The upcoming expansion of Medicaid under the Affordable Care Act (ACA) won't lead physicians to reduce the number of new Medicaid patients they accept, suggests a study in the November issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.
However, doctors may be less likely to accept those patients who remain uninsured, according to an analysis of historical data by Lindsay M. Sabik, PhD, and Sabina Ohri Gandhi, PhD, of Virginia Commonwealth University, Richmond. They write, "Our results suggest that after increases in Medicaid coverage within a market, access may be limited for the remaining patients."
Doctors Likely to Continue Accepting Medicaid Patients After Expansion...
As part of the ACA, Medicaid coverage will expand substantially beginning in 2014, with the goal of improving the health of people who were previously uninsured. Whether that goal is achieved will partly depend on how doctors respond to changes in their local market - and how those decisions affect low-income individuals who rely on "safety-net" care.
Drs Sabik and Gandhi analyzed data from a long-term, nationwide study of changes in the health care system (the Community Tracking Study Physician Survey). Physician survey responses from the mid-1990s to the mid-2000s were analyzed to assess how market-level changes in Medicaid coverage affected doctors' acceptance of new patients: both patients covered by Medicaid and uninsured patients who were unable to pay.
For most of the period studied, Medicaid coverage rates increased while uninsurance rates trended lower. Both rates varied between different markets. About 70 percent of physicians surveyed were in solo or group medical practice.
The data suggested that changes in Medicaid coverage did not significantly affect doctors' acceptance of new Medicaid patients. "[P]hysicians who were already accepting (or not accepting) Medicaid patients before changes in Medicaid coverage rates continue to do so," Drs Sabik and Gandhi write.
On average, new Medicaid patients were accepted by about 72 percent of office-based and 90 percent of facility-based doctors (those who work at hospitals or other facilities). These rates remained about the same after changes in Medicaid coverage.
...But May Not Accept Patients Who Remain Uninsured
However, when Medicaid coverage rates increased, physicians became less likely to accept new uninsured patients. For each one percentage point increase in Medicaid coverage, there was a one-half point decrease in the likelihood that doctors would accept new uninsured patients.
Office-based physicians were more likely to stop accepting new uninsured patients in response to changes in Medicaid coverage. Charity care was unaffected by changes in Medicaid coverage, but increased in markets where more people became uninsured.
While Medicaid expansion will reduce the number of people who are uninsured, "coverage does not guarantee access," the researchers write. Practice decisions made by doctors in response to financial incentives will affect access to care for newly insured patients. Estimates suggest that "a substantial number" of people will remain uninsured despite Medicaid expansion, and some states do not plan to expand Medicaid coverage.
"Our results indicate that past changes in market-level Medicaid coverage have not been associated with changes in overall physician acceptance of new Medicaid patients or the share of a physician's practice revenue from Medicaid,"
Drs Sabik and Ghandi write. However, changes in Medicaid coverage "have led to lower acceptance of uninsured patients, particularly among office-based physicians."
Based on their findings, Drs Sabik and Ghandi suggest that additional support or incentives may be needed to ensure access to care for people who are still uninsured after Medicaid expansion. "Future research should assess how changes in physician workforce and incentives to physicians under the ACA affect care for those newly insured by Medicaid and the remaining uninsured," the researchers conclude.