Health Insurance Expansion and Physician Distribution

摘要 历史上主导美国医生队伍讨论的两个问题是 医生总供应量的充分性和医生的地理分布。虽然有几篇文章 观察到最近的保险扩大可能会增加对医生服务的需求和 因此放大了对医生短缺的担忧，到目前为止还没有研究系统地分析 扩招对医师地域分布的潜在影响。年保险覆盖面的收益 近年来，扩大医疗补助计划的州的规模比未扩大的州大得多，因此 增加医疗保健需求，为扩张中的医生创造更多新的收入机会 各州。此外，在扩张州内，盈利机会可能已经扩大到最大 弱势社区的学位，那里的保险覆盖率基线最低， 覆盖面最广。通过市场交易所扩大弱势社区的覆盖面 也可能为这些社区创造新的收入机会做出了贡献。已被占用 总而言之，随着时间的推移，这些影响可能会吸引更多的医生来到那些历史上 被剥夺了最多的权利。 据我们所知，拟议中的项目将是评估保险效果的第一项研究 扩展美国医生的执业地点决定。具体地说，它将审查四个目标： 目标1.评估保险扩大的影响--具体地说，评估医疗补助扩大和 市场交换覆盖面的增长-基于新医生(即刚刚毕业的医生 医学教育)决定在哪里建立他们的第一个实践。 目标2.评估这种扩张是否不成比例地导致更多的新医生建立他们的第一家 在贫困社区，例如城市贫困地区、小城镇和农村地区的做法。 目标3.评估在弱势社区首次开业的新医生 在保险扩展在教育和资格(即董事会认证、国家和地区)方面有所不同之后 医学院的声望)，来自在其他社区开设第一家诊所的新医生。 目的4.评估保险扩大对现有医生(即有 已建立的实践)关于是否以及将其实践迁移到何处的决定。 为了检验这些目标，我们将分析多个大型国家数据集。我们的医生经验模型 当地执业选择将捕捉医生市场领域的广泛属性，包括收入 机会，并使我们能够模拟各种潜在政策干预的影响。这项研究 研究结果将对未来十年的医疗保健政策产生巨大的影响。

ABSTRACT Two of the concerns that have historically dominated discussions of the physician workforce in the US are the adequacy of the total supply of physicians and physicians' geographical distribution. While several articles have observed that the recent insurance expansion may increase demand for physician services and consequently amplify the concern of physician shortages, no study to date has systematically analyzed the potential influence of the expansion on physicians' geographical distribution. Gains in insurance coverage in recent years have been much larger in states that expanded Medicaid than in non-expansion states, thereby increasing demand for health care and creating more new earnings opportunities for physicians in expansion states. Further, within expansion states, earnings opportunities are likely to have expanded to the greatest degree in disadvantaged communities, where baseline rates of insurance coverage were lowest and gains in coverage greatest. Greater coverage gains in disadvantaged communities through the marketplace exchanges are likely to have contributed to the creation of new earnings opportunities in these communities as well. Taken together, these effects could, over time, attract more physicians to those communities that have historically been most deprived of them. To our knowledge, the proposed project will be the first study to assess the effect of the insurance expansion on the practice location decisions of physicians in the US. Specifically, it will examine four Aims: Aim 1. To assess the effect of the insurance expansion – specifically, of the Medicaid expansion and the growth in marketplace exchange coverage – on new physicians' (i.e., physicians just finishing graduate medical education) decisions regarding where to set up their first practices. Aim 2. To assess whether the expansion disproportionately led more new physicians to set up their first practices in disadvantaged communities, e.g., disadvantaged urban areas, small towns, and rural areas. Aim 3. To assess whether new physicians who set up their first practices in disadvantaged communities after the insurance expansion differed in education and qualifications (i.e., board certification, country, and prestige of medical school) from new physicians who set up their first practices in other communities. Aim 4. To assess the effect of the insurance expansion on established physicians' (i.e., physicians with already established practices) decisions regarding whether and where to relocate their practices. To examine the aims, we will analyze multiple large national data sets. Our empirical model of physicians' practice local choices will capture a wide range of attributes of physician market areas, including earnings opportunities, and permit us to simulate the effects of a variety of potential policy interventions. The study findings will have enormous relevance for health care policy over the next decade.