Differences in primary care utilization by primary care availability in the first year of Virginia Medicaid Expansion

Context: Primary care is essential to health but barriers include affordability of care and accessibility of physicians. Importantly, Virginia's Medicaid expansion reduced cost-related barriers to accessing care for over 700,000 individuals.

Objective: Understand remaining barriers to primary care use, including geographic accessibility, for Medicaid members.

Study aesign and analysis: Multilevel linear probability models used to test the association between primary care utilization and geographic accessibility of primary care providers (PCP) after controlling for demographic characteristics, medical conditions, rurality, and neighborhood-level racial and economic segregation.

Setting or Dataset: 2019-2020 Virginia Department of Medical Assistance Services database (demographic, enrollment, and claims data).

Population studied: A cohort of individuals newly enrolled in Virginia Medicaid expansion who: 1) were between the ages of 19-64, 2) remained continuously enrolled in full Medicaid benefits for twelve months, and 3) enrolled during the first six months of Virginia Medicaid expansion (January 1, 2019 to June 30, 2019).

Intervention/Instrument: None

Outcome Measures: The outcome was any primary care use in the first twelve months of enrollment. Primary care visits were defined as an outpatient visit with a family medicine clinician (MD/DO/NP), internal medicine physician (MD/D), pediatrician (MD/DO), OBGYN (MD/DO), or in a Rural or Federally Qualified Health Center. The geographic accessibility of PCPs for Medicaid patients at the time of enrollment was constructed at the census tract level using the 2-Stage Floating Catchment method.

Results: Our sample included 234,296 Virginians with 87.6% having complete data. Of these, 117,481 (57.2%) individuals had at least one primary care visit. Black individuals were 3.0 percentage points (PP) less likely than White individuals to have at least one primary care visit (p<0.001) in the adjusted analysis. Primary care use significantly differed by MCO plan in adjusted analysis (>90% of Medicaid members are enrolled in MCOs). Primary care use was significantly higher for individuals living in neighborhoods with adequate geographic accessibility of Medicaid PCPs compared to neighborhoods with insufficient Medicaid PCPs (0.6 PP; p=0.017).

Conclusion: While Medicaid expansion coverage lowers barriers to primary care, including cost, barriers like PCP access are associated with differences in primary care use.