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What increases access?

Although the Affordable Care Act will grant Medicaid to nearly 17 million new enrollees, new research suggests that  supply-side reforms are needed to ensure adequate access to health care for both public and private paying patients.

The Patient Protection and Affordable Care Act (ACA) approaches access to health care by two means: (1) expanding public coverage by making more persons eligible for Medicaid and (2) by increasing the fees that are paid to physicians for certain services and therefore increasing the supply-side of care.  In order to assess the impact of such an expansion, the authors chose to assess the paralleled expansion of the Children’s Health Insurance Program (CHIP).  They analyzed CHIP’s ability to affect those enrolled as far as actual utilization and also the effect on the supply of physician services as average payment rates to physicians varied.

The authors specifically chose to provide this macrolevel analysis. Such an analysis takes into account that coverage expansion might have “spillover effects” on individuals who do not themselves become newly eligible or covered, Coverage expansions also depend on whether and how their effects impact the supply side of the health care market.  A more limited microlevel analysis instead assumes that only those individuals with new eligibility or coverage are affected.

States with the largest CHIP expansions from 1997-1998 to 2008-2009 showed a larger decrease in physician utilization (based on the percent change of physician visits per child per year) compared to those states with smaller CHIP expansions.  The implication is that the supply-side effects of CHIP (decreased reimbursement rates and cumbersome managed care tools), actually decreased the level of actual utilization.

Enrollment in public coverage by children in lower socioeconomic quartiles increased substantially over the same decade. There were spillover effects for those children in the highest socioeconomic quartile (and otherwise not deemed newly eligible) as their enrollment in public coverage increased by about 2 percentage points.  This supports the theory of public insurance crowding-out private coverage.

Compared with the scope of a state’s CHIP enrollment expansion, increased Medicaid physicians fees were more closely associated with improvements in access, i.e. increased physician visits per year among children in all socioeconomic groups (though not statistically significant). Increasing physician fees for Medicaid makes it significantly more likely that higher socioeconomic children have doctor visits and reduces the likelihood that any child will have a barrier to care.

The authors concluded that the spillover effects of coverage expansion are real.  They also highlighted the implication that the greatest benefits of the expanded public coverage in the Affordable Care Act lie in improved financial protections afforded to patients, not necessarily the increase in health services received.


This analysis points out a crucial differentiation between priorities of health care financing and increasing access to health care. The changes brought forth within the Affordable Care Act are financial adjustments and redistribution of our already flawed payment system.

The larger issue of how to actually provide care to a larger number of patients within our current specialist-oriented, reactive, and defensive environment still remains to be addressed.  We can pay for more children, indigent, and sickly patients to receive care, but if we do not have a system in place to actually provide that care and ideally assess its quality the solution is not legitimate.

The supply side of our system (the providers of health care) represents an unfortunate bottleneck that must be transversed in order to increase access to care for all.   Increasing reimbursement rates and promoting other incentives for participation in our public programs (Medicaid, CHIP, and Medicare) are necessary as we seek to strengthen access to services.

White C. “A Comparison of Two Approaches to increasing Access to Care: Expanding Coverage versus Increasing Physician Fees.” Health Services Research. 2012 Epub ahead of print. 


Kameron Matthews, MD, Esq.

Kameron Matthews, MD, JD, FAAFP
About Kameron Matthews, MD, JD, FAAFP

Lead Analyst – Access to Care Kameron Matthews MD, JD is a board-certified family physician and currently serves as Deputy Executive Director of Provider Relations and Services in the Office of Community Care at the Veterans Health Administration in Washington, DC. She earned her medical degree from Johns Hopkins University and her law degree from the University of Chicago. Contact: Facebook | Twitter | More Posts

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