A Report on Access to Health Care for Medicaid, Medicare, and CHIP Patients Under the ACA

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Access to health care is a key issue the U.S. government targeted for improvement through the Affordable Care Act. Despite rates of private and public insurance coverage rising, availability of health care providers remains a national issue, and the distribution of access among the different insurance types is not equal.1 Numerous studies have found that a distinct difference in ability to establish access to health care exists between those patients covered by Medicaid, Medicare, or CHIP, and patients who are privately insured. This issue can indirectly affect emergency department use, as they have no limit to access under EMTALA. One such study found that up to 90% of health care providers accept new patients with private insurance, but less than 75% accept new patients with public coverage such as Medicare and Medicaid.1 Children with public insurance were also twice as likely to be declined as a new patient compared to privately insured children.1

The Kaiser Family Foundation found more promising data showing that 96% of Medicare patients have a usual source of primary care, and 90% are able to schedule timely appointments for both routine and specialty care, and that only a small number of Medicare patients who sought a new primary care physician had problems finding one (2%), which was comparable with privately insured adults ages 50-64. The 2012 National Electronic Health Records Survey revealed that 91% of non-pediatric physicians accept new Medicare patients, the same rate as those with private insurance, but suggests overall physician acceptance of new Medicare patients is most likely related to local market factors rather than issues regarding Medicare overall, and this differs by state, specialty, size of practice, and medical degree. Further investigation is needed.2

Access to health care for Medicaid, Medicare, and CHIP patients varies widely across each state as well as regionally within each state, which can cause emergency department visits to rise if access to primary care is an issue. Health care provider acceptance rates for Medicaid patients are less than Medicare patients and privately insured patients, and are also lower in states with lower Medicaid reimbursement rates. The National Center for Health Statistics Data Brief from March 2015 found that 95.3% of health care providers were accepting new patients in 2013, 84.7% were accepting new privately insured patients and 83.7% were accepting new Medicare patients, but only 68.9% were accepting new Medicaid patients in 2013. This study also found regional differences between metropolitan areas, which accepted only 67.2% of new Medicaid patients, and regions outside of metropolitan areas, which accepted up to 85.7%. These acceptance rate trends were similar for the Medicare population as well, with the metropolitan acceptance rate being 82.9% and the non-metropolitan regional rates being 91.2%. State differences were also quite varied, and ranged from a Medicare acceptance rate in Hawaii of 75.5%, to North Dakota at 95.2%. For Medicaid it ranged from a 38.7% acceptance in New Jersey, to 96.5% in Nebraska.3

New physician data from Medicare shows that less than 1% of health care providers have ‘opted out’ of seeing Medicare patients, and of those 1%, about 42% are psychiatrists.2 Specialties overall accepted less Medicaid patients than Medicare patients, and both were less than privately insured patients. Psychiatry accepted 43% new Medicaid, 55% new Medicare, and 67% new private. OBGYN accepted 75% new Medicaid, 89% new Medicare, and 96% new private. Other medical/surgical specialties accepted 76% new Medicaid, 96% new Medicare, and 94% new private patients. Among pediatric specialties, 71% participated in Medicaid and CHIP, 51% accepted all Medicaid and CHIP, 45% accepted some, and only 36% of all specialists providing pediatric care accepted all Medicaid and CHIP covered individuals as new patients.4

This past March a recent AAMC data analysis revealed a projected shortage of non-primary care physicians between 28,200-63,700 by 2025,6 which will likely only cause the publicly insured percentages of health care access to decrease.

Access to health care is slowly improving among the publicly insured, but it continues to remain an issue which is indirectly affecting emergency department use, as well as causing increased difficulty in getting our patients follow up with the appropriate primary care physician or specialist after a visit to the ED. Studies in 2007 by the Kaiser Foundation showed that Medicare and Medicaid patients were already the highest ED users, even compared to privately insured and uninsured patients.5

Medicaid expansion is another issue that may play a factor in access to care for those insured with Medicaid. As of May this year, Medicaid expansion for low-income adults had effect in 29 states, as well as the District of Columbia, and as of this past January, about 70 million people were enrolled. Almost two-thirds of all Medicaid and CHIP enrollees are residing in the states that implemented Medicaid expansion.6 Time will tell if the expansion of Medicaid and increased enrollment will further decrease access to care.

We continue to struggle with primary care access for this patient population, which will remain a continued problem for our emergency departments as the AAMC study projected a shortage of 46,000-90,000 physicians overall by 2025, and more specifically a shortage of primary care physicians between 12,500-31,100.7

References

  1. Gindi RM, Kirzinger WK, Cohen RA. Health insurance coverage and adverse experiences with physician availability: United States, 2012. NCHS data brief, no
    138, 2013.
  2. Boccuti C, Swoope C, Damico A, et al: Medicare Patients’ Access to Physicians: A Synthesis of the Evidence. Kaiser Family Foundation Issue Brief. 2013.
  3. Hing E, Decker SL, Jamoom E: Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013. NCHS data brief, no
    195, 2015.
  4. MACPAC analysis of the 2009-2010 National Ambulatory Medical Care Survey as detailed in the Session on Access to Specialty Care March 2015 Report
  5. Kaiser Family Foundation, Characteristics of Frequent Emergency Department Users, October 2007.
  6. Kaiser Family Foundation, Recent Trends in Medicaid and CHIP Enrollment as of January 2015: Early Findings from the CMS Performance Indicator Project, March 2015 Issue Brief.
  7. The Complexities of Physician Supply and Demand: Projections from 2013-2025, Forecasting and economic modeling done at the request of the AAMC.
Kristen Cadden Swann, MD

Kristen Cadden Swann, MD

Chair, EMRA Ultrasound Division, University of Virginia Health System, Charlottesville, VA
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