Candon, Molly

Hempstead, Katherine

Kenney, Genevieve M

Polsky, Daniel

Rhodes, Karin

Saloner, Brendan

Wissoker, Douglas

English

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Issue Briefs Leonard Davis Institute of Health Economics
3-1-2017
Primary Care Appointment Availability and the
ACA Insurance Expansions
Molly Candon
University of Pennsylvania, candon@wharton.upenn.edu
Daniel Polsky
University of Pennsylvania, polsky@wharton.upenn.edu
Brendan Saloner
Douglas Wissoker
Katherine Hempstead
See next page for additional authors
Follow this and additional works at: http://repository.upenn.edu/ldi_issuebriefs
Part of the Health Economics Commons
LDI briefs are produced by LDI's policy team. For more information please contact Janet Weiner at weinerja@mail.med.upenn.edu.
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/115
For more information, please contact repository@pobox.upenn.edu.
Candon, Molly; Polsky, Daniel; Saloner, Brendan; Wissoker, Douglas; Hempstead, Katherine; Kenney, Genevieve M.; and Rhodes,
Karin. Primary Care Appointment Availability and the ACA Insurance Expansions. LDI Issue Briefs. 2017; 21 (5).
https://ldi.upenn.edu/brief/primary-care-appointment-availability-and-aca-insurance-expansions
Primary Care Appointment Availability and the ACA Insurance
Expansions
Keywords
primary care, appointment availability, Affordable Care Act, ACA, insurance
Disciplines
Health Economics
Comments
LDI briefs are produced by LDI's policy team. For more information please contact Janet Weiner at
weinerja@mail.med.upenn.edu.
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
Author(s)
Molly Candon, Daniel Polsky, Brendan Saloner, Douglas Wissoker, Katherine Hempstead, Genevieve M.
Kenney, and Karin Rhodes
This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/115
Our recently published letter in 
JAMA Internal Medicine finds that 
access to primary care improved for 
patients with Medicaid and remained 
stable for patients with private 
coverage across 10 study states
Prior to the ACA, concerns were raised about 
whether the primary care workforce would 
be able to meet increases in demand for 
care when previously uninsured populations 
began seeking health care. Ensuring that 
appointments are made available to Medicaid 
patients is particularly challenging because 
physicians are less likely to accept new 
Medicaid patients compared to the privately 
insured, largely due to lower reimbursement 
rates in Medicaid. Issues with access are 
not necessarily exclusive to the Medicaid 
population, however. With more insured adults 
seeking appointments from a relatively stable 
supply of primary care providers, privately-
insured patients could also be affected. 
To assess the ACA’s impact on primary care 
access, we used two waves of data from a 
study in which simulated patients requested 
new patient appointments from primary 
care practices in Arkansas, Georgia, Illinois, 
Iowa, Massachusetts, Montana, New Jersey, 
Oregon, Pennsylvania, and Texas between 
November 2012 and March 2013 and January 
2016 and May 2016. Trained callers varied by 
age, sex, and race/ethnicity and were randomly 
assigned an insurance type (Medicaid or 
private coverage) and clinical scenario (a 
check-up or newly-diagnosed untreated 
hypertension). The methods are described 
fully here.
We estimated changes in access to 
primary care between 2012/13 and 2016 
for Medicaid and private coverage by 
measuring the percentage of callers receiving 
an appointment. For those receiving 
appointments, we also measured the share 
of short wait times (7 days or less) and long 
wait times (more than 30 days) to paint a 
fuller picture of patients’ access. All data were 
weighted to make them representative to the 
distribution of people with different insurance 
types across counties; weights were scaled so 
that each state contributes equally to cross-
state averages. 
Our results show that appointment availability 
increased 5.4 percentage points for Medicaid 
patients, with no significant change in 
appointment availability for the privately 
insured. While the gap in appointment 
availability between Medicaid and private 
coverage remains, it fell from nearly 27 
percentage points in 2012 to 20 percentage 
points in 2016. (Figures 1, 2)
Both Medicaid and private coverage 
patients faced slight increases in wait times, 
however: Medicaid patients experienced a 6.7 
percentage point decline in short wait times 
and patients with private coverage faced a 4.1 
percentage point decline in short wait times, 
which translates into a one-day increase in 
median wait times for both groups. 
COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDI
March 2017 | Vol. 21, No. 5.
BRIEFIssue
PRIMARY CARE APPOINTMENT AVAILABILITY  
AND THE ACA INSURANCE EXPANSIONS 
Molly Candon, PhD; Daniel Polsky, PhD; Brendan Saloner, PhD; Douglas Wissoker, PhD;  
Katherine Hempstead, PhD; Genevieve M. Kenney, PhD; Karin Rhodes, MD
In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 
10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid 
increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, 
both Medicaid patients and the privately insured experienced a one-day increase in median wait times. 
Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new 
Medicaid enrollees. In this Issue Brief, we summarize our study’s findings, expand on possible explanations, and extend the analysis by 
examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care 
increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these 
results suggest coverage provisions in the ACA have not overwhelmed primary care capacity. 
What explains the improved 
appointment availability during a 
period of increasing demand?
At least three factors may explain the increase 
in appointment availability over the study 
period. First, practices may be extending wait 
times in order to accommodate a larger group 
of new patients, as suggested by the increase in 
wait times.
Second, broad investments in primary care and 
practice redesign could have further improved 
primary care’s ability to accommodate increases 
in demand. While our study does not provide 
definitive evidence on the precise mechanisms, 
it is likely that both policy and market factors 
are at work. For example, the ACA greatly 
expanded the capacity of federally qualified 
health centers and promoted shifts to team-
based care, capitated Medicaid managed care, 
and patient-centered medical homes. There 
is also a growing trend of retail clinics, which 
have been linked to a decrease in office-
based primary care. During the time frame of 
our study, there have been other changes in 
payment models and operational arrangements, 
including staffing arrangements that increase 
physician flexibility, consolidation of small 
practices into larger health systems, and data 
sharing.
Third, more providers may take Medicaid 
patients if Medicaid enrollees become a larger 
portion of the pool of insured individuals. In 
pediatrics, over one in three children is insured 
by Medicaid/CHIP and the vast majority of 
pediatricians accept public insurance. We 
explore this third possibility by assessing how 
the increases in appointment availability relate 
to state-level decisions to expand Medicaid.
What about the Medicaid expansions?
The ACA’s Medicaid expansion provided funds 
and gave states the option to extend Medicaid 
eligibility to nonelderly adults with incomes 
below 138 percent of the federal poverty level. 
As of February 2017, 25 states and the District 
of Columbia have expanded Medicaid using 
the program structure of traditional Medicaid, 
six states have expanded with a Section 1115 
waiver which can allow for more cost-sharing 
2
BRIEFIssueLDI
 
 
 
0%
20%
40%
60%
80%
100%
AR* GA IA IL MA MT NJ OR PA TX Average
2012/13 2016
Notes: Because AR expanded Medicaid via a private option, the Medicaid group in 2016 includes medically frail enrollees that 
stayed on traditional Medicaid. 
Source: Polsky D, Candon M, Saloner B, Wissoker D, Hempstead K, Kenney GM, Rhodes K. Changes in Primary Care Access 
between 2012 and 2016 for New Patients with Medicaid and Private Coverage. JAMA Internal Medicine. 2017; 177(4), doi:10.1001/
jamainternmed.2016.9662.
FIGURE 1.
Availability of New Patient Primary Care Appointments for Medicaid Enrollees
Source: Polsky D, Candon M, Saloner B, Wissoker D, Hempstead K, Kenney GM, Rhodes K. Changes in Primary Care Access 
between 2012 and 2016 for New Patients with Medicaid and Private Coverage. JAMA Internal Medicine. 2017; 177(4), doi:10.1001/
jamainternmed.2016.9662. 
FIGURE 2.
Availability of New Patient Primary Care Appointments for Private Coverage Enrollees
 
 
 
0%
20%
40%
60%
80%
100%
AR GA IA IL MA MT NJ OR PA TX Average
2012/13 2016
BRIEFIssueLDI
3
and other features than Medicaid typically 
permits, and 19 states have opted out. Between 
2013 and 2016, the number of individuals with 
Medicaid coverage increased over 35 percent 
in states that expanded Medicaid and only 12 
percent in states that did not expand Medicaid. 
In our sample, some states chose to expand 
Medicaid under the ACA and others did not. 
(Table 1) To examine the effects of extending 
Medicaid eligibility on primary care access, we 
grouped states according to the timing and 
nature of their expansions. Our treatment group 
included Illinois, Iowa, New Jersey, Oregon, 
and Pennsylvania, all of whom initiated their 
expansions in 2014 or 2015. Because Montana’s 
expansion began during data collection in 
2016, we placed them in our control group 
alongside Georgia and Texas, states that have 
not extended Medicaid eligibility as of February 
2017. Our results are robust when Montana is 
treated as an expansion state.
We exclude Massachusetts from our analysis 
because it officially adopted the ACA’s 
Medicaid expansion, but had already began to 
cover low-income adults through its state-
led reform effort in 2006. Between 2012 and 
2016, appointment availability did not change 
in Massachusetts and, notably, it was the only 
state to experience a decrease in wait times. 
We also exclude Arkansas because it expanded 
Medicaid in 2014 using an 1115 private option 
waiver, with the vast majority of newly eligible 
Medicaid enrollees obtaining coverage through 
the new marketplaces created under the 
ACA and the medically fragile remaining on 
Medicaid. Recent work explores Arkansas’s 
expansion in depth. Between 2012 and 2016, 
there was no change in access for Medicaid 
enrollees, but private coverage enrollees faced 
lower appointment availability and longer wait 
times.
In the five study states that expanded Medicaid 
in 2014 or 2015 (IL, IA, NJ, OR, PA), Medicaid 
appointment availability increased by 9.5 
percentage points, from 54.9 percent to 64.4 
percent (Table 2, Figure 3). Illinois experienced 
the largest increase in appointment availability 
for Medicaid (20.0 percentage points), 
followed by Iowa (8.1 percentage points) 
and Pennsylvania (7.2 percentage points). 
For private coverage enrollees, appointment 
availability declined in Oregon (-8.9 percentage 
points) and increased in Pennsylvania (6.5 
percentage points). In the three study states 
that did not expand Medicaid in 2014 and 
2015 (GA, MT, TX), there were no significant 
changes in appointment availability for either 
insurance type. (Figure 3, Table 2)
While surprising, these results are consistent 
with an audit in Michigan that found increased 
Medicaid appointment availability, particularly 
in areas with the largest gains in Medicaid 
patients and a second study that found 
improved access and affordability for adults 
targeted by the expansion.
The relationship between changes in wait 
times and state-level Medicaid expansions is 
less clear. In 2014 and 2015 expansion states, 
Medicaid enrollees faced a 9.1 percentage  
point decrease in the share of short wait times, 
but no change in the share of long wait times. 
Among privately insured patients, there was  
no change in the share of short wait times,  
TABLE 1.   
ACA Medicaid Expansion Status of 10 Study States as of February 2017
ACA Medicaid Expansion in 2014/15 No ACA Medicaid Expansion
•  Illinoisa                                        • Oregon
•  Iowaa,b                                        • Pennsylvania (2015)
• New Jersey
•  Georgia
•  Texas
Private Option Expansion ACA Medicaid Expansion Not Implemented in 2014/15
•  Arkansas •  Massachusetts (2006)
•  Montana (2016)
aIllinois and Iowa both transitioned from primary care case management to Medicaid managed care during the interim. 
bIowa had a private option for small portion of the Medicaid expansion population in 2014 only.
0%
20%
40%
60%
80%
100%
IA, IL, NJ, OR, PA GA, MT, TX IA, IL, NJ, OR, PA GA, MT, TX
2012/13 2016
Medicaid Private Coverage
Notes: IA, IL, NJ, OR, and PA expanded Medicaid eligibility to low-income, nonelderly adults in 2014 and 2015. MT didn’t expand 
Medicaid until 2016. As of February 2017, GA and TX have not expanded Medicaid. AR and MA are excluded from the key 
comparisons because of the uniqueness of their Medicaid expansions and the difficulty identifying them as a traditional expansion 
state or a plausible comparison.
FIGURE 3.
Availability of New Patient Primary Care Appointments for Medicaid and Private Coverage by 
2014/15 Medicaid Expansion Status
BRIEFIssueLDI
4
and a 2.7 percentage point increase in the  
share of long wait times. In states that did 
not expand Medicaid in 2014 and 2015, both 
insurance types experienced an overall  
increase in wait times.
Since this audit was restricted to in-network 
offices, our estimates do not reflect changes 
in the size of Medicaid networks or for 
established patients. Some changes to health 
care delivery, such as Iowa and Illinois moving 
to capitated managed care, may confound our 
ability to link Medicaid expansions to changes 
in appointment availability. Finally, we only 
include 10 states and 27 percent of the national 
nonelderly population – though states were 
selected to provide geographic, demographic, 
and health care-related variation, our results 
may not be generalizable to other settings.
Policy Implications 
As policymakers from across the political 
spectrum consider changes to the current 
health care system, it is crucial to understand 
the ACA’s full impact. Our 10-state audit study 
asks whether primary care access is changing 
as more people gain health insurance under the 
ACA. Overall, we find increases in primary care 
appointment availability for new patients with 
Medicaid in states that expanded Medicaid, 
with no offsetting decline in appointment 
availability for patients with private coverage. 
Our findings suggest that the influx of millions 
of newly-insured patients under the ACA has 
not overwhelmed primary care capacity, which 
should allay concerns that capacity constraints 
would compromise access to care, particularly 
within Medicaid.
ABOUT LDI  
 
Since 1967, the Leonard Davis Institute 
of Health Economics (LDI) has been 
the leading university institute dedicated 
to data-driven, policy-focused research 
that improves our nation’s health and 
health care. Originally founded to 
bridge the gap between scholars in 
business (Wharton) and medicine at 
the University of Pennsylvania, LDI 
now connects all of Penn’s schools and 
the Children’s Hospital of Philadelphia 
through its more than 250 Senior 
Fellows. 
 
LDI Issue Briefs are produced by  
LDI’s policy team. For more information  
please contact Janet Weiner at  
weinerja@mail.med.upenn.edu. 
COLONIAL PENN CENTER
3641 LOCUST WALK
PHILADELPHIA, PA 19104-6218
LDI.UPENN.EDU 
P: 215-898-5611
F: 215-898-0229
 @PENNLDI
AUTHORS 
Molly Candon, PhD 
Postdoctoral Fellow, LDI
Daniel Polsky, PhD 
Executive Director, LDI
Brendan Saloner, PhD 
Johns Hopkins Bloomberg School of Public 
Health
Douglas Wissoker, PhD 
Urban Institute
Katherine Hempstead, PhD 
Robert Wood Johnson Foundation
Genevieve M. Kenney, PhD 
Urban Institute
Karin Rhodes, MD 
Northwell Health Office of Population Health 
Adjunct Senior Fellow, LDI
TABLE 2.   
Analysis of Medicaid Expansion State Changes from 2012/13 to 2016 in Primary Care Appointment 
Availability Rate and the Share of Short and Long Wait Times for New Simulated Patients
2012/13 2016
Percentage 
Point 
Difference 
# of calls
APPOINTMENT AVAILABILITY
Medicaid
Medicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 54.9% 64.4% 9.5*** 4,173
Comparison States (GA, MT, TX) 68.0% 68.4% 0.4 2,071
Private Coverage
Medicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 84.3% 82.5% -1.8 4,717
Comparison States (GA, MT, TX) 90.2% 89.2% -1.0 2,389
SHORT WAIT TIME (7 DAYS OR LESS)
Medicaid
Medicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 58.6% 49.5% -9.1*** 2,536
Comparison States (GA, MT, TX) 59.6% 50.8% -8.8** 1,361
Private Coverage
Medicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 57.7% 55.5% -2.2 3,990
Comparison States (GA, MT, TX) 59.8% 51.6% -8.2*** 2,122
LONG WAIT TIMES (30 DAYS OR MORE)
Medicaid
Medicaid Expansion Initiated in 2014/15 (IA, IL, NJ, OR, PA) 8.5% 10.5% 2.0 2,536
Comparison States (GA, MT, TX) 7.9% 12.6% 4.7* 1,361
Private Coverage
Medicaid Expansion Initiated in 2014/15 (IA, IL, NJ, OR, PA) 5.8% 8.5% 2.7** 3,990
Comparison States (GA, MT, TX) 5.3% 11.5% 6.2*** 2,122
Notes: * p<0.05, ** p<0.01, *** p<0.001. AR and MA are excluded from the key comparisons because of the uniqueness of their Medicaid 
expansions and the difficulty identifying them as a traditional expansion state or a plausible comparison.


Primary Care Appointment Availability and the ACA Insurance Expansions

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics3-1-2017Primary Care Appointment Availability and theACA Insurance ExpansionsMolly CandonUniversity of Pennsylvania, candon@wharton.upenn.eduDaniel PolskyUniversity of Pennsylvania, polsky@wharton.upenn.eduBrendan SalonerDouglas WissokerKatherine HempsteadSee next page for additional authorsFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsPart of the Health Economics CommonsLDI briefs are produced by LDI's policy team. For more information please contact Janet Weiner at weinerja@mail.med.upenn.edu.This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/115For more information, please contact repository@pobox.upenn.edu.Candon, Molly; Polsky, Daniel; Saloner, Brendan; Wissoker, Douglas; Hempstead, Katherine; Kenney, Genevieve M.; and Rhodes,Karin. Primary Care Appointment Availability and the ACA Insurance Expansions. LDI Issue Briefs. 2017; 21 (5).https://ldi.upenn.edu/brief/primary-care-appointment-availability-and-aca-insurance-expansionsPrimary Care Appointment Availability and the ACA InsuranceExpansionsKeywordsprimary care, appointment availability, Affordable Care Act, ACA, insuranceDisciplinesHealth EconomicsCommentsLDI briefs are produced by LDI's policy team. For more information please contact Janet Weiner atweinerja@mail.med.upenn.edu.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.Author(s)Molly Candon, Daniel Polsky, Brendan Saloner, Douglas Wissoker, Katherine Hempstead, Genevieve M.Kenney, and Karin RhodesThis brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/115Our recently published letter in JAMA Internal Medicine finds that access to primary care improved for patients with Medicaid and remained stable for patients with private coverage across 10 study statesPrior to the ACA, concerns were raised about whether the primary care workforce would be able to meet increases in demand for care when previously uninsured populations began seeking health care. Ensuring that appointments are made available to Medicaid patients is particularly challenging because physicians are less likely to accept new Medicaid patients compared to the privately insured, largely due to lower reimbursement rates in Medicaid. Issues with access are not necessarily exclusive to the Medicaid population, however. With more insured adults seeking appointments from a relatively stable supply of primary care providers, privately-insured patients could also be affected. To assess the ACA’s impact on primary care access, we used two waves of data from a study in which simulated patients requested new patient appointments from primary care practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas between November 2012 and March 2013 and January 2016 and May 2016. Trained callers varied by age, sex, and race/ethnicity and were randomly assigned an insurance type (Medicaid or private coverage) and clinical scenario (a check-up or newly-diagnosed untreated hypertension). The methods are described fully here.We estimated changes in access to primary care between 2012/13 and 2016 for Medicaid and private coverage by measuring the percentage of callers receiving an appointment. For those receiving appointments, we also measured the share of short wait times (7 days or less) and long wait times (more than 30 days) to paint a fuller picture of patients’ access. All data were weighted to make them representative to the distribution of people with different insurance types across counties; weights were scaled so that each state contributes equally to cross-state averages. Our results show that appointment availability increased 5.4 percentage points for Medicaid patients, with no significant change in appointment availability for the privately insured. While the gap in appointment availability between Medicaid and private coverage remains, it fell from nearly 27 percentage points in 2012 to 20 percentage points in 2016. (Figures 1, 2)Both Medicaid and private coverage patients faced slight increases in wait times, however: Medicaid patients experienced a 6.7 percentage point decline in short wait times and patients with private coverage faced a 4.1 percentage point decline in short wait times, which translates into a one-day increase in median wait times for both groups. COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDIMarch 2017 | Vol. 21, No. 5.BRIEFIssuePRIMARY CARE APPOINTMENT AVAILABILITY  AND THE ACA INSURANCE EXPANSIONS Molly Candon, PhD; Daniel Polsky, PhD; Brendan Saloner, PhD; Douglas Wissoker, PhD;  Katherine Hempstead, PhD; Genevieve M. Kenney, PhD; Karin Rhodes, MDIn the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study’s findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity. What explains the improved appointment availability during a period of increasing demand?At least three factors may explain the increase in appointment availability over the study period. First, practices may be extending wait times in order to accommodate a larger group of new patients, as suggested by the increase in wait times.Second, broad investments in primary care and practice redesign could have further improved primary care’s ability to accommodate increases in demand. While our study does not provide definitive evidence on the precise mechanisms, it is likely that both policy and market factors are at work. For example, the ACA greatly expanded the capacity of federally qualified health centers and promoted shifts to team-based care, capitated Medicaid managed care, and patient-centered medical homes. There is also a growing trend of retail clinics, which have been linked to a decrease in office-based primary care. During the time frame of our study, there have been other changes in payment models and operational arrangements, including staffing arrangements that increase physician flexibility, consolidation of small practices into larger health systems, and data sharing.Third, more providers may take Medicaid patients if Medicaid enrollees become a larger portion of the pool of insured individuals. In pediatrics, over one in three children is insured by Medicaid/CHIP and the vast majority of pediatricians accept public insurance. We explore this third possibility by assessing how the increases in appointment availability relate to state-level decisions to expand Medicaid.What about the Medicaid expansions?The ACA’s Medicaid expansion provided funds and gave states the option to extend Medicaid eligibility to nonelderly adults with incomes below 138 percent of the federal poverty level. As of February 2017, 25 states and the District of Columbia have expanded Medicaid using the program structure of traditional Medicaid, six states have expanded with a Section 1115 waiver which can allow for more cost-sharing 2BRIEFIssueLDI   0%20%40%60%80%100%AR* GA IA IL MA MT NJ OR PA TX Average2012/13 2016Notes: Because AR expanded Medicaid via a private option, the Medicaid group in 2016 includes medically frail enrollees that stayed on traditional Medicaid. Source: Polsky D, Candon M, Saloner B, Wissoker D, Hempstead K, Kenney GM, Rhodes K. Changes in Primary Care Access between 2012 and 2016 for New Patients with Medicaid and Private Coverage. JAMA Internal Medicine. 2017; 177(4), doi:10.1001/jamainternmed.2016.9662.FIGURE 1.Availability of New Patient Primary Care Appointments for Medicaid EnrolleesSource: Polsky D, Candon M, Saloner B, Wissoker D, Hempstead K, Kenney GM, Rhodes K. Changes in Primary Care Access between 2012 and 2016 for New Patients with Medicaid and Private Coverage. JAMA Internal Medicine. 2017; 177(4), doi:10.1001/jamainternmed.2016.9662. FIGURE 2.Availability of New Patient Primary Care Appointments for Private Coverage Enrollees   0%20%40%60%80%100%AR GA IA IL MA MT NJ OR PA TX Average2012/13 2016BRIEFIssueLDI3and other features than Medicaid typically permits, and 19 states have opted out. Between 2013 and 2016, the number of individuals with Medicaid coverage increased over 35 percent in states that expanded Medicaid and only 12 percent in states that did not expand Medicaid. In our sample, some states chose to expand Medicaid under the ACA and others did not. (Table 1) To examine the effects of extending Medicaid eligibility on primary care access, we grouped states according to the timing and nature of their expansions. Our treatment group included Illinois, Iowa, New Jersey, Oregon, and Pennsylvania, all of whom initiated their expansions in 2014 or 2015. Because Montana’s expansion began during data collection in 2016, we placed them in our control group alongside Georgia and Texas, states that have not extended Medicaid eligibility as of February 2017. Our results are robust when Montana is treated as an expansion state.We exclude Massachusetts from our analysis because it officially adopted the ACA’s Medicaid expansion, but had already began to cover low-income adults through its state-led reform effort in 2006. Between 2012 and 2016, appointment availability did not change in Massachusetts and, notably, it was the only state to experience a decrease in wait times. We also exclude Arkansas because it expanded Medicaid in 2014 using an 1115 private option waiver, with the vast majority of newly eligible Medicaid enrollees obtaining coverage through the new marketplaces created under the ACA and the medically fragile remaining on Medicaid. Recent work explores Arkansas’s expansion in depth. Between 2012 and 2016, there was no change in access for Medicaid enrollees, but private coverage enrollees faced lower appointment availability and longer wait times.In the five study states that expanded Medicaid in 2014 or 2015 (IL, IA, NJ, OR, PA), Medicaid appointment availability increased by 9.5 percentage points, from 54.9 percent to 64.4 percent (Table 2, Figure 3). Illinois experienced the largest increase in appointment availability for Medicaid (20.0 percentage points), followed by Iowa (8.1 percentage points) and Pennsylvania (7.2 percentage points). For private coverage enrollees, appointment availability declined in Oregon (-8.9 percentage points) and increased in Pennsylvania (6.5 percentage points). In the three study states that did not expand Medicaid in 2014 and 2015 (GA, MT, TX), there were no significant changes in appointment availability for either insurance type. (Figure 3, Table 2)While surprising, these results are consistent with an audit in Michigan that found increased Medicaid appointment availability, particularly in areas with the largest gains in Medicaid patients and a second study that found improved access and affordability for adults targeted by the expansion.The relationship between changes in wait times and state-level Medicaid expansions is less clear. In 2014 and 2015 expansion states, Medicaid enrollees faced a 9.1 percentage  point decrease in the share of short wait times, but no change in the share of long wait times. Among privately insured patients, there was  no change in the share of short wait times,  TABLE 1.   ACA Medicaid Expansion Status of 10 Study States as of February 2017ACA Medicaid Expansion in 2014/15 No ACA Medicaid Expansion•  Illinoisa                                        • Oregon•  Iowaa,b                                        • Pennsylvania (2015)• New Jersey•  Georgia•  TexasPrivate Option Expansion ACA Medicaid Expansion Not Implemented in 2014/15•  Arkansas •  Massachusetts (2006)•  Montana (2016)aIllinois and Iowa both transitioned from primary care case management to Medicaid managed care during the interim. bIowa had a private option for small portion of the Medicaid expansion population in 2014 only.0%20%40%60%80%100%IA, IL, NJ, OR, PA GA, MT, TX IA, IL, NJ, OR, PA GA, MT, TX2012/13 2016Medicaid Private CoverageNotes: IA, IL, NJ, OR, and PA expanded Medicaid eligibility to low-income, nonelderly adults in 2014 and 2015. MT didn’t expand Medicaid until 2016. As of February 2017, GA and TX have not expanded Medicaid. AR and MA are excluded from the key comparisons because of the uniqueness of their Medicaid expansions and the difficulty identifying them as a traditional expansion state or a plausible comparison.FIGURE 3.Availability of New Patient Primary Care Appointments for Medicaid and Private Coverage by 2014/15 Medicaid Expansion StatusBRIEFIssueLDI4and a 2.7 percentage point increase in the  share of long wait times. In states that did not expand Medicaid in 2014 and 2015, both insurance types experienced an overall  increase in wait times.Since this audit was restricted to in-network offices, our estimates do not reflect changes in the size of Medicaid networks or for established patients. Some changes to health care delivery, such as Iowa and Illinois moving to capitated managed care, may confound our ability to link Medicaid expansions to changes in appointment availability. Finally, we only include 10 states and 27 percent of the national nonelderly population – though states were selected to provide geographic, demographic, and health care-related variation, our results may not be generalizable to other settings.Policy Implications As policymakers from across the political spectrum consider changes to the current health care system, it is crucial to understand the ACA’s full impact. Our 10-state audit study asks whether primary care access is changing as more people gain health insurance under the ACA. Overall, we find increases in primary care appointment availability for new patients with Medicaid in states that expanded Medicaid, with no offsetting decline in appointment availability for patients with private coverage. Our findings suggest that the influx of millions of newly-insured patients under the ACA has not overwhelmed primary care capacity, which should allay concerns that capacity constraints would compromise access to care, particularly within Medicaid.ABOUT LDI   Since 1967, the Leonard Davis Institute of Health Economics (LDI) has been the leading university institute dedicated to data-driven, policy-focused research that improves our nation’s health and health care. Originally founded to bridge the gap between scholars in business (Wharton) and medicine at the University of Pennsylvania, LDI now connects all of Penn’s schools and the Children’s Hospital of Philadelphia through its more than 250 Senior Fellows.  LDI Issue Briefs are produced by  LDI’s policy team. For more information  please contact Janet Weiner at  weinerja@mail.med.upenn.edu. COLONIAL PENN CENTER3641 LOCUST WALKPHILADELPHIA, PA 19104-6218LDI.UPENN.EDU P: 215-898-5611F: 215-898-0229 @PENNLDIAUTHORS Molly Candon, PhD Postdoctoral Fellow, LDIDaniel Polsky, PhD Executive Director, LDIBrendan Saloner, PhD Johns Hopkins Bloomberg School of Public HealthDouglas Wissoker, PhD Urban InstituteKatherine Hempstead, PhD Robert Wood Johnson FoundationGenevieve M. Kenney, PhD Urban InstituteKarin Rhodes, MD Northwell Health Office of Population Health Adjunct Senior Fellow, LDITABLE 2.   Analysis of Medicaid Expansion State Changes from 2012/13 to 2016 in Primary Care Appointment Availability Rate and the Share of Short and Long Wait Times for New Simulated Patients2012/13 2016Percentage Point Difference # of callsAPPOINTMENT AVAILABILITYMedicaidMedicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 54.9% 64.4% 9.5*** 4,173Comparison States (GA, MT, TX) 68.0% 68.4% 0.4 2,071Private CoverageMedicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 84.3% 82.5% -1.8 4,717Comparison States (GA, MT, TX) 90.2% 89.2% -1.0 2,389SHORT WAIT TIME (7 DAYS OR LESS)MedicaidMedicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 58.6% 49.5% -9.1*** 2,536Comparison States (GA, MT, TX) 59.6% 50.8% -8.8** 1,361Private CoverageMedicaid Expansion in 2014/15 (IA, IL, NJ, OR, PA) 57.7% 55.5% -2.2 3,990Comparison States (GA, MT, TX) 59.8% 51.6% -8.2*** 2,122LONG WAIT TIMES (30 DAYS OR MORE)MedicaidMedicaid Expansion Initiated in 2014/15 (IA, IL, NJ, OR, PA) 8.5% 10.5% 2.0 2,536Comparison States (GA, MT, TX) 7.9% 12.6% 4.7* 1,361Private CoverageMedicaid Expansion Initiated in 2014/15 (IA, IL, NJ, OR, PA) 5.8% 8.5% 2.7** 3,990Comparison States (GA, MT, TX) 5.3% 11.5% 6.2*** 2,122Notes: * p<0.05, ** p<0.01, *** p<0.001. AR and MA are excluded from the key comparisons because of the uniqueness of their Medicaid expansions and the difficulty identifying them as a traditional expansion state or a plausible comparison.

https://repository.upenn.edu/cgi/viewcontent.cgi?article=1114&amp;context=ldi_issuebriefs

Primary Care Appointment Availability and the ACA Insurance Expansions

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