The Effect of the Children’s Health Insurance Program on Pediatricians’ Work Hours

Abstract

Objective: Our study examines changes in physicians' work hours in response to a coverage expansion. Methods: We use as a natural experiment the Children's Health Insurance Program (CHIP), which was established in 1997 and significantly expanded children's eligibility for public health insurance coverage. The magnitude of the CHIP expansion varied across states and over time, allowing its effects to be identified using a state-year fixed effects model. We focus on pediatricians, and we measure their selfreported work hours using multiple waves (pre-and post-CHIP) of the physician survey component of the Community Tracking Study. To address endogeneity concerns, we instrument for CHIP enrollment using key program features (income eligibility cutoffs and waiting times). Results:We find a large negative relationship between the magnitude of a state's CHIP expansion and trends in pediatricians' work hours. This relationship could be due to key supply-side features of CHIP, including relatively low provider reimbursements and heavy use of managed care tools. He, F., White, C. Keywords: E2 IntroductionThe Congressional Budget Office (CBO) has estimated that providing insurance coverage for all of those who are currently uninsured would increase the demand for health care services by 2 to 5 percent (Congressional Budget Office, 2008). But, for the quantity of services to actually increase, providers have to supply the additional care, and it is not clear whether, or how, they will do so. Based on a purely demand-driven model of physician labor supply, the CBO and other researchers have hypothesized that a large coverage expansion could lead, in the short run, to physicians working longer hours to accommodate such an influx of patient demand. On the other hand, a supply-driven model hypothesizes that physicians could choose to work fewer hours with a large coverage expansion, due to constraints on the supply side. To test between the two hypotheses, we analyze the impact of the Children's Health Insurance Program (CHIP), a public health insurance program for children in low-and middle-income families.Established in 1997, CHIP has several features that make it well suited to our purposes. First, the CHIP expansion was large, resulting in almost one in five children becoming newly eligible for public coverage-that expansion in eligibility is roughly similar in magnitude to the expansion for adults that will occur under the Affordable Care Act (ACA). Second, states play a central role in designing and financing their CHIP programs, and have some latitude to determine eligibility criteria. As a result, eligibility criteria and other key program features vary widely from state to state, which we exploit in our analysis. Third, CHIP was established relatively recently. This allows access to fairly rich and recent data sources, and also makes it more plausible that any findings would be relevant to upcoming reforms.We use a state-year level panel data analysis, with observations spanning the period before and after the establi...

The Impact of Insurance Expansions on the Already Insured: The Affordable Care Act and Medicare

“…Garthwaite (2012) finds that pediatricians decreased their labor supply in response to the Children's Health Insurance Program (CHIP) expansions, demonstrating a potential pathway for reduced utilization among already-insured children. He and White (2013) also find a decrease in pediatrician work hours associated with CHIP expansions. In contrast, Chen (2017) finds that physicians increase their total hours of care supplied in response to Medicaid eligibility expansions, and Chen et al (2018) suggest that CHIP reauthorization led pediatricians to pursue further training and accept private practice positions (relative to hospital employment).…”

Essays in health and labor economics

“…I find that pediatric physicians who practice medicine in areas with the average level of physician concentration and above the national poverty rates significantly reduced their total working hours per week by about 1.78 hours per week. Physicians reduce their time on direct patient care activities about 1.97 hours per week, which is consistent from early studies (Enterline et al 1973;Garthwaite 2012;He and White 2013). Physicians' working hours in competitive areas were more strongly impacted by the expansion.…”

“…Garthwaite (2011) found that the introduction of SCHIP decreased the number of hours spent with patients, but increased physicians' program participation. He and White (2013) examined the change in physicians' work hours in response to the SCHIP expansion. They found a large negative relationship between the magnitude of a SCHIP expansion and trends in pediatricians' work hours.…”

“…Empirical methodsI follow the approach similar to that previous literatures(Gaynor and Serra (2012),Garthwaite (2013),He and White (2013)). I use a triple difference model to estimate the impact of SCHIP on physicians' response and how the response varies by levels of physician concentrations.For a triple difference model, I use pediatricians as a treatment group and internal medicine physician as a control group.…”

A Comprehensive Assessment of Four Options for Financing Health Care Delivery in Oregon

“…(For historical examples of that type of reallocation, see Stewart and Enterline [1961] and .) It is improbable that physicians' work schedules would expand proportionally with the increase in patient demand (Enterline, McDonald, and McDonald, 1973;He and White, 2013), particularly among the half of physicians practicing in Oregon who were employees in 2015 (Oregon Health Authority, 2016). In the long run, providers might delegate larger roles to ancillary staff to increase output (Buchmueller, Miller, and Vujicic, 2016) or develop enhanced triage strategies to prioritize the provision of services to patients with the greatest clinical need (Aaron and Schwartz, 1984).…”