Effects of the Medicaid expansion on the the compensation of new primary care physicians

Relatore:  Josè Escarce - UCLA
  martedì 14 giugno 2022 alle ore 12.00 In presenza + Zoom Webinar.

Objectives: The Affordable Care Act of 2014 increased health insurance coverage for U.S. working-age adults through the insurance marketplaces, which sell subsidized private insurance, and expansion of public Medicaid coverage to adults with incomes <138% of poverty. All states set up marketplaces, but only some states, home to 64% of Americans, expanded Medicaid. Thus, the “demand shock” from the expansion was not universal. Qualitative studies have found that physician organizations in expansion states increased physician recruitment in response to the demand shock, and we recently found that after the expansion higher numbers of new general internists established their first practices in expansion states (and lower numbers in non-expansion states) than would have if every state had expanded. This study examines whether the expansion affected the compensation of new primary care physicians (PCPs) (general internists, family physicians, and pediatricians). We posit that the expansion raised compensation for internists and family doctors, but not for pediatricians, since the expansion did not have an appreciable effect on children.

Methods: Subjects were 2,003 new PCPs responding to the 2009-2018 Surveys of Residents Completing Training in New York State (60% response rate), which included information on the characteristics and location of the jobs physicians took. The primary outcome was self-reported starting base salary, and the secondary outcome was anticipated bonuses. We used a difference-in-differences (D-in-D) design to assess changes in outcomes for new PCPs before and after the Medicaid expansion in expansion states versus non-expansion states. Covariates included physician characteristics, job characteristics, time-varying state characteristics, and state and year fixed effects.

Results: Preliminary analyses confirmed parallel trends in outcomes in expansion and non-expansion states prior to the expansion. The D-in-D estimate was that starting salaries for general internists in expansion states, relative to non-expansion states, rose by 5.0% (p<.05) compared to what they would have been without the expansion. The point estimate was suggestive of an increase for family physicians as well, but the estimate was imprecise. There was no effect of the expansion on starting salaries for pediatricians. The expansion also increased anticipated bonuses in rural areas. Sensitivity analyses found the same results. Notably, inspection of salary trends in non-expansion states suggests that the expansion may have increased salaries in those states as well, possibly as physician organizations in those states raised salaries to reduce the loss of physicians. This effect cannot be identified.

Discussion: Our results suggest that enhanced physician recruitment in expansion states, intended to address the increased demand for care from the expansion, was accompanied by higher starting salaries. A limitation of our design is that we could not assess whether salaries eventually also rose in non-expansion states as they tried to blunt to the loss of physicians to expansion states. It seems likely that the Medicaid expansion has contributed to higher physician incomes.

Zoom link: https://univr.zoom.us/j/81928099936


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Paolo Pertile

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Data pubblicazione
3 giugno 2022

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