The Doctor Might See You Now: The Supply Side Effects of Public Health Insurance Expansions

Abstract

In the United States, public health insurance programs cover over 90 million individuals. Changes in the scope of these programs, such as the Medicaid expansions under the recently passed Patient Protection and Affordable Care Act, may have large effects on physician behavior. This study finds that following the implementation of the State Children's Health Insurance Program, physicians decreased the number of hours spent with patients, but increased their participation in the expanded program. Suggestive evidence is found that this decrease in hours was a result of shorter office visits. These findings are consistent with the predictions from a mixed-economy model of physician behavior with public and private payers and also provide evidence of crowd out resulting from the creation of SCHIP.

The Affordable Care Act and Ambulance Response Times

“…3 Garthwaite (2012) Massachusetts reform led to shorter hospital stays. Kondo and Shigeoka (2013) found that hospitals increased their capacity (as measured by number of beds) after the introduction of universal health insurance in Japan, but there were no noteworthy changes in the numbers of medical institutions, physicians, or nurses.…”

The Impact of Health Reform on Purchased Care Access: National Health Reform and Modernization of the Military Health System Study

“…When trying to accommodate higher demand by increasing volume, physicians can change treatment intensity and decrease their work per patient. While this increases volume and the number of patients that the physician treats, it may also raise quality of care concerns if the previous treatment intensity was optimal from the payer or patient perspective (Garthwaite, 2012;McDonald et al, 1974). On the other hand, studies have shown that physicians might simply work longer hours to see more patients without changing treatment intensity or expand health care supply through a broader use of nurse practitioners, physician assistants, or other providers (Kaiser Family Foundation, 2013).…”

“…Depending on the marginal revenue of seeing patients insured through higher reimbursement rates (e.g., privately insured), physicians may reduce their caseload or stop treating patients with lower relative payments, such as those insured by TRICARE or Medicaid (Kemp, 2012). Indeed, data show that despite increases in both Medicaid payment rates and its enrollment over the previous decade and some evidence on increased access to care (Baker and Royalty, 1997;Garthwaite, 2012), the share of physicians accepting Medicaid patients had decreased (Cunningham and May, 2006). 1 Several studies have shown, however, that low or nonparticipation rates varied spatially, as they are associated with such factors as the size of the Medicaideligible population in the geographic area (Mitchell, 1991) and other community-level characteristics, such as income per capita (Perloff et al, 1997).…”

“…Conversely, some private physicians might accept a small number of individuals, but their offices might not be set up to accommodate Medicaid coverage, and thus their patients might have to seek care elsewhere. The number of physicians who would newly accept Medicaid patients under a Medicaid expansion is likely small (Garthwaite, 2012;Sabik and Gandhi, 2013;Tu et al, 2010;White, 2012). As noted by authors at the Center for Studying Health Systems Change analyzing the Boston market after Massachusetts passed health reform, "Approximately two out of three newly insured people are covered by MassHealth or Commonwealth Care, and most of them have continued to use the same safety net providers they had used when uninsured, though perhaps at a higher utilization rate" (Tu et al, 2010).…”

Public health insurance expansions and hospital technology adoption

“…14 We follow papers such as Currie and Gruber (2001), DeLeire, Lopoo, andGarthwaite (2012) in estimating the reduced-form effect of simulated Medicaid eligibility. In the spirit of Currie and Gruber (1996), we have also estimated instrumental variable regressions in which we instrument for the actual fraction of CPS respondents eligible for Medicaid with the simulated fraction eligible for Medicaid.…”