The first year evidence on the impact of the ACA on patient experience of provider access among Medicaid enrollees

The Affordable Care Act (ACA) in 2010 is a significant coverage expansion. The uninsured rate has dropped to the lowest in the decades. A large share of this expansion has come through Medicaid. With this development, there has been a discussion of whether health care capacity can meet the growing demand particularly among Medicaid beneficiaries.

We assessed how Medicaid patients’ experience of barriers to provider access has changed after the Medicaid expansion in the adult population. Prior work was based on either provider survey or audit research (simulated patient approach), which can only assess hypothetical access problems among new enrollees. We focused on patients’ actual experience of provider access for both new and continuous enrollees using the 2013-2014 National Health Interview Survey (NHIS) data.  We measured patient experience of barriers to provider access by: (1) having been told that a clinic did not accept respondent’s health care coverage, and (2) having any trouble finding a general doctor or provider who would see the respondent. We analyzed the model separately for “established” (those who have continuously had the current coverage for the past 12 months) and “new” enrollees (those who have had any change in coverage).

For the purpose of analysis, we limited the pre-expansion period to 2013 to control for the increase in the Medicaid reimbursement in 2012. We used a difference-in-differences approach and compared the pre- and post-ACA changes in provider access by Medicaid enrollees with those by the privately insured.

Our preliminary analysis indicated that the overall patient experience of access to providers among Medicaid beneficiaries improved after ACA compared with those privately covered. We found that the share of enrollees who experienced providers’ coverage refusal decreased from 6.1% to 5.5% among Medicaid enrollees, compared to an increase from 1.9% to 2.2% among those privately covered. The proportion of people with any difficulty finding a provider with availability decreased from 4.9% to 4.3% in Medicaid, while the corresponding number in private coverage changed from 1.7% to 2.1%. The difference-in-differences estimates were -0.0179 (p<0.002). However, the analysis of new enrollees showed a different result: providers’ refusal of Medicaid worsened from 3.5% to 9.4%, while the refusal rate in private increased from1.9% to 3.7%.

During the first year after the ACA implementation, the decline in barriers to access for Medicaid patients was entirely concentrated in established Medicaid beneficiaries. Conversely, new Medicaid enrollees experienced greater provider refusal at a higher rate than private enrollees. Consistent with existing audit studies, we found significantly greater barriers to access for new Medicaid beneficiaries after the ACA implementation. However, these prior results hide a different pattern—established Medicaid beneficiaries actually experienced fewer barriers to access following the ACA. 

We are in the process of acquiring restricted access NHIS data (i.e., information on state and county) and will explore relationships among Medicaid expansion, provider reimbursement, and patient experience of access to care between states with and without Medicaid expansion. We will also analyze additional access measures, such as experience of delayed care, waiting time, and affordability.