The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists.

BACKGROUND: A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them. OBJECTIVE: The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them. RESEARCH DESIGN: We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion. SUBJECTS: A total of 32,102 new general internists. RESULTS: Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states. CONCLUSIONS: States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States.

BACKGROUND: Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand. OBJECTIVE: The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices. RESEARCH DESIGN: Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation. SUBJECTS: The sample consisted of 160,842 physicians in 8 specialty groups. RESULTS: Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states. CONCLUSIONS: The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

Graduate Medical Education, 2022-2023.

This Appendix presents 2022 National GME Census data detailing the numbers and types of ACGME-accredited training programs and the residents and fellows in them.

Easing the Entry of Qualified International Medical Graduates to U.S. Medical Practice.

ABSTRACT: Almost one quarter of physicians and physicians-in-training in the United States are international medical graduates (IMGs), meaning they have graduated from a medical school not accredited in the United States. Some IMGs are U.S. citizens and others are foreign nationals. IMGs, many of whom have years of training and experience gained in their countries of origin, have long contributed to the U.S. health care system, especially by providing care to populations that have been historically underserved. Additionally, many IMGs contribute to the diversity of the health care workforce, which can enhance the health of the population. The diversity of the United States is increasing, and racial and ethnic concordance between a physician and a patient has been linked to improved health outcomes.IMGs must meet national- and state-level licensing and credentialing standards like any other U.S. physician. This assures the ongoing quality of the care provided by the medical workforce and protects the public. However, at the state level, variation in standards and standards that may be more challenging to meet than those for U.S. medical school graduates may hamper IMGs' contributions. IMGs who are not U.S. citizens also face visa and immigration barriers.In this article, the authors present insights gleaned from Minnesota's model IMG integration program as well as changes made in 2 states in response to the COVID-19 pandemic. Improving and streamlining processes for IMGs to be licensed and credentialed as well as the policies governing visas and immigration, where appropriate, can ensure that IMGs will be willing and able to continue to practice when and where they are needed. This, in turn, could increase the contribution of IMGs to addressing health care inequities, improving health care access through service in federally designated Health Professional Shortage Areas, and reducing the impact of potential physician shortages.

An increasing number of states filled Conrad 30 waivers for recruiting international medical graduates.

To address physician shortages in the United States, Congress created the Conrad 30 visa waiver program allowing non-citizen international medical graduates to obtain visas to practice medicine in underserved areas. There is little information on whether states have effectively used the program. To fill the gap, we examined the growth and distribution of Conrad physicians between 2001 and 2020. We found that the number of states filling all of their annual allocated Conrad slots increased over the last two decades, yet one-half of the states still did not fill their allowed slots in 2020. Our analysis also revealed substantial variations across states in the number of Conrad physicians by specialty (eg, primary care physicians and psychiatrists), geography (eg, rural vs urban areas and physician shortage vs non-shortage areas). Our findings suggest that states can better use the Conrad program to meet healthcare needs across specialties and geographic areas.