Medicaid Increases ER Visits

This Policy Prescriptions^® review is written by Dr. Seth Trueger. He blogs at MDAware.org and can also be found via Twitter @MDAware or tweeting for Emergency Physicians Monthly @epmonthly. 

In 2008, Oregon had some limited funding to expand their Medicaid program. Given the limited funding, they held a lottery for Oregon residents aged 19-64 who were uninsured for at least 6 months, making less than the federal poverty level ($10,400 per individual or $21,200 for a family of four), and with assets under $2000. Nearly 90,000 Oregonians signed up for the lottery; about 30,000 were selected to then apply for Medicaid in 8 separate drawings throughout 2008 and about 1/3 of those enrolled in Medicaid (Oregon Health Plan or OHP).

In this study, (OHIE) investigators looked at 12 Portland area hospitals that accounted for nearly all emergency department (ED) visits (and half of inpatient hospitalization) in the greater Portland area. The sample covered about 1/3 of the newly-enrolled OHP population. Using administrative data, they compared ED visits during the study period (March 10 2008 to September 30, 2009) among lottery winners (whether or not they enrolled in OHP), OHP enrollees, and those who applied for the lottery but were not selected.

The main outcome was the change in ED visits among lottery winners (i.e. treatment group) who had an average of 13.2 months of OHP coverage compared to non-winners (i.e. control group). Medicaid increased the probability of having an ED visit by 7 percentage points: 41.5% of the treatment group had at least 1 ED visit over the 18-month study period vs. 34.5% in the control group. On average, Medicaid led to a 40% increase in ED visits, from 1.02 to 1.43 visits during the 18-month study period. Interestingly, the only statistically significant increase was among subjects who had no ED visits prior to the study period.

The authors also used the NYU Billings algorithm to characterize the increase in ED visits. They found no difference in “Emergent, Not Preventable” visits but significant increases in ambulatory-care sensitive visits (both preventable and primary care treatable).

Commentary

First and foremost, the Oregon Health Insurance Experiment once again shows us something that is no surprise: increased access to care leads to increased access of care.

Poor individuals have multiple barriers to health care, whether they are insured or not. Shifting some people from uninsured status to the Medicaid program removes some, but not all, of these barriers.

Emergency departments are easier to access than primary care offices for a variety of reasons. It will take time to see if the t’s Medicaid expansion results in better primary care access and care.

Additionally, it’s important to keep in mind that the Billings algorithm is meant to assess how well works – not whether certain ED visits are appropriate or not. As Aaron Carroll notes, more ED visits may not be a bad thing, as the recently uninsured likely have pent-up demand for health care services.

Taubman, SL, et al. Science. 2014; online first.

by

Seth Trueger, MD

This Policy Prescriptions^® review is written by Dr. Seth Trueger. He blogs at MDAware.org and can also be found via Twitter @MDAware or tweeting for Emergency Physicians Monthly @epmonthly.