Health Reform WK-EDGE Urban Institute studies impact of ACA expansion on health care access
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Tuesday, September 10, 2019

Urban Institute studies impact of ACA expansion on health care access

By Cathleen Calhoun, J.D.

Are media outlets and others overstating concerns that ACA expansion will limit health care access for Medicare patients?

Concerns expressed by some in the media and by other writers that the expansion of health care coverage under the Patient Protection and Affordable Care Act (ACA) will make health care access more difficult among Medicare patients may be overstated, according to a brief by the Urban Institute. The brief cited evidence showing that access has only been minimally impacted. Analysis was done of trends in physicians’ acceptance of Medicare patients, Medicaid patients, and privately insured individuals from 2011 to 2016—the period before, during, and after the major ACA (P.L. 111-148) coverage expansions.

The brief stated two main objectives: (1) to assess trends in physicians’ acceptance of Medicare patients from 2011 to 2016, capturing the period before, during, and after the major ACA coverage expansions; and (2) to estimate the impact of the ACA’s Medicaid expansion on physician acceptance of Medicare by using a difference-in-differences approach to compare outcomes in Medicaid expansion states with those in nonexpansion states. Medicare acceptance rates were compared with physicians’ acceptance of Medicaid and privately insured patients for both objectives.

Surveys used. Analysis was done from two physician surveys in order to examine changes in Medicare patients’ access to physicians and assess the impact of the ACA Medicaid expansion. The National Ambulatory Medical Care Survey-National Electronic Health Records Survey (NAMCS-NEHRS), a nationally representative mixed-mode survey of office-based physicians that collects information on physician and practice characteristics (but does not have a large enough sample size to generate sub-state estimates) was the first survey used. Since the NAMCS-NEHRS survey did not have a large enough sample size for sub-state estimates, the SK&A physician database, a census of ambulatory health care sites with a large enough sample size to produce statistically reliable estimates of physicians’ willingness to accept Medicare patients at the county level, was used to supplement the information.

Physician acceptance rates. The share of office-based physicians on the NAMCS-NEHRS that accepted new Medicare patients remained constant at approximately 88 percent between 2011 and 2015. Also, in each year, the share of physicians that accepted Medicare patients on the SK&A was close to the share that accept new Medicare patients on the NAMCS-NEHRS. Physician acceptance rates for Medicaid patients were significantly lower than acceptance rates for Medicare patients, but remained stable over the analysis period. Physician acceptance rates for new privately insured patients on the NAMCS-NEHRS significantly increased and became as high as the acceptance rate for new Medicare patients.

Before and after ACA expansion. New Medicare patients were accepted in the majority of office-based physicians in Medicaid expansion and nonexpansion states before and after the 2014 ACA coverage expansions. The study found that, according to both surveys, nearly 90 percent of office-based physicians in Medicaid expansion and nonexpansion states accepted Medicare patients in 2011-2013. Also, the Medicare acceptance rate on the NAMCS-NEHRS remained constant in 2014–2015 in expansion states (a change of 0.1 percentage points) and decreased by 2.1 percentage points (p-value=0.06) in nonexpansion states. On the SK&A, the share of office-based physicians that accepted Medicare patients only changed 0.2 percentage points in expansion states and 0.5 percentage points in nonexpansion states from 2011-2013 and from 2014 to 2016.

On the county level, distribution shifted toward higher Medicare acceptance rates over time, consistent with the national trend.

Analysis. Physician availability overall and in states and counties did not worsen in most areas after implementation of the ACA coverage expansion, according to the brief. Even with concerns that coverage expansions under the ACA could worsen access to care for the Medicare population, the study found no adverse effects of the Medicaid expansion on physician acceptance of new Medicare patients. The study also did not find evidence that the Medicaid expansion lessened physician acceptance of new Medicaid or privately insured patients.

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