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Simulated Patients Shed Light on Disparities in Access to Health Care
Simulated Patients Shed Light on Disparities in Access to Health Care

Disparities in access to health care faced by racial and ethnic minorities, people living in poverty, and other vulnerable populations in the US are well-documented. The Affordable Care Act (ACA) was meant to change that. Many of the key provisions of President Obama’s signature health care reform law—the Patient’s Bill of Rights, federal investment in primary care training programs, modernizing infrastructure, and insuring more people—were designed to increase access to health care for millions of US citizens. Several years into the rollout of “Obamacare,” researchers are collecting and analyzing data that will help determine whether the ACA has succeeded in narrowing the disparity gap.

Health economist Dr. Rajiv Sharma and his colleagues Drs. Arnab Mitra and Sarah Tinkler of Portland State University’s Department of Economics have broadened PSU’s community health research portfolio with their NIH-funded Longitudinal Access to Physicians study. Their work addresses whether, and in what ways, access to primary health care providers has changed in the wake of the ACA for people of different races, ethnicities, and genders who are privately insured, covered by Medicare or Medicaid, or uninsured.

The Longitudinal Access to Physicians study is the first of its kind to consider the roles of race/ethnicity and gender in relation to insurance coverage of access to primary care. Its design innovations included creating simulated patients with distinct profiles to audit the system and using students posing as family members of the “patients” in phone calls seeking information about appointments from health care providers. These innovations, Dr. Sharma explained, allowed the researchers to control for the low levels of responsiveness and responder bias introduced into similar studies that collect data via surveys and to avoid the problematic data from Medicaid and Medicare payment records that may not accurately represent subgroups within the population.

“In a sense, we’ve taken the pulse of the American healthcare system in the run-up to and after the implementation of some of the major provisions of the Affordable Care Act,” Dr. Sharma said. “We’re measuring how often our simulated patients are offered appointments with a primary care physician or an alternative provider and that is a key indicator of the performance of the system as a whole. Our analysis of the data collected by students during thousands of phone calls can help us answer the question: now that we’ve had this huge overhaul and expansion of health care, is access improving and, if so, for whom and to what degree?”

The team’s initial findings, published in the journal Economics Letters demonstrate that in 2013, the year before the expansion of Medicaid, some subgroups of the population experienced far greater difficulties accessing primary care than others. A simulated Hispanic woman on Medicaid, for instance, had just a fourteen percent chance of being offered an appointment during a phone call placed by a student posing as a family member. A white, uninsured male, on the other hand, had a seventy percent chance of being offered an appointment.

In the months following their initial publication, the research team has continued to analyze data. Their investigations have yielded several forthcoming publications and presentations, including one paper that suggests nurse practitioners might be an untapped resource in the nation’s primary health care system, and another that examines racial, ethnic, and gender-based disparities in offers of appointments in relation to how generously states compensate physicians who take Medicaid. Future publications, Dr. Sharma explained, will explore whether disparities exist for patients who are obese, smokers, or who live in poverty.

“What we’re starting to see as we analyze the data,” Dr. Tinkler said, “is that access might be improving overall, but some groups are being left behind. That might indicate that if you want to see better access for certain subgroups of the population, a more targeted policy than the ACA may be needed.”

“That is how we hope our work can inform the conversation around reducing disparities in access to primary health care,” Dr. Sharma said. “This research can help policy-makers identify what is working and what is not in the system and direct resources to address gaps in access.”

Recent estimates suggest twenty million Americans have obtained health insurance under the ACA. Much of the research emerging in the wake of the rollout of Obamacare shows that the likelihood of all racial and ethnic groups being uninsured has gone down since 2014. And while those are positive signs for the nation’s healthcare system, narrowing the gaps in access to care faced by racial and ethnic minorities, people living in poverty, and other vulnerable populations will likely require further efforts. Economists like Drs. Tinkler and Sharma are helping to identify places where gaps in access continue to exist and where policy could be directed to remedy them. It will be a long process and there’s still much to be done, but their work is bringing us closer to a health care system that ensures, as President Obama recently said in a speech, that health care is not a privilege for the few but a right for everyone living in America.