A good doctor is hard to find—and for those with Medicaid or without health insurance at all, finding a new primary care doctor is almost impossible. According to an audit study headed by physician Karin Rhodes, the difference in access to primary care is even more extreme than we might expect. New patients with Medicaid were far less likely to obtain a doctor’s appointment than their privately insured peers, and uninsured patients had it hardest of all: only 15.4% could obtain an appointment without paying more than $75 at the time of service.

One reason this disparity has gone undetected until now is that physicians overestimate how many Medicaid patients they treat by up to 40%. In order to get a true read, Rhodes uses an audit study, which is perhaps the most powerful tool social scientists can use to measure discrimination. In Rhodes’ simulated patient study, a team of 10 field staff members was selected for diversity in race and age based on the sound of their voices in a phone audition. After being trained to pose as new patients, they made 11,347 calls to doctors’ offices in 10 states to assess “business as usual”. On each attempt to make an appointment with a primary care physician, a caller was prompted to adopt the persona of a patient with one of three insurance types: private, Medicaid, or no insurance. In this way, two otherwise identical “patients” were presented in the real-world situation of making an appointment, and the only characteristic that varied was their insurance type, which was experimentally manipulated by the researcher. As a result, using the audit method allowed Rhodes’ team to test exactly how much of the difference in outcomes was due solely to insurance type.

Overall, 87.4% of privately insured callers were able to schedule an appointment, compared to 57.9% of Medicaid callers. Among uninsured patients, 78.8% were able to see the doctor, but only if they could pay a fee of $75 or more in full at the time of service. The median out-of-pocket cost for a primary care visit was $120, and fewer than one-fifth of practices allowed flexible payment arrangements.

Rhodes’ study assessed the capacity of the primary care system before the Affordable Care Act’s 2014 coverage expansion. The ACA is projected to cover 25 million formerly uninsured Americans. Because access to primary care is considered vital to improving population health outcomes, system that is already strained may make the ACA’s goals harder to achieve. This means that the system of providers accepting Medicaid needs to be strengthened before coverage increases will translate into gains in access to primary care.

In War and Peace, Leo Tolstoy wrote, “Everything depends on upbringing.” Parents who agree have devised limitless strategies for optimal child-rearing. To test one strategy, sociologists Susan Dumais, Richard Kessinger, and and Bonny Ghosh investigated whether parents’ involvement at school could provide an advantage on children’s teacher evaluations. They found that it did improve the kids’ scores for language and literacy, approach to learning, and interpersonal skills—but only in all three categories if children also came from white, college-educated families.

This research builds on Annette Lareau’s finding that families’ approaches to parenting differ depending on their economic and educational resources. In contrast to working-class parents, both black and white middle-class parents, she found, tend to parent with “concerted cultivation.” These parents create a highly organized schedule of structured activities for their children, are active in their schools, and train them to interact confidently with adults. Lareau suggests that middle-class children might be able to obtain a more customized education and be viewed as more socially competent by their teachers because of the resulting ability to negotiate.

While exploring how this advantage might work, Dumais, Kessinger, and Ghosh determine that certain parenting practices are more beneficial for children in particular racial or socioeconomic groups. For instance, parental volunteering only benefits all three of the teacher evaluations for white children from college-educated families. On the flip side, white children of high-school educated families receive poorer evaluations if their parents attend conferences, as do African American children of college-educated families when their parents request a specific teacher. The authors interpret these findings as sound rationale for Tolstoy’s lament: “I often think how unfairly life’s good fortune is sometimes distributed. ” Undeniably, each family’s unique racial and educational background still triggers barriers in the educational system.