Health policy/brief research report
National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries

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Study objective

We compare the association between barriers to timely primary care and emergency department (ED) utilization among adults with Medicaid versus private insurance.

Methods

We analyzed 230,258 adult participants of the 1999 to 2009 National Health Interview Survey. We evaluated the association between 5 specific barriers to timely primary care (unable to get through on telephone, unable to obtain appointment soon enough, long wait in the physician's office, limited clinic hours, lack of transportation) and ED utilization (≥1 ED visit during the past year) for Medicaid and private insurance beneficiaries. Multivariable logistic regression models adjusted for demographics, socioeconomic status, health conditions, outpatient care utilization, and survey year.

Results

Overall, 16.3% of Medicaid and 8.9% of private insurance beneficiaries had greater than or equal to 1 barrier to timely primary care. Compared with individuals with private insurance, Medicaid beneficiaries had higher ED utilization overall (39.6% versus 17.7%), particularly among those with barriers (51.3% versus 24.6% for 1 barrier and 61.2% versus 28.9% for ≥2 barriers). After adjusting for covariates, Medicaid beneficiaries were more likely to have barriers (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 1.30 to 1.52) and higher ED utilization (adjusted OR 1.48; 95% CI 1.41 to 1.56). ED utilization was even higher among Medicaid beneficiaries with 1 barrier (adjusted OR 1.66; 95% CI 1.44 to 1.92) or greater than or equal to 2 barriers (adjusted OR 2.01; 95% CI 1.72 to 2.35) compared with that for individuals with private insurance and barriers.

Conclusion

Compared with individuals with private insurance, Medicaid beneficiaries were affected by more barriers to timely primary care and had higher associated ED utilization. Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.

Introduction

The Patient Protection and Affordable Care Act seeks to increase health insurance coverage by expanding Medicaid eligibility.1 As a result, insurance coverage with Medicaid is expected to increase by 16 million persons during the next decade and may increase overall health care and emergency department (ED) utilization.2 Although Medicaid expansion will decrease financial barriers to care, other barriers persist, including limited availability of primary care physicians, clinics not being open at convenient times, and transportation issues. Furthermore, the prevalence of barriers to timely primary care for all Americans has increased during the past decade, and these barriers were associated with increasing ED utilization.3

The ED is an important bellwether for access to care, the most common venue for acute care, and the most frequent source of inpatient admissions.4 Accordingly, barriers to primary care and associated ED utilization are important indicators of health care system performance. Given the limited number and availability of primary care providers, there may be increasing barriers to timely primary care and associated ED visits for current and newly enrolled Medicaid with health insurance expansion through the Patient Protection and Affordable Care Act. Previous studies in single states have evaluated the association between barriers to primary care and ED utilization, specifically for Medicaid beneficiaries.5, 6 However, to our knowledge the role of barriers to timely primary care in the higher observed ED utilization rates for Medicaid beneficiaries has not been evaluated on a national level.

The primary objective was to describe barriers to timely primary care among Medicaid beneficiaries compared with that for individuals with private insurance and to characterize how these barriers are associated with ED utilization. We hypothesized that Medicaid beneficiaries will have more barriers to care and higher associated ED utilization.

Section snippets

Study Design

Each year, the National Center for Health Statistics conducts the National Health Interview Survey, a cross-sectional household interview survey representative of the noninstitutionalized US civilian population. We received a waiver from our institutional review board to analyze the National Health Interview Survey data from 1999 to 2009.

The sample was obtained by using a stratified, multistage probability study design with unequal probabilities of selection. The National Health Interview

Results

Table 1 displays demographics, socioeconomic status, health conditions, and outpatient care utilization among adults with Medicaid and private insurance. Compared with adults with private insurance, Medicaid beneficiaries were less likely to report having a usual source of care.

Overall, Medicaid beneficiaries were more than twice as likely to have greater than or equal to 1 ED visit (39.6% versus 17.7% for private insurance). Each of the 5 measured barriers to timely primary care was more

Limitations

By using data from an existing national survey, we were limited to questions already in the survey and could not alter or add other questions. The study results might have been stronger if we had had a question that directly addressed the causal relationship between the barriers to timely primary care and ED utilization. Additionally, the National Health Interview Survey was based on self-reported data, so barriers and ED utilization could not be confirmed and are subject to recall bias. The

Discussion

The effect of state programs to expand Medicaid coverage on ED utilization has been mixed. In Massachusetts, there was higher ED utilization, but in Oregon—where adults were randomized to Medicaid enrollment—early results do not show an increase in ED utilization.7, 8 To our knowledge, this is the first national study to characterize the association between barriers to timely primary care and ED utilization in Medicaid compared with private insurance beneficiaries. Consistent with previous

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Cited by (0)

Supervising editor: Melissa L. McCarthy, ScD

Author contributions: PTC and AAG conceived the study, obtained institutional review board approval, and performed data collection and the primary data analysis. All authors contributed to the study design. All authors contributed to the analysis and interpretation of data and article revision. PTC drafted the article. AAG takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Funded by an Emergency Medicine Foundation/Society of Academic Emergency Medicine Medical Student Grant.

Please see page 5 for the Editor's Capsule Summary of this article.

A podcast for this article is available at www.annemergmed.com.

Publication date: Available online March 13, 2012.

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