• Mary Bollinger, Jeff Pyne, Anthony Goudie, Xiaotong Han, Teresa J Hudson, and Joseph W Thompson.
• Department of Psychiatry, Center for Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA. MJBollinger@uams.edu.
• J Gen Intern Med. 2021 Jun 1; 36 (6): 167316811673-1681.

BackgroundPatient ratings of their healthcare experience as a quality measure have become critically important since the implementation of the Affordable Care Act (ACA). The ACA enabled states to expand Medicaid eligibility to reduce uninsurance nationally. Arkansas gained approval to use Medicaid funds to purchase a qualified health plan (QHP) through the ACA marketplace for newly eligible beneficiaries.ObjectiveWe compare patient-reported satisfaction between fee-for-service Medicaid and QHP participants.DesignThe Consumer Assessment of Healthcare Providers and Systems (CAHPS) was used to identify differences in Medicaid and QHP enrollee healthcare experiences. Data were analyzed using a regression discontinuity design.ParticipantsNewly eligible Medicaid expansion participants enrolled in Medicaid during 2013 completed the Consumer Assessment of Health Providers and Systems (CAHPS) survey in 2014. Survey data was analyzed for 3156 participants (n = 1759 QHP/1397 Medicaid).MeasuresMeasures included rating of personal and specialist provider, rating of all healthcare received, and whether the provider offered to communicate electronically. Demographic and clinical characteristics of the enrollees were controlled for in the analyses.MethodsRegression-discontinuity analysis was used to evaluate differential program effects on positive ratings as measured by the CAHPS survey while controlling for demographic and health characteristics of participants.Key ResultsAdjusted logistic regression models for overall healthcare (OR = 0.71, 95%CI = 0.56-0.90, p = 0.004) and personal doctor (OR = 0.68, 95%CI = 0.53-0.87, p = 0.002) predicted greater satisfaction among QHP versus Medicaid participants. Results were not significant for specialists or for use of electronic communication with provider.ConclusionsUsing a quasi-experimental statistical approach, we were able to control for observed and unobserved heterogeneity showing that among participants with similar characteristics, including income, QHP participants rated their personal providers and healthcare higher than those enrolled in Medicaid. Access to care, utilization of care, and healthcare and health insurance literacy may be contributing factors to these results.

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