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Health Serv Res. 2012 Jun;47(3 Pt 1):963-83. doi: 10.1111/j.1475-6773.2011.01378.x. Epub 2012 Feb 2.

A comparison of two approaches to increasing access to care: expanding coverage versus increasing physician fees.

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Center for Studying Health System Change, 1100 1st St. NE, 12th Floor, Washington, DC 20002-4221, USA.



To compare the effects of a coverage expansion versus a Medicaid physician fee increase on children's utilization of physician services. PRIMARY DATA SOURCE: National Health Interview Survey (1997-2009).


We use the Children's Health Insurance Program, enacted in 1997, as a natural experiment, and we performed a panel data regression analysis using the state-year as the unit of observation. Outcomes include physician visits per child per year and the following indicators of access to primary care: whether the child saw a physician, pediatrician, or visited an ER in the last year, and whether the parents reported experiencing a non-cost-related access problem. We analyzed these outcomes among all children, and separately among socioeconomic status (SES) quartiles defined based on family income and parents' education.


Children's Health Insurance Program had a major impact on the extent and nature of children's insurance coverage. However, it is not associated with any change in the aggregate quantity of physician services, and its associations with indicators of access are mixed. Increases in physician fees are associated with broad-based improvements in indicators of access.


The findings suggest that (1) coverage expansions, even if they substantially reduce patient cost sharing, do not necessarily increase physician utilization, and (2) increasing the generosity of provider payments in public programs can improve access among low-SES children, and, through spillover effects, increase higher-SES children as well.

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