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Racial and ethnic disparities in access to health care is growing in the United States. Minorities 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. It is known that minorities are less likely to use any medical service or receive preventive care. Their rates of preventable hospitalizations and unmet health needs are substantially higher than those of Caucasians. A complexity of these disparities may be caused by the physician’s failure to participate in the Medicaid program. In a recent study is showed Medicaid recipients were almost half as likely to be offered an appointment within one week compared with those claiming to have private insurance. This article also looks at the connection between the patient’s race and the physician’s participation in Medicaid. The question is 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. There were three hypotheses that were tested. They are:

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.

The Medicaid Segregation Hypothesis

Sloan and colleagues influenced what they call the “two-market demand model”. Physicians prefer to treat private-paying patients until the point at which the marginal revenue in the private market falls below the Medicaid fee. In urban areas with greater physician supply, primary care physicians were found to be less likely to participate in Medicaid. Since most physicians' offices in urban areas are located in affluent areas, the residential segregation of Medicaid and private-paying patients would result in many physicians facing low demand from Medicaid patients. It was hypothesized that physicians in high-income urban areas have few or no Medicaid patients, those low-income areas have mainly Medicaid patients. Poor Medicaid beneficiaries and their wealthier, privately insured counterparts live in different neighborhoods, which is a theory, that Fossett and Peters states that invokes segregation. Their theory does not consider physicians' preference for higher income patients or concern about “mixing” patients from different socioeconomic classes and neither does it refer to race or ethnicity.

Three Important and Sometimes Conflated Distinctions

• Race versus Poverty
• Racial versus Economical Residential Segregation
• Composition versus Segregation

“The segregation of both minorities and the poor has been implicated in the development of economically depressed neighborhoods, which in turn limits residents' access to quality jobs, education, safety, social networks, and health care. Even though they are related, segregation by poverty and segregation by race differ, are driven by different dynamics, and in fact have only a moderate correlation. Economic segregation is a common feature of American residential life, but because housing is generally viewed as a free-market commodity, segregation based on individuals' willingness and ability to pay is often seen as inevitable and unproblematic. Racial segregation, in contrast, has been driven largely by racism at both the institutional and individual levels. This has been repeatedly documented through the use of fair-housing audits, in which two people of different races pose as equally qualified and visit the same real estate agent or landlord in succession. “Approximately 15 to 30 percent of the time, African Americans and Hispanics receive less information about available housing units and are invited to inspect fewer apartments and homes than whites are”. One explanation may be that the landlords or real estate agents may have a prejudice against these minorities. Another reason is that agents discriminate against minorities because they fear upsetting, violating the norms and expectations of their white clients. Composition versus segregation have been conflated in the Medicaid physician participation literature. Composition is a population's proportion of individuals with particular characteristics. Composition is related to segregation in that many measures of segregation compare composition across sub units in a larger geographic unit. Racial composition appears to influence social policy. “Studies over the last twenty-five years have found that those states with a greater percentage of African Americans have stricter welfare sanctions as well as lower income-support levels”.

A Notable Void

Physicians' participation in Medicaid and the racial segregation and composition of the geographic areas where they practice does not directly address the extent to which the racial composition of the Medicaid population might influence their decision to participate. It is important given the correlation between race and Medicaid eligibility and in light of the growing recognition of the influence of patient race in medical treatment more generally. Patient race historically has been a key factor determining a person's access to health care in the United States. ” The passage of the Civil Rights Act made it illegal for hospitals to segregate explicitly on the basis of race, although they have not yet completely desegregated Continued segregation is based partly on the continued residential segregation of racial minorities. Doctor’s office are not subject to Civil Rights Acts regulations. If physicians want, they can refuse to treat minority patients or treat them differently from their white patients. It also has been reported that physicians have also segregated their waiting areas on economic and possibly by racial bias. Most unequal treatment is because of the physician’s bias. This is possibly one of the contributions to disparities in healthcare. “This conclusion, though somewhat controversial is based on research indicating that physicians' decisions seem to be partly influenced by patient race. The strongest such evidence comes from audit studies finding that physicians' treatment recommendations and health assessments are different for black (or black women) patient-actors than they are for white patient-actors presenting with identical symptoms”. These research findings agree with popular perceptions: national survey results show that approximately one-third of physicians and almost half of adults in the United States believe that the health care system often treats people unfairly "based on what their race or ethnic background is". In conclusion, the literature on physicians' participation in Medicaid often touches on race and segregation but does not consistently differentiate between residential racial and economic segregation. Nor has it systematically addressed the possible influence of Medicaid patient race.

Methods and Measures

The two primary data sources used were the Community Tracking Study Physicians Survey (CTS), which provides physician-level data on Medicaid participation, and U.S. Census 2000 data for county-level race and poverty composition and segregation measures. The CTS is a large, nationally representative telephone survey of physicians. The sample was drawn from the master files of the American Medical Association and the American Osteopathic Association and excludes federally employed physicians, those outside the continental United States, and those in training. The 2000 Census data was the second source used in this study. The census provided race data at the census track and county levels for calculating racial residential segregation. It also provided poverty data at the census track and county levels for calculating poverty segregation and county data based on the percentage of the poor nonwhite population. There was also other measures used as covariates. These included the Medicare/Medicaid reimbursement ratio, the percentage of the county's population receiving Medicaid and the county-level Medicaid managed care penetration rate, the ratio of physicians to population, Race, Segregation, Physicians' Participation in Medicaid 249 and a measure of Medicaid program hassle. The Medicaid program hassle measure is the percentage of pediatricians surveyed in each state citing Medicaid paperwork concerns as a “very important” factor for limiting or not participating in Medicaid.

All practicing physicians were included in the CTS sample, with the exception of psychiatrists. Institutional providers, which are those who are working in hospitals, clinics, and medical schools and as well as office based providers were included in order to examine the availability of all physicians to the Medicaid population.

“The dependent variable used was whether or not a physician accepted new Medicaid patients. The CTS asked the physicians: "Is the practice accepting all, most, some, or no new patients who are insured through Medicaid, including Medicaid managed care patients?" There was also a version contrasting the physicians who did not accept Medicaid at all. The racial composition of the Medicaid population was looked at on the federal level instead of the county level because it was not available.

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