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Jessica Greene, Jan Blustein, And Beth C. Weitzman

Excerpted from:  Jessica Greene, Jan Blustein, And Beth C. Weitzman,  Race, Segregation, and Physicians' Participation in Medicaid, The Milbank Quarterly, Vol. 84, No. 2, 2006 (pp. 239 to 272) (Full Article)


Many studies have explored the extent to which physicians' characteristics and Medicaid program factors influence physicians' decisions to accept Medicaid patients. In this article, we turn to patient race/ethnicity and residential segregation as potential influences. Using the 2000/2001 Community Tracking Study and other sources we show that physicians are significantly less likely to participate in Medicaid in areas where the poor are nonwhite and in areas that are racially segregated. Surprisingly and contrary to the prevailing Medicaid participation theory we find no link between poverty segregation and Medicaid participation when controlling for these racial factors. Accordingly, this study contributes to an accumulating body of circumstantial evidence that patient race influences physicians' choices, which in turn may contribute to racial disparities in access to health care.

The literature documenting racial and ethnic disparities in access to health care in the United States is growing. African Americans and Latinos, for example, are less likely to have a consistent source of care and are more apt to consider the emergency department their medical care home than whites are, even after controlling for sociodemographic differences Minorities also are less likely to use any medical services or to receive preventive care, and their rates of preventable hospitalizations and unmet health needs are substantially higher than those of whites .

The dynamics underlying these disparities are undoubtedly complex. One contributing factor may be physicians' failure to participate in the Medicaid program . Historically, physicians' participation in Medicaid has been suboptimal. National studies document that between 15 and 30 percent of private physicians do not accept any Medicaid patients and many more limit their participation. . The potential for limited access is clear: in a recent audit study, callers posing as Medicaid recipients were almost half as likely to be offered an appointment within one week compared with those claiming to have private insurance. Minority Americans are disproportionately affected by physicians' limited participation in Medicaid, since African Americans, Latinos, and Native Americans are two and half times more likely to have Medicaid coverage than whites are.

Another body of research suggests a connection between patient race and physicians' participation in Medicaid.1 This literature explores the influence of residential segregation on physicians' participation in Medicaid. However, as we shall detail here, that empirical work leaves open the question as to whether physicians' participation is linked to residential segregation based on poverty or race and whether the racial composition of the Medicaid population itself matters. For this article, we empirically tested three competing, but not mutually exclusive, hypotheses about physicians' participation in Medicaid as it relates to race, poverty, and segregation. The three hypotheses are as follows:

    1.  Physicians are more likely to accept Medicaid patients in areas where the poor are white.
    2. Physicians are less likely to accept Medicaid patients in areas that are more racially segregated.
    3. Physicians are less likely to accept Medicaid patients in areas that are more economically segregated.

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To date, studies of physicians' participation in Medicaid have generally been interpreted as supporting the Medicaid (poverty) segregation hypothesis. This hypothesis says that in economically segregated urban areas, physicians are less likely to accept Medicaid patients because of the combination of low Medicaid demand and practice economics. At the same time, this literature has suggested that racial segregation and/or composition also influence the participation decision. But as reviewed here, none of the studies ostensibly supporting the Medicaid (poverty) segregation hypothesis controlled for these race-related factors. In this article, we explored what happened to the poverty segregation factor when we controlled for local racial factors. Under these circumstances, we found that poverty segregation had a substantially attenuated effect on participation. This is one contribution of our work.

We also documented that local race-related factors exhibited robust relationships with physicians' participation in Medicaid, even when controlling for poverty segregation. Physicians' inclination to participate in Medicaid is influenced by the race of the local Medicaid population and also by the local racial segregation patterns. When the poor population was composed of a greater proportion of non-Hispanic whites, primary care and specialty physicians were more likely to participate in Medicaid. The effect of the racial makeup of the local poor was quite large: physicians were 11 percentage points more likely to participate in Medicaid if they practiced in a county with the highest quartile of "percentage of the poor that are white," compared with those practicing in the lowest quartile. In addition, our findings point to a role for local racial segregation. Physicians were several percentage points less likely to participate in Medicaid in counties with the highest level of white/nonwhite residential segregation.

Thus, this study has contributed to the accumulating body of circumstantial evidence that patient race influences physicians' choices and behaviors. Most of the earlier research in this field concentrated on differences in communication, diagnosis, and treatment. In this study we found that patient race also appears to influence access to physicians. This raises the question as to why patient race and/or local segregation patterns should influence physicians' decisions to participate in Medicaid.

Certainly race, racism, and segregation are pervasive features of American social life, influencing employment, housing, education, and medical care. We believe it therefore would be surprising if physicians' decisions to participate in Medicaid were free of racial considerations.

How the reported patterns of physicians' participation influence disparities in access to care for Medicaid recipients needs to be investigated further. It is notable that almost half of all people of color living below the poverty threshold reside in counties where less than 25 percent of the poor are white. At a minimum we would expect that Medicaid recipients in these counties, as well as those residing in highly segregated counties, would have more difficulty finding a physician willing to accept Medicaid coverage. It is also quite plausible that Medicaid recipients in these counties experience more restricted overall access to physicians.

Although our study does not address the dynamics underlying the observed patterns, we can offer two possible scenarios. First, we would expect fewer physicians to participate in Medicaid in areas where the poor are nonwhite if the physician's racial bias or stereotyping influenced his or her decision to participate in Medicaid. This does not necessarily imply intentional or conscious discrimination against minority Medicaid patients. Rather, physicians, like all people, are likely to feel most comfortable interacting with people who are like them. To the extent that most physicians are white, they may be more motivated to care for the poor when the poor also are white.

Second, the findings related to lower participation levels in highly racially segregated areas are consistent with physicians' concern about "mixing" white, privately insured patients with minority Medicaid patients. Like real estate agents working in prejudiced communities who discriminate against minorities in order to avoid alienating white clients, physicians may be less inclined to participate in Medicaid in highly segregated areas because of the perception (real or otherwise) that their established patients would be uncomfortable sharing the waiting room with low-income minority patients. Clearly, more work is needed to ascertain the dynamics underlying the patterns described here.

Our findings do point to one approach to improving physicians' participation for minority Medicaid recipients: increasing the pool of minority physicians. As we showed, African American and Asian physicians were more likely than white physicians to participate in Medicaid. Furthermore, minority physicians were more likely than whites to participate in Medicaid in counties where most of the poor were nonwhite and in areas that had high levels of racial segregation. This finding is consistent with earlier studies showing that minority physicians are generally more likely to treat low-income and minority patients. Over the last five years, however, even though the number of new Asian physicians has risen, the number of African American and Hispanic medical school graduates has dropped. In order to increase the percentage of minority physicians, policymakers will need to raise, rather than cut, funding for training minority physicians.

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