Date of Award

January 2022

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Walter Kernan


Academic Health Centers (AHCs) in the US have many roles, including educating the healthcare workforce, research and patient care. Many AHCs also serve as safety-net providers, caring for persons who are socioeconomically disadvantaged, underinsured, or uninsured. In this research, we examined how AHCs balance their role as safety net providers with their efforts to provide equitable care in adult primary care internal medicine. Our co-primary aims were to estimate the proportion of AHCs that maintain physically separate adult primary care clinics for patients with Medicaid, compared with other insurance, and compare selected features of clinics with high and low populations of patients with Medicaid. We sought to enroll the top 10 AHCs in terms of NIH funding and an additional 40 AHCs that were selected randomly. We successfully interviewed chiefs of general internal medicine at 39 AHCs, interviewed medical directors at 33 AHCs, and collected data for 83 clinics. Our main finding was that 3 AHCs (9%) [95% CI 2,24] maintained two physically separate clinics that differed by ≥40% in the proportion of patients with Medicaid. A total of 7 AHCs (21%) [95% CI 9, 39] maintained clinics that differed by ≥30% (42%) [95% CI 25, 63], 14 AHCs (42%) [95% CI 25, 61] had clinics that differed by ≥20% and 22 AHCs (67%) [95% CI 48, 82] had clinics that differed by ≥10%. Clinics with a higher proportion of patients with Medicaid were more likely to have resident physicians as primary providers of longitudinal care, less likely to have attending physicians as primary providers of longitudinal care and were more likely to serve patients who are Black or Hispanic. We conclude that Academic Health Centers commonly maintain physically separate clinics to care for patients with Medicaid. These clinics possess different provider arrangements that may affect various dimensions of care, including continuity of care, availability, and quality of care.


This thesis is restricted to Yale network users only. It will be made publicly available on 06/01/2027