A lot of time, and a lot of ink, has been spent talking about access and Medicaid. Many who oppose the expansion of the program will point to the fact that sometimes evidence shows that fewer doctors accept Medicaid insurance than other types of coverage. There's some truth there. Medicaid does often reimburse at a lower rate than other insurance coverage, and sometimes doctors don't want to accept those lower rates. But there's more to the story.
The recent Medicaid expansion, however, has provided us with the opportunity to explore how children are able to find doctors when on Medicaid and CHIP, especially as Medicaid raised its reimbursement rates as part of Medicare parity. Sandra Decker explored much of this in a recent manuscript, "Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children’s Health Insurance Program":
Objective. To estimate the relationship between physicians’ acceptance of new Medicaid patients and access to health care.Data Sources. The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.
Study Design. Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children’s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.
More children who lived in states where fewer than 60% of primary care providers accepted new Medicaid patients had trouble finding a doctor or difficulty finding someone to see their child (2.9%) than in states where 75% or more of primary care physicians did (1.1%). No such differences existed for those with private insurance. More children in the <60% states didn't get care in the last year because waits in the office were too long (8.6%) than in the 75%+ states (4.0%), too. The disparities, and the difficulties, were worse for children who had a significant health condition or developmental disability. Almost 16% of kids with significant health conditions or developmental delay experienced a clinic not accepting their insurance in states with less than 60% of primary care docs accepting new Medicaid patients, versus only 3.5% of such kids having this issue in states with at least 75% of primary care docs accepting new Medicaid patients.
One of the nice aspects of the ACA, though, was that it raised reimbursement to more Medicare like levels. This study tried to see if that might make a difference. The answer is a qualified "yes". The data show that in states where the Medicaid to Medicare primary care fee ratio was under 50%, about 10% of kids with a health condition or developmental delay experienced a doctor's office or clinic not take their insurance, verses less than 4% of such children having that experience in states with a fee ratio of 75% or more. About 9% of kids like this didn't get care in the last year because the wait in the office was too long in states with fee ratios less than 50% versus only 4% of kids experiencing this issue in states with a fee ratio of 75% or more.
In other words, when more docs accept Medicaid, fewer kids experience issues with access. When Medicaid reimburses more, fewer kids experience issues with access.
None of this is terribly surprising. Nor is it hard to understand. But it provides a nice data point to bring up when people want to cut Medicaid or make it spend less. The reason it's so cheap, relative to other types of insurance, is that it does often pay less. However, I'm often struck by how often people who complain about how Medicaid has access issues are also the same people who want to see us spend less on Medicaid. The way to improve access is to spend more. When Medicaid looks more like Medicare, kids have a much easier time.
Of course all this may be moot. The Medicaid fee raises weren't a permanent part of the ACA. They will expire soon, unless action is taken by Congress.
[Editor's Note: For more insights on the research and data questions policymakers have about Medicaid, please see AcademyHealth's recently released Listening Project report: Improving the Evidence Base for Medicaid Policymaking.]