Why Expanded Medicaid Coverage Could Lead to More Emergency Room Visits

Emergency Room

Adults who are covered by Medicaid, the government-backed health-care plan for low-income Americans, use emergency rooms 40 percent more than those in similar circumstances who do not have health insurance, according to a unique new study in which one of our assistant professors, Heidi Allen, participated as an investigator.

The study further showed that the pattern holds across all demographic categories, types of visits, times of day, and kinds of ailments that might have been treated by primary care physicians.

These findings appear to contradict one of the key claims of President Obama and other proponents of the Affordable Care Act—that an expansion of Medicaid to the uninsured would cause them to choose to access the primary health care system instead of going to the emergency room for treatment, which is far more costly.

But Professor Allen thinks that a plausible explanation lies in the interviews she conducted to understand the decision-making behind whether or not to go to an emergency department. As she told a New York Times reporter for an article on the study that appeared last week, many of the newly insured reported their frustration with not being able to obtain same-day or next-day appointments in the primary care system.

The study in which Dr. Allen participated is known as the Oregon Health Insurance Experiment. Taking advantage of Oregon’s recent use of a lottery to assign access to Medicaid, Dr. Allen—along with colleagues from Harvard School of Public Health, MIT, and the National Bureau of Economic Research, including principal investigators Katherine Baicker and Amy Finkelstein—were able to examine emergency room records for roughly 25,000 people over 18 months. They evaluated and compared the behavior of those state residents who obtained Medicaid coverage through the lottery with that of failed lottery applicants, who were otherwise similar but continued to lack coverage. Because of these unique conditions, the study has been hailed as the first randomized controlled trial of the effect of covering the uninsured with Medicaid.

Initially, the study showed that Oregon’s lottery applicants who obtained Medicaid increased their use of primary and preventive care. But as this latest finding shows, they also increased their use of emergency services.

When asked to elaborate on her point in last week's Times for the sake of this post, Dr. Allen explained that because “same or next day appointments are difficult to come by in busy primary care clinics," the emergency department "may be the only option when something is wrong and needs to be checked out right away."

She went on to say that, ultimately, the emergency department findings may be further evidence that insurance improves access to care. In this case, the newly insured don't have to face financial catastrophe in order to be evaluated.

“Interviews with the uninsured reveal they often go to great lengths to avoid emergency department bills," she said, which often include home stitches, borrowing pain medications and antibiotics from friends and families, and “hoping for the best” with scary symptoms such as chest pain and episodes of dizziness. According to Professor Allen, the insured "go to the emergency department for these problems because they can."  She added that in five years as an emergency department social worker in Oregon, she never had the sense that Medicaid led to an abuse of the emergency department's services.

Noting that Amitabh Chandra, a professor and director of health policy research at the Harvard Kennedy School of Government, called the Oregon study, with its strong design and clear result, “breathtaking” in the Times article where Dr. Allen was quoted, Jeanette Takamura, dean of the Columbia School of Social Work, said: “Dr. Allen and her colleagues have helped both health researchers and health policy makers narrow in on the most effective levers for change. No doubt their subsequent work will help to illuminate the entire knot of variables that contribute to health behaviors.”

The study's latest findings were published January 2, 2014 in the journal Science, the leading international journal for original scientific research that is published by the American Association for the Advancement of Sciences.

The other two major papers to emerge from the study are:

—Contributed by ML Awanohara

Image: Grand River Hospital Emergency Entrance, courtesy of Nick Matthews (Flickr).

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