Original Article

Do Geographic Region, Pathologic Chronicity, and Hospital Affiliation Affect Access to Care Among Medicaid- and Privately Insured Foot and Ankle Surgery Patients?

Authors: Charles Pitts, MD, Haley McKissack, MD, Bradley Alexander, BS, Mohit Jain, MD, Jun Kit He, MD, Aaradhana Jha, MD, Amit Momaya, MD, Ashish Shah, MD


Objectives: Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices.

Methods: Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative’s acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus).

Results: Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices.

Conclusions: Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Labrum JT 4th, Paziuk T, Rihn TC, et al. Does Medicaid insurance confer adequate access to adult orthopaedic care in the era of the Patient Protection and Affordable Care Act? Clin Orthop Relat Res 2017;475:1527–1536. 2. Medford-Davis LN, Lin F, Greenstein A, et al. “I broke my ankle”: access to orthopedic follow-up care by insurance status. Acad Emerg Med 2017;24:98–105. 3. Wiznia DH, Nwachuku E, Roth A, et al. The influence of medical insurance on patient access to orthopaedic surgery sports medicine appointments under the affordable care act. Orthop J Sport Med 2017;5:2325967117714140. 4. Baraga MG, Smith MK, Tanner JP, et al. Anterior cruciate ligament injury and access to care in South Florida: does insurance status play a role? J Bone Joint Surg Am 2012;94:e183. 5. Bruggeman NB, Turner NS, Dahm DL, et al. Wound complications after open achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res 2004;(427):63–66. 6. Kadakia AR, Dekker RG 2nd, Ho BS. Acute Achilles tendon ruptures: an update on treatment. J Am Acad Orthop Surg 2017;25:23–31. 7. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2007;28:759–777. 8. Mann RA. Disorders of the first metatarsophalangeal joint. J Am Acad Orthop Surg 1995;3:34–43. 9. Gulati V, Jaggard M, Al-Nammari SS, et al. Management of achilles tendon injury: a current concepts systematic review. World J Orthop 2015;6:380–386. 10. Sutherland JM, Wing K, Younger A, et al. Relationship of duration of wait for surgery and postoperative patient-reported outcomes for hallux valgus surgery. Foot Ankle Int 2019;40:259–267. 11. Ricketts T. Geography and disparities in health care. In: Swift EK, ed. Guidance for the National Healthcare Disparities Report. Washington, DC: The National Academies Press; 2002. 12. Medicaid.gov. Monthly Medicaid & CHIP application, eligibility determination, and enrollment reports & data. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/monthly-reports/index.html. Accessed August 20, 2019. 13. Sommers BD. Health care reform’s unfinished work—remaining barriers to coverage and access. N Engl J Med 2015;373:2395–2397. 14. American Orthopaedic Foot & Ankle Surgeons. Find a foot and ankle orthopaedic surgeon. https://footcaremd.org/find-a-foot-and-ankleorthopaedic-surgeon. Accessed November 3, 2020. 15. Patterson BM, Draeger RW, Olsson EC, et al. A regional assessment of Medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access. J Bone Joint Surg Am 2014;96:e156. 16. Association of American Medical Colleges. Advocacy and policy. https://www.aamc.org/advocacy/medicaid. Accessed November 3, 2020. 17. Kim CY, Wiznia DH, Hsiang WR, et al. The effect of insurance type on patient access to knee arthroplasty and revision under the Affordable Care Act. J Arthroplasty 2015;30:1498–1501.