A study released yesterday found that, for those newly insured through Medicaid, access to health insurance doesn’t reduce ER visits:
Advocates for health care expansion reason that the newly insured will seek out health care more often, but will choose a primary-care physician over the ER. One reason the uninsured tend to go to the ER when they do finally seek treatment is that it’s their only option. You need to present an insurance card to get service at most physicians’ offices, whereas the ER is legally bound to attend to any case that comes through the door. Once insured, a patient does have every reason to see a primary-care physician and skip the ER: As every American knows, you don’t go to the ER for a good time. You go there expecting to sit under a glaring fluorescent light on a hard-backed plastic seat for four hours (if you’re lucky), surrounded by a combination of crying babies and hacking coughs. If you’ve got the option of making an appointment at your doctor’s office instead, you take it. But according to the Oregon study, the newly insured still choose the ER over the doctor’s office. What’s more, the increase in ER use documented by the study comes in large part from patients with ailments like cuts and sprains—problems that could have been managed through a primary-care physician or by an urgent care clinic (both of which are covered by Medicaid). Patients aren’t, in fact, substituting primary care for the ER to the extent that many insurance advocates have hoped they would.
Brandy Zadrozny worries that our emergency rooms can’t handle the extra workload:
The Medicaid population is expanding at a time when the general strain on the nation’s emergency care facilities is both growing and used disproportionally by Medicaid patients (They made up a third of emergency room visitors (PDF) in 2010 but make up just 16 percent of the population). And while 38 percent of adult Medicaid patients had at least one emergency department visit in the past year, only 16 percent of the privately insured and 21 percent of the uninsured made similar visits. The visits of Medicaid patients are also more likely to be classified as non-emergencies.
The increase in ER use comes as no surprise to Avik Roy:
[O]ne of the big holes in the myth of uninsured “free riders” is that the uninsured only account for 15 percent of the population, 14 percent of total ER visits, and 12 percent of aggregate ER expenditures, according to a study by the Kaiser Family Foundation. Medicaid beneficiaries, by contrast, accounted for 9 percent of the population, 15 percent of visits, and 9 percent of expenses. Given all of this data and experience, it was obvious that expanding coverage through Obamacare would increase taxpayer costs, not reduce them. But predictably, the pro-Obamacare “fact-checkers,” like those at PolitiFact, have been nowhere to be found.
Suderman thinks this calls into question the efficacy of Medicaid:
These findings ought to spark a rethinking of Medicaid’s value and effectiveness. It’s not enough to provide some positive benefit. It’s also important to ask whether there are other, better, less expensive and resource-intensive ways of achieving the same goal. If Medicaid is to be a financial smoothing program rather than a health-improvement program, then we ought to treat it like one, and make reforms accordingly.
Kliff speaks to a health economist who defends the Medicaid expansion:
[Jonathan] Gruber, the MIT economist, doesn’t see the Harvard study as a compelling case against expanding Medicaid. There are still other benefits to insurance coverage, he says, that aren’t about saving public funding. Separate research on the Oregon expansion, published last spring in the New England Journal of Medicine, found Medicaid enrollees to have significantly lower rates of depression and were more able to pay their medical bills. “The overall notion is we’re getting people more health care,” Gruber says. “There are huge improvements in mental health. For those who want to argue that expanding Medicaid is a free lunch, this is bad. But that was never the right argument.”
Reihan counters this type of argument:
Imagine if the debate over the Affordable Care Act had unfolded as follows — the president stated that in the interests of improving the mental health of low-income uninsured Americans, but not necessarily improving their health along other dimensions, he hoped to pass a large and expensive Medicaid expansion; to address the needs of the medically uninsurable population, he intended to implement a series of new insurance regulations that would, among other things, prompt the cancelation of large numbers of insurance policies serving the individual and small group insurance markets, with the net result being a reduction in the number of Americans with private insurance coverage, despite new subsidies aimed at low- to moderate-income households; and to finance these new initiatives, he’d restrict the growth of Medicare expenditures and he would raise various new taxes. It’s not obvious to me that this bundle would have struck many voters, including Democratic voters, as attractive.
Harold Pollack weighs in:
The effect size was pretty small—about one extra ED visit per recipient, every 3.5 years or so. In dollar terms, this amounts to an estimated annual expenditure increase of something like $120 per recipient. We can’t say from this paper whether the extra ED visits were valuable or cost-effective. We can say that these results will embarrass some liberal advocates who argued that expanded coverage would reduce overall rates of ED use.
It should. This talking point was never properly evidence-based or even particularly plausible given prior research. It’s not obvious that reducing the rate of ED use is even a sensible policy goal. Advocates across the political spectrum should stop using the ED for cheap talking points about the mythical savings associated with universal coverage or about the misbehavior of Medicaid recipients who supposedly waste huge amounts of money through overuse.
Aaron Carroll argues that more ER visits don’t necessarily constitute a problem:
[U]ntil someone proves to me that the increased ED use was unnecessary, I don’t know why anyone would assume it’s a bad thing. If our goal is to increase people’s access to the health care system, getting more people insurance (like Medicaid) is a good tool for that. If our goal is to help people make more effective use of the healthcare system, increasing coverage isn’t necessarily going to be as good a tool. I’m sure there will be a ton of partisan hay made out of this being another “broken promise”, but I’m not participating in that.
Adrianna McIntyre’s perspective:
Individuals of different socioeconomic statuses have heterogeneous needs, priorities, beliefs, and limitations when it comes to accessing health care—so rational behavior is going to be similarly varied. With expanded coverage, a central challenge on the health policy scene is making the delivery system adapt to meet the needs of a more diverse patient population. That’s something insurance alone can’t do.
Austin Frakt adds:
Ultimately, my view is that “overuse” of the ED reflects the broader problem that the health system is not very responsive to consumer demand or sensitive to all types of consumers. (The disparities literature is relevant here.) In other words, it’s not consumers making “bad” choices, but the system offering poor ones.