A study from Science found that those on Medicaid in Oregon made 40% more visits to the emergency department.
The Oregon Health Insurance Experiment included about 90,000 low-income people and assigned 30,000 of them to Medicaid by lottery. It’s essentially a naturally-occurring randomized controlled trial.
The result seems to have caught the public policy experts by off guard:
“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard University’s School of Public Health and one of the authors of the study.
But ask any practicing physician, and most would say the result is of little surprise.
The promise of insurance doesn’t guarantee access to care. Especially with Medicaid. To save money, Medicaid continually pressures physician reimbursements down, and obstructs care with a number of bureaucratic hurdles that exceed most private insurers. Cumbersome pre-authorizations and overly restrictive drug formularies, for instance.
It’s no wonder why fewer primary care doctors and specialists accept Medicaid.
Another reason is one of convenience. Adrianna McIntyre at The Incidental Economist points to a Health Affairs study that interviewed Medicaid recipients, asking them why they chose the emergency department.
One response is telling:
For patients covered by Medicaid, the direct financial cost of an ED visit and physician office visit were similar; however, the overall cost of ambulatory care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider.
One respondent reported: “When I go to my primary, I don’t have a copay. I don’t have a copay in the ER either. But my primary may send me to 2 or 3 specialists, and sometimes there is a copay for them. Plus time off from work to go see them. It’s cheaper to just go to the ER.”
Primary care involves regular office visits to properly manage chronic diseases like hypertension and diabetes. According to McIntyre, this time cost is a greater barrier for Medicaid patients, who may have to deal with time off from work, child care, or transportation issues more frequently than their middle and upper class counterparts.
The emergency department has grown into a one-stop shop, where patients have 24/7 access to studies and consultants that would require separate visits and co-pays in the ambulatory setting. Primary care has to evolve into a viable alternative that matches the convenience of the emergency department. Health reform offers very little to move the needle in that direction.
The Oregon Medicaid findings highlight a central flaw in the Affordable Care Act. Expanding insurance without expanding the primary care infrastructure drives more patients to the hospital. Until that is effectively addressed, expect more newly insured patients beyond Oregon to use the emergency department for primary care.
Kevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.