Our primary care infrastructure is likely to face increased strain in the wake of the major coverage expansions of the Affordable Care Act (ACA) in 2014. It is therefore critical that we have accurate baseline measures of current primary care access prior to the insurance expansions. Our overall goal was to develop accurate estimates of primary care capacity by insurance status before ACA implementation using a rigorous methodology that can be replicated after the expansions.

To measure access to primary care, we used a “simulated patient methodology”, where trained field staff posed as patients requesting a new patient appointment. Access was defined as: 1) the ability to obtain an appointment for routine care or care for a serious health concern (untreated hypertension) and 2) time to the appointment (conditional on getting an appointment).  Callers were assigned to either Medicaid, commercial, or no insurance coverage. They requested the earliest possible appointment and did not volunteer their insurance status unless asked. If given an appointment, they stated the name of a specific insurance plan that data suggested the practice accepted. Appointments were cancelled at the end of the call. Our unit of analysis was the primary care practice. Calls were conducted in 10 states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas) selected to be diverse in terms of region, size, population density, primary care workforce, reliance on Medicaid Managed Care, generosity of Medicaid payment rates, and projected increase in coverage under the ACA.

We called a total of 13,871 practices across the 10 states.  For states with fewer PCPs, this represented the census of practice; practices in larger states were sampled by county with weights corresponding to the proportion of actual patients with each insurance condition in that county. Overall, 80 percent of privately-insured callers obtained an appointment, compared to 52 percent of Medicaid callers, and 11 percent of uninsured callers, able to bring ~$75 to the visit and make arrangements to pay the remainder. Appointment rates varied widely across states; 92% in Montana and ~65% in Massachusetts and Oregon for privately-insured. For Medicaid, access ranged from 80% in Montana to a low of 35% in Oregon. Uninsured appointment rates varied from 3% (New Jersey) to 21% (Montana). Variations in mean wait times by health condition and insurance status were not clinically meaningful: 14 compared to 12 days for Medicaid compared to private insurance. However, there were large variations by state; mean wait times for an appointment were ~ 7 days in Texas and Iowa, but wait times in Massachusetts averaged 24-28 days.

Our study complements ongoing household and provider surveys, illustrating the current availability of primary care for new patients prior to full ACA implementation. Future work will assess within state variation and measure the impact of the primary care rate bump in increasing primary care access for Medicaid enrollees. Given current capacity constraints, fee increases may be more effective if they are paired with strategies to expand the supply of primary care providers.