Medicaid Expansion Hasn't Driven Up Demand for Emergency Care

It’s a hotly debated question about healthcare reform: How does Medicaid expansion impact emergency department usage? Some thought leaders suggest expanding Medicaid eligibility and funding increases emergency department use, further stressing an already stressed system. But recent data may show a different story.

George Washington (GW) University researchers published a study examining the impact of insurance expansion on emergency department use across 37 states in 2014—the first year of expanded Medicaid eligibility under the Affordable Care Act (ACA). Their research shows initial concerns of deluged emergency departments may have been unwarranted.

The study’s key takeaway is that “total ED visits grew by less than 3 percent in 2014 compared to 2012—13, with no significant difference between expansion and nonexpansion states.” This is hardly the sharp increase many expected. Still, with Medicaid accounting for more than $495 billion in state and federal spending in 2014, it’s important to understand all the expansion consequences impacting emergency departments.

Medicaid is jointly funded by state and federal governments, so eligibility requirements may vary state to state. Generally speaking, Medicaid is available to low-income individuals and families, qualified pregnant women, and people with disabilities. Under the ACA, income eligibility for Medicaid rose to 133% of the poverty line, which sparked a dramatic increase in enrollment. As of January 2016, nearly 73 million people were enrolled in Medicaid and the accompanying Children’s Health Insurance Program. This marks a 27% increase from the summer of 2013, before the ACA was enacted.

The GW study indicates this significant increase in Medicaid patients didn’t result in a corresponding increase in emergency department visits. But what about the concerns that Medicaid patients overuse emergency departments for routine care? Such a problem would drive up costs and increase wait times for patients with actual emergencies. As it turns out, those concerns aren’t supported by data either.

A study published by the Center for Studying Health System Change shows that Medicaid patients overwhelmingly visit emergency departments for semi-urgent, urgent, or emergent issues—not nonemergency conditions. In addition, the severity of emergency that brings Medicaid patients to emergency departments is roughly comparable to patients with private insurance.

However, Medicaid patients still visit emergency departments at a much higher rate (45.8 visits per 1000 enrollees) than privately insured patients (24 visits per 1000 members). While the majority of those visits are for legitimate emergencies, many of those visits could be avoided with earlier intervention. A heart attack may be prevented by regular visits with a primary care physician. A diabetic coma may be avoided with routine diabetes management protocol. With the average emergency department visit up to 4 times the cost of an office-based visit, it only makes sense to steer the expanding Medicaid enrollees away from emergency departments when appropriate.

Unfortunately, barriers prevent those patients from seeking primary, and often preventive, care. Medicaid patients may not have transportation to a physician’s office. They may work hourly jobs, making it difficult to schedule appointments during office hours. Doctors also get paid less to treat Medicaid patients, further limiting the pool of doctors from which to choose.

While expanding Medicaid eligibility is a first step in reducing the uninsured population, the underlying impact on emergency services clearly needs more study. One thing is certain: Some of our assumptions are not supported by initial data. But with Medicaid accounting for one-third of our total national health expenditure, policymakers, public health professionals, healthcare providers, insurers, and patients all have a stake in understanding the financial and health impact of expanded coverage.