Provider Directory Accuracy and Access to Pediatric Primary Care in Pennsylvania’s ACA Marketplace: A Simulated Patient Study

OBJECTIVE: Access to pediatric primary care is foundational to children's health, yet insurance coverage does not guarantee timely access. This study examines barriers to pediatric primary care access in Pennsylvania's Affordable Care Act (ACA) marketplace, including provider directory inaccuracies, capacity constraints, wait times, travel burdens, and language-concordant care availability. METHODS: We conducted a simulated patient study from March through August 2023, fielding 2,084 calls on behalf of 654 simulated pediatric patients across all rating regions and insurers. Callers used carrier directories to contact the nearest listed pediatric clinician, documenting appointment outcomes, wait times, travel times, and reasons for failure using a structured instrument. Binary outcomes were analyzed using logit regression; continuous outcomes used OLS with robust standard errors. RESULTS: Of 2,084 calls, only 1,016 (48.8%) reached an individual to assess directory information (evaluable calls). On each patient's first call, only 320 of 654 (48.9%) were evaluable; among these, 35.6% resulted in a scheduled appointment. Among all evaluable calls, 30.3% resulted in an appointment, with carrier-level rates ranging from 15.2% to 47.3%. Considering all attempts, only 14.8% resulted in an appointment. Mean wait time was 39.6 days and mean travel time was 26.0 minutes. Provider directory inaccuracies affected 55.9% of evaluable calls. Callers requesting Spanish-speaking clinicians were more likely to obtain appointments but faced longer travel times (37.9 vs. 24.2 minutes). CONCLUSIONS: Pediatric patients in ACA marketplace plans face substantial access barriers driven by pervasive directory inaccuracies and capacity limitations, with meaningful variation across carriers and populations.