not (e.g., Pennsylvania and Texas). If increases in
demand owing to these expansions challenged
provider capacity, we might have expected smaller
changes in appointment availability in New Jersey
and Illinois, but such findings did not materialize.
We also did not observe longer waiting times as
a way to increase the availability of new-patient
appointments.
Our finding that the increase in reimburse-
ments was related to increased availability of ap-
pointments for Medicaid enrollees indicates that
the policy probably had the intended effect, de-
spite the many questions that have been raised
about the limited duration of the policy, insuf-
ficient provider outreach and education, remain-
ing payment gaps relative to private insurance,
administrative complexities, and delays in im-
plementation.
13,14,17,22
Although there is mixed
evidence about whether the hike in Medicaid re-
imbursements increased the number of newly
participating Medicaid providers,
14,17
we found
strong evidence that providers who were already
participating in a Medicaid plan in 2012 were more
willing to schedule an appointment with a new
Medicaid patient in 2014. Although our findings
are consistent with the fact that currently partici-
pating providers are able to boost their panel of
Table 3. Waiting Times for Appointments for New Patients, According to
the State, Insurance Type, and Time Period.*
State Medicaid
Waiting Times Private-Insurance
Waiting Times
Period 1 Period 2 Period 1 Period 2
median no. of calendar days
All 10 states 6666
States with larger increases
in payments
New Jersey 4455
Pennsylvania 8 9 7 9
Illinois 5 4 5 5
Texas 5 4 5 5
States with smaller increases
in payments
Georgia 5 5 6 6
Arkansas 6 7 5 6
Massachusetts 16 10 13 11
Oregon 7 9 7 7
Iowa 5 7 6 5
Montana 7 7 8 6
* P<0.05 for the comparison between period 1 and period 2 for the Medicaid
groups in Iowa and Massachusetts and for the private-insurance groups in
Arkansas, Montana, and Pennsylvania.
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Appointment Availability after Medicaid Payment Increases
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543
Medicaid patients at little cost, additional research
is needed to identify whether states that elect to
extend the Medicaid reimbursement hikes have
increases in the number of participating providers.
Although the federal government declined to
extend funding for the reimbursement increases,
some states maintained higher reimbursements
because they were willing to face the subsequent
budgetary effects. Currently, only 15 states plan
to continue the reimbursement increases.
19
Other
research has shown that the average national Med-
icaid reimbursement to primary care physicians
would fall by 43% in 2015 if all states let the pay-
ment increase expire, but the 24 states that are
not planning to continue the payment increase
would have an even larger 47% reduction.
23
Our
analysis shows that opting not to extend the
enhanced payments may significantly decrease
the availability of primary care appointments for
Medicaid enrollees, particularly in states that had
low Medicaid reimbursements before the increase.
Our study has several important limitations.
First, our audit methods focused on the avail-
ability of appointments among providers who
already participated in a Medicaid plan and were
not designed to examine changes in the number
of providers participating in these networks.
More rigorous research on this secondary effect
is needed. Second, our focus was on a stable
cohort of physician offices rather than a repre-
sentative cohort in each period. We were limited
by the fact that the second period did not include
new offices that opened between the two peri-
ods. Third, the timing of data collection was not
ideal. Half of the first period was during the
first 3 months of 2013, when the reimbursement
increase was theoretically in effect but not yet
implemented. Thus, if practices were already
reacting to the policy, we may have underesti-
mated its effect. Data were collected in the fall
or winter during the first period and during the
spring or summer during the second period. Thus,
if there were seasonal effects, we could not ac-
count for them. However, the absence of change
in appointment availability in the private-insur-
ance group suggests that seasonal effects do not
Table 4. Differences in Availability of Primary Care Appointments for New Patients after Increases in Medicaid
Reimbursement, According to Insurance Status.*
State Difference in
Medicaid Group Difference in
Private-Insurance Group
Difference between
Medicaid Group and
Private-Insurance Group
percentage points
All 10 states 7.7±1.3† −0.6±0.9 8.3±1.4†
States with larger increases in payments
All 4 states 13.5±1.9† −0.3±1.2 13.8±2.3†
New Jersey 10.8±2.6† −4.7±2.0‡ 15.5±3.3†
Pennsylvania 12.8±5.1† 7.2±2.7† 5.6±6.0
Illinois 18.3±3.2† −0.9±1.6 19.2±3.3†
Texas 12.0±3.4† −2.8±1.9 14.8±3.6†
States with smaller increases in payments
All 6 states 3.9±1.6‡ −0.8±1.3 4.7±1.8†
Georgia 3.9±3.6 1.5±2.3 2.4±4.0
Arkansas 5.5±4.3 −5.9±2.1† 11.4±4.7‡
Massachusetts 4.2±4.5 8.6±3.0† −4.4±2.7
Oregon −2.9±3.7 −8.4±3.4‡ 5.5±5.1
Iowa 5.9±3.6 1.2±1.7 4.7±3.0
Montana 6.8±2.6† −1.7±3.3 8.5±3.7‡
* Plus–minus values are means ±SE, clustered according to county.
† P<0.01.
‡ P<0.05.
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544
explain the increase in availability in the Medic-
aid group. Fourth, our study focused only on
access for new adult patients — the group gain-
ing eligibility under the insurance expansions in
the ACA — and did not address appointment
availability or waiting times for established pa-
tients, children, or the elderly. Finally, we exam-
ined the experiences in just 10 states, represent-
ing 27% of the national nonelderly population.
21
The inclusion of only a limited number of states,
although these were selected to provide geo-
graphic and health system diversity,
21
could cre-
ate idiosyncratic patterns that would limit the
generalizability of our results to all states.
In conclusion, we found that the increases in
Medicaid reimbursements mandated by the ACA
were associated with significant increases in the
availability of new-patient appointments for pri-
mary care for Medicaid enrollees across 10
states. Public perception has focused on whether
the Medicaid payment hikes would increase the
number of providers in private practice who par-
ticipate in the Medicaid program. Our findings
suggest that providing higher Medicaid pay-
ments is an effective strategy for ensuring access
to enrollees among already participating prima-
ry care providers. Whether the costs and bene-
fits of the policy warrant ongoing federal or
state investment will need to be determined.
Supported by a grant (70160) from the Robert Wood Johnson
Foundation.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Katherine Hempstead, Ari Friedman, Brendan Sa-
loner, Robert Nathenson, Martha Van Haitsma, Tiana Pyer-
Pereira, David Chearo, and the field staff at the Universit y of
Chicago Survey Laboratory.
Difference in Appointment Availability
(percentage points)
20
10
15
5
0
−10
−5
0 20 40 60 80 100 120
Medicaid Reimbursement Increase (%)
BPrivate-Insurance Group
AMedicaid Group
Difference in Appointment Availability
(percentage points)
20
10
15
5
0
−10
−5
0 20 40 60 80 100 120
Medicaid Reimbursement Increase (%)
MT IA
AR
10 State
TX
IL
PA
NJ
MA
OR
MA PA
IA GA
10 State
TX
MT
AR
IL
NJ
OR
GA
Slope of trend, 0.125
P=0.03
Slope of trend, 0.017
P=0.78
Figure 1. Correlation between Differences in Appointment Availability
and Increases in Medicaid Payments in 10 States.
Shown is the correlation between increases in Medicaid payments and per-
centage-point differences in the availability of primary care appointments
in the Medicaid group (Panel A) and private-insurance group (Panel B).
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