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Looking to Massachusetts for Answers

A complicated case study gives conflicting answers to emergency departments.

in 2006 served as a model for the (ACA), and many policy experts are closely following the state to estimate what we can expect with the ACA. One important question to policymakers and the public is whether the ACA will decrease emergency department (ED) visits.

Source: Robbie Shade (Flickr/CC)

Source: Robbie Shade (Flickr/CC)

A new study published in Medical Care this year specifically focused on ED use by people who gained Commonwealth Care (CommCare) after health reform in Massachusetts. CommCare in Massachusetts is similar to the marketplace plans in the ACA that people buy with the help of subsidies from the government.

Overall, those enrolling in CommCare decreased their ED visits by 4%. However, the actual effect depended on what type of insurance patients had before enrollment.

Patients who had MassHealth/Medicaid before CommCare decreased their ED visits by 7%, and those who were part of the Health Safety Net (a program that helped cover some hospital and clinic bills) decreased their ED visits by 18%. However, those who did not have public assistance from either government program before CommCare actually increased their ED visits by 12%.

Why did one group enrolled in CommCare increase their ED use while the other groups decreased it? One theory is that patients who had been completely without health care had more pent up demand. The fact that those who had been without public assistance for longer periods of time increased their numbers of ED visits seems to support this.

Another theory is that the relative cost of an ED visit to the patient was the motivating factor.

Many CommCare plans charge patients copays for ED visits. Before enrolling in CommCare, patients who were uninsured would have been responsible for the entire ED bill. The ED copay with CommCare might seem like a bargain after enrollment, whereas patients with Health Safety Net or MassHealth would have already received assistance with ED bills.

What can we learn from Massachusetts?

If the cause of ED use is the amount of pent up demand for health care, then we can expect people getting marketplace plans through the ACA in other states to have a history of less financial assistance before enrollment. This will lead to subsequent increases in ED use. However, if the cause of ED use is relative copay costs, then the high-deductible plans most people are enrolling in through the ACA marketplaces could discourage ED use.

commentary by Laura Medford-Davis, MD


BACKGROUND: In 2006, Massachusetts expanded insurance coverage to many low-income individuals.

OBJECTIVES: This study aimed to estimate the change in emergency department (ED) utilization per individual among a cohort who qualified for subsidized health insurance following the Massachusetts health care reform.

RESEARCH DESIGN: We obtained Massachusetts public health insurance enrollment data for the fiscal years 2004-2008 and identified 353,515 adults who enrolled in Commonwealth Care, a program that subsidizes insurance for low-income adults. We merged the enrollment data with statewide ED visit claims and created a longitudinal file that indicated each enrollee’s ED visits and insurance status each month during the preenrollment and postenrollment periods.

MEASURES: We estimated the ratio in an individual’s odds of an ED visit during the postperiod versus preperiod by conditional logistic regression.

RESULTS: Among the 112,146 CommCare enrollees who made at least 1 ED visit during the study period, an individual’s odds of an ED visit decreased 4% [odds ratio (OR)=0.96; 95% confidence interval (CI), 0.94, 0.98] postenrollment. However, it varied significantly depending on preenrollment insurance status. A person’s odds of an ED visit was 12% higher in the postperiod among enrollees not publicly insured prior (OR=1.12; 95% CI, 1.10, 1.25), but was 18% lower among enrollees who transitioned from the Health Safety Net, a program that pays for limited services for low-income individuals (OR=0.82; 95% CI, 0.78, 0.85).

CONCLUSIONS: Expanding subsidized health insurance did not uniformly change ED utilization for all newly insured low-income adults in Massachusetts. PMID: 25464165

Lee, J, et al. Medical Care. 2015; 53 (1): 38-44.

Laura Medford-Davis, MD
About Laura Medford-Davis, MD

Dr. Medford-Davis is an assistant professor at Baylor College of Medicine and works as a consultant for McKinsey&Company. She began writing for Policy Prescriptions® in 2013. Contact: Website | Facebook | Twitter | More Posts