Access to Primary Care Appointments Following 2014 Insurance Expansions

The Effect of Medicaid Expansion on Racial/Ethnic and Gender Disparities in Access to Primary Care among Medicaid Patients

OBJECTIVES

This study aims to examine the effect of Medicaid expansion on access and disparities in primary care following passage of the Affordable Care Act.

DATA SOURCE

A 2013-2016 audit of a national random sample of US primary care physicians was used STUDY DESIGN: We analyzed new patient appointment data from calls to 2574 physicians made before and after the quasi-experiment created by Medicaid expansion. Simulated patients were differentiated by race/ethnicity (Black, Hispanic, White) and gender (male and female).

PRINCIPAL FINDINGS

In 2013, compared to White men, Hispanic women were at a - 19 (95% CI - 36, - 2) and - 23 (95% CI - 44, - 1) percentage point disadvantage in probability of an appointment offer in expansion and non-expansion states, respectively. Post Medicaid expansion offers to Hispanic women increased by 37 percentage points (95% CI 21, 53) and offers to Black women increased by 21 percentage points (95% CI 5, 38) in expansion states. By 2016, offers to Hispanic and Black men in expansion states rose. Hispanic women remained at a - 16 percentage-point disadvantage (95% CI - 26, - 6) relative to White men in non-expansion states.

CONCLUSION

Improved access to primary care and reduced racial/ethnic and gender disparities following earlier Medicaid expansions suggest that further expansions may increase access and reduce disparities.

Preventive Care Needs of the North Carolina Medicaid Expansion Population

Introduction

Effective December 2023, North Carolina expanded Medicaid eligibility to cover individuals up to 138% of the Federal Poverty Level. The authors sought to understand the preventive care needs of the newly Medicaid-eligible population.

Methods

The authors conducted a repeat cross-sectional analysis using the 2016, 2018, 2020, and 2022 North Carolina Behavioral Risk Factor Surveillance Survey. The authors defined the Medicaid expansion population as those aged 18-64 years with household incomes below 138% Federal Poverty Level and reporting no current source of insurance. The authors compared with those enrolled in traditional Medicaid and all nonelderly adult North Carolinians, evaluating up-to-date use of preventive care services. Survey weights were used to estimate total unmet need.

Results

The authors estimated 294,000 individuals in the Medicaid expansion population in 2022. Preventive care use was low for the expansion population in all years. In 2022, 36.7% (27.7%-46.8%) reported having a regular source of care, 40.2% (31.1%-50%) reported a past-year wellness visit, and 45.7% (36.6%-55.2%) reported delaying needed care owing to cost. Among eligible respondents, 28.6% (13.8%-50.2%) were up to date with colorectal cancer screening (vs 49.4% [30.5%-68.4%] for traditional Medicaid and 71% [67.3%-74.4%] for all North Carolina population). It was estimated that 176,000 in the expansion population needed a wellness visit; 186,000 needed a regular care provider; and 66,000 needed 1 or more cancer screening.

Conclusions

The North Carolina Medicaid expansion population has a high number of unmet preventive care needs. North Carolina should consider approaches to improve provider capacity for those in Medicaid and promote preventive care and risk reduction for the newly enrolled expansion population.

Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care

While significant progress has been made in reducing disparities within the US health care system, notable gaps remain. This article explores existing disparities within pediatric congenital heart disease care. Congenital heart disease, the most common birth defect and a leading cause of infant death, has garnered substantial attention, revealing certain disparities within the US health care system. Factors such as race, ethnicity, insurance coverage, socioeconomic status, and geographic location are all commonalities that significantly affect health disparities in pediatric congenital heart disease. This comprehensive review sheds light on disparities from diverse perspectives in pediatric care, demonstrates the inequities and inequalities leading to these disparities, presents effective solutions, and issues a call to action for providers, institutions, and the health care system. Recognizing and addressing these disparities is imperative for ensuring equitable care and enhancing the long-term well-being of children affected by congenital heart disease. Implementing robust, evidence-based frameworks that promote responsible and safe interventions is fundamental to enduring change.

Assessment of Obstructive Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease in Primary Care

Study Objectives

Observational studies link untreated obstructive sleep apnea (OSA) with adverse outcomes in chronic obstructive pulmonary disease (COPD). The first step in addressing OSA is a clinical assessment. However, given competing demands and a lack of high-quality evidence, it is unclear how often such assessments occur. We explored the documentation of OSA assessment among patients with COPD in primary care, and the patient and provider characteristics associated with these assessments.

Methods

We conducted a cross-sectional study of patients with clinically diagnosed COPD at 2 primary care practices. We abstracted charts to determine whether providers assessed OSA, defined as documentation of symptoms, treatment, or a referral to sleep medicine. We performed multivariable mixed-effects logistic regression to assess the associations of patient and provider characteristics with OSA assessment.

Results

Among 641 patients with clinically diagnosed COPD, 146 (23%) had OSA assessed over a 1-year period. Positive associations with OSA assessment included body mass index ≥ 30 (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-7.0), pulmonary subspecialist visits (OR 3.9, 95%CI 2.4-6.3), and a prior sleep study demonstrating OSA documented within the electronic medical record (OR 18.0, 95%CI 9.0-35.8). Notably, patients identifying as Black were less likely to have OSA assessed than those identifying as White (OR 0.5, 95%CI 0.2-0.9).

Conclusions

Providers document an assessment of OSA among a quarter of patients with COPD. Our findings highlight the importance of future work to rigorously test the impact of assessment on important health outcomes. Our findings also reinforce that additional strategies are needed to improve the equitable delivery of care.

Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China

BACKGROUND

Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation.

METHODS

We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.

RESULTS

A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with  < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.

CONCLUSIONS

Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

Trends in Racial and Ethnic Disparities in Barriers to Timely Medical Care Among Adults in the US, 1999 to 2018

Importance

Racial and ethnic disparities in delayed medical care for reasons that are not directly associated with the cost of care remain understudied.

Objective

To describe trends in racial and ethnic disparities in barriers to timely medical care among adults during a recent 20-year period.

Design, Setting, and Participants

This was a serial cross-sectional study of 590 603 noninstitutionalized adults in the US using data from the National Health Interview Survey from 1999 to 2018. Data analyses were performed from December 2021 through August 2022.

Exposures

Self-reported race, ethnicity, household income, and sex.

Main Outcomes and Measures

Temporal trends in disparities regarding 5 specific barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.

Results

The study cohort comprised 590 603 adult respondents (mean [SE] age, 46.00 [0.07] years; 329 638 [51.9%] female; 27 447 [4.7%] Asian, 83 929 [11.8%] Black, 98 692 [13.8%] Hispanic/Latino, and 380 535 [69.7%] White). In 1999, the proportion of each race and ethnicity group reporting any of the 5 barriers to timely medical care was 7.3% among the Asian group; 6.9%, Black; 7.9%, Hispanic/Latino; and 7.0%, White (P > .05 for each difference compared with White individuals). From 1999 to 2018, this proportion increased across all 4 race and ethnicity groups (by 5.7, 8.0, 8.1, and 5.9 percentage points [pp] among Asian, Black, Hispanic/Latino, and White individuals, respectively; P < .001 for each), slightly increasing the disparities between groups. In 2018, compared with White individuals, the proportion reporting any barrier was 2.1 and 3.1 pp higher among Black and Hispanic/Latino individuals (P = .03 and P = .001, respectively). There was no significant difference in prevalence between Asian and White individuals. There was a significant increase in the difference in prevalence between Black individuals and White individuals who reported delaying care because of long waiting times at the clinic or medical office and because of a lack of transportation (1.5 pp and 1.8 pp; P = .03 and P = .01, respectively). In addition, the difference in prevalence between Hispanic/Latino and White individuals who reported delaying care because of long waiting times increased significantly (2.6 pp; P < .001).

Conclusions and Relevance

The findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups.

Primary Care Access During the COVID-19 Pandemic: a Simulated Patient Study

BACKGROUND

Primary care practices have experienced major strains during the COVID-19 pandemic, such that patients newly seeking care may face potential barriers to timely visits.

OBJECTIVE

To quantify availability and wait times for new patient appointments in primary care and to describe how primary care practices are guiding patients with suspected COVID-19.

DESIGN

Trained callers conducted simulated patient calls to 800 randomly sampled primary care practices between September 14, 2020, and September 28, 2020.

PARTICIPANTS

We extracted complete primary care physician listings from large commercial insurance networks in four geographically dispersed states between September 10 and 14, 2020 (n=11,521). After excluding non-physician providers and removing duplicate phone numbers, we identified 2705 unique primary care physician practices from which we randomly sampled 200 practices in each region.

MAIN MEASURES

Primary care appointment availability, median wait time in days, and practice guidance to patients suspecting COVID-19 infection.

KEY RESULTS

Among 56% of listed practices that had accurate contact information listed in the directory, 84% offered a new patient in-person or virtual appointment. Median wait time was 10 days (IQR 3-26 days). The most common guidance in case of suspected COVID-19 was clinician consultation, which was offered in 41% of completed calls. Callers were otherwise directed to on-site testing (14%), off-site testing (24%), a COVID-19 hotline (8%), or an urgent care/emergency department (12%), while 2% of practices had no guidance to offer.

CONCLUSIONS

Despite resource constraints, most reachable primary care practices offered timely new patient appointments as well as direct COVID-19 care. Pandemic mitigation strategies should account for and support the central role of primary care practices in the community-based pandemic response.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

BACKGROUND

Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited.

METHODS

We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians.

DISCUSSION

The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.

Naloxone Availability and Pharmacy Staff Knowledge of Standing Order for Naloxone in Pennsylvania Pharmacies

OBJECTIVE

To assess the availability and price of naloxone as well as pharmacy staff knowledge of the standing order for naloxone in Pennsylvania pharmacies.

METHODS

We conducted a telephone audit study from December 2016 to April 2017 in which staff from Pennsylvania pharmacies were surveyed to evaluate naloxone availability, staff understanding of the naloxone standing order, and out-of-pocket cost of naloxone.

RESULTS

Responses were obtained from 682 of 758 contacted pharmacies (90% response rate). Naloxone was stocked (ie, available for dispensing) in 306 (45%) pharmacies surveyed. Of the 376 (55%) pharmacies that did not stock naloxone, 118 (31%) stated that they could place an order for naloxone for pickup within 1 business day. Responses by pharmacy staff to questions about key components of the standing order for naloxone were collected from 581 of the 682 pharmacies who participated in the survey (85%). Of the 581 pharmacy staff members who stated that they either stocked or could order naloxone, 64% correctly answered all questions pertaining to understanding of the naloxone standing order. The respective median out-of-pocket prices stated in the audit varied by formulation and ranged from $50 to $4000. Staff from national pharmacies were significantly more likely than staff from regional/local chain and non-chain pharmacies to correctly answer that a prescription was not required to obtain naloxone (68.5%, 57.7%, and 52.4% respectively, (P = 0.0045).

CONCLUSIONS

Multiple barriers to naloxone access exist in pharmacies across a large, diverse state, despite the presence of a standing order to facilitate such access. Limited availability of naloxone in pharmacies, lack of knowledge or understanding by pharmacy staff of the standing order, and variability in out-of-pocket cost for this drug are among these potential barriers. Regulatory or legal incentives for pharmacies or drug manufacturers, education efforts directed toward pharmacy staff members, or other interventions may be needed to increase naloxone availability in pharmacies.

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care

BACKGROUND

Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs.

OBJECTIVES

Examine the changes in reasons for ED use associated with Medicaid expansion.

RESEARCH DESIGN

Difference-in-difference analysis.

SUBJECTS

We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259).

MEASURES

We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states.

RESULTS

Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022].

CONCLUSIONS

Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

Higher Rates of Preventive Health Care With Commercial Insurance Compared With Medicaid: Findings From the Arkansas Health Care Independence "Private Option" Program

BACKGROUND

A requirement of the Arkansas Medicaid Section 1115 demonstration waiver was to evaluate the level of care received for Medicaid expansion eligible beneficiaries enrolled in commercial Qualified Health Plans (QHPs) in the Health Care Independence "Private Option" Program. This allowed for a direct comparison of Medicaid and commercial system performance serving similar newly covered adults.

RESEARCH DESIGN

In 2014, assignment to either Medicaid or a QHP was made based upon a psychometrically derived continuous composite score to exceptional health care needs assessment screener using a sharp a priori threshold cutpoint. Using a regression discontinuity design we compared preventive care (flu vaccination and screening rates) services in the 2 programs over 3 years.

RESULTS

Compared with Medicaid enrollees, a higher percentage of QHP enrollees consistently received eligible preventive care screenings with 15.3, and 6.9% more receiving at least 1 or all eligible screenings, respectively. For individual preventive care outcomes and compared with Medicaid enrollees over the 3 years under study, a higher percentage of eligible QHP enrollees received a flu shot, cholesterol screenings, glycated hemoglobin assessment, and cervical and breast cancer periodic assessments. No differences were found for colorectal periodic assessments.

CONCLUSIONS

These findings suggest that at least for preventive services, the Medicaid federal equal access requirement is not being met for those within Medicaid fee-for-service coverage. This persisted across all 3 years of the program. Differential payment rates for services between Medicaid and QHPs are likely a major contributing factor.

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

PURPOSE

We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion.

METHODS

We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county.

RESULTS

Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees.

CONCLUSIONS

In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

Access to Primary, Mental Health, and Specialty Care: a Comparison of Medicaid and Commercially Insured Populations in Oregon

OBJECTIVE

To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.

DESIGN

Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).

PARTICIPANTS

420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015.

OUTCOME

Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.

RESULTS

Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.

CONCLUSIONS

This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.

Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women

OBJECTIVE

To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA).

METHODS

A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma.

RESULTS

The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups.

CONCLUSION

Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion

OBJECTIVES

Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion.

STUDY DESIGN

Statewide survey of PCPs informed by semistructured interviews.

METHODS

After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients.

RESULTS

Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.

CONCLUSIONS

In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.

Spatial dynamics of access to primary care for the medicaid population

Primary care (PC) has always been underestimated and underinvested by the United States health system. Our goal was to investigate the effect of Medicaid expansion and the Affordable Care Act (ACA) provisions on PC access in Broome County, NY, a county that includes both rural and urban areas, and can serve as a benchmark for other regions. We developed a spatial system dynamics model to capture different stages of PC access for the Medicaid population by using the health belief model constructs and simulate the effect of several hypothetical interventions on PC utilisation. The government data portals used as data sources for calibrating our model include the New York State Department of Health, the Medicaid Delivery System Reform Incentive Payment (DSRIP) dashboards, and the US census. In our unique approach, we integrated the simulation results within Geographical Information System (GIS) maps, to assess the influence of geospatial factors on PC access. Our results identify hot spot demographic areas that have poor access to PC service facilities due to transportation constraints and a shortage in PC providers. Our decision support tool informs policymakers about programmes with the strongest impact on improving access to care, considering spatial and temporal characteristics of a region.

Code Red: The Essential Yet Neglected Role of Emergency Care in Health Law Reform

The United States' health care system is mired in uncertainty. Public opinion on the Patient Protection and Affordable Care Act ("ACA") is undeniably mixed and politicized. The individual mandate, tax subsidies, and Medicaid expansion dominate the discussion. This Article argues that the ACA and reform discourse have given short shrift to a more static problem: the law of emergency care. The Emergency Medical Treatment and Active Labor Act of 1986 ("EMTALA") requires most hospitals to screen patients for emergency medical conditions and provide stabilizing treatment regardless of patients' insurance status or ability to pay. Remarkably, this law strengthened the health safety net in a country that has no universal health care. But it is an unfunded mandate that responded to the problem of emergency care in a flawed fashion and contributed to the supposed "free rider" problem that the ACA attempted to cure. But the ACA has also not been effective at addressing the issue of emergency care. The ACA's architects reduced funding for hospitals that serve a disproportionate percentage of the medically indigent but did not anticipate the Supreme Court's ruling in NFIB v. Sebelius, which made Medicaid expansion optional. Public and non-profit hospitals now face a scenario of less funding and potentially higher emergency room utilization due to continued uninsurance or underinsurance. Alternatives to the ACA have been insufficiently attentive to the importance of emergency care in our health system. This Article contends that any proposal that does not seriously consider EMTALA is incomplete and bound to produce some of the same problems that have dogged the American health care system for the past few decades. Moreover, the Article shows how notions of race, citizenship, and deservingness have filtered into this health care trajectory, and in the context of reform, have the potential to exacerbate existing health inequality. The paper concludes with normative suggestions on how to the mitigate EMTALA's problems in ways that might improve population health.