Medicaid Expansion States See Uptick in ER Visits

Findings in 25-state study challenge the notion that the expansion of health insurance coverage under the Affordable Care Act would reduce emergency department visits, but that’s not necessarily bad.  

States that expanded Medicaid coverage under the Affordable Care Act saw 2.5 emergency department visits more per 1,000 people after 2014, while the share of ED visits by the uninsured decreased by 5.3%, according to a study this week in Annals of Emergency Medicine.

“Medicaid expansion had a larger impact on the healthcare system in places where more people were expected to gain coverage,” study lead author Sayeh Nikpay, PhD, of Vanderbilt University, said in remarks accompanying the study. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, as in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”

Nikpay analyzed patient visits in 14 states that expanded Medicaid coverage and 11 that did not and found that the share of visits covered by private insurance remained constant for expansion states and increased by several percentage points for non-expansion states. Gains in insurance coverage in non-expansion states were almost entirely in the form of private coverage, not Medicaid.

Increases in ED visits were largest for injury-related visits. There was also a large change in payer mix for dental visits, because dental ED visits are most prevalent among low-income, non-elderly adults on Medicaid. Out-of-pocket dental costs were reported as one of the more unaffordable types of care among the target population for Medicaid expansion under the ACA.

Ari Friedman, MD, of Boston’s Beth Israel Deaconess Medical Center, wrote an accompanying editorial and said that the increased ED visits in the expansion states “runs contrary to the prediction by many policymakers that by providing greater access to primary care, insurance expansion would break the decades-long trend of increasing ED volume.”

Friedman said there was scant evidence to support that prediction, but plenty of actual experience from states such as Oregon, which demonstrated that decreasing the cost of healthcare by providing for health insurance leads to an increase in care use of all kinds, be it in the ED or the primary care setting.

“More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good,” Friedman said. “Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients' care needs as patients themselves define them, the emergency department has a key role to play in a flexible system."