Why does Medicaid increase emergency department use?

The interpretation of results of a policy study lies in the political inclination of the beholder.

If one likes the results they are “ground breaking.” If they are not in line with our world view there are “nuances” of hypothesis testing that detractors have overlooked, it’s too “premature” to draw conclusions and “further research” is needed. Statisticians, like lawyers, can be recruited to argue any point of view to meaningless insignificance.

This is natural. Instead of begrudging these biases it is best to listen to opinions on both sides as they can be instructive.

The Oregon Health Insurance Experiment (OHIE) studied the impact of Medicaid on outcomes and utilization of services. In Oregon, Medicaid was expanded by a lottery. This is as close to randomization as possible. Research in social sciences is hindered by the difficulty in randomization.

The latest results, published in Science, found that Medicaid expansion increased emergency department (ED) use by 40%.  The finding challenges an assumption: the economically disadvantaged utilize the emergency department because of lack of insurance.

This assumption is the basis of another assumption: uncompensated care by emergency department shifts costs to the insured. In turn this assumption leads to a train of assumptions: expanding insurance will keep people healthier by enabling them to visit their primary care physician (PCP), so less likely to present to the emergency department with advanced disease, and health care costs will actually decrease.

To what extent the Congressional Budget Office used these assumptions in their original models that showed the Affordable Care Act, in the long run, is budget neutral is uncertain. But there is little doubt that this assumption trail needs to be revisited.

That’s one interpretation. Here is another.

The ED is not the back office of US health care but its central headquarters. It is a system within a system. ED provides adequate, often excellent, and time-sensitive care.

Consider a shift worker straddling the federal poverty level who has abdominal pain for the past 3 months. It is 10pm on Saturday night and he has finally decided that his symptoms need to be addressed. He can walk in to the ED — no phone call, no appointment, no receptionist telling him that the PCP does not take new Medicaid patients. He will be seen, perhaps with a delay, investigated thoroughly and diagnosed or reassured. For him this is access. This is his reality.

ED is excellent not just in dealing with acute problems but in managing, at least initially, chronic problems. It takes a decent snapshot of a person’s health. It applies a decent bandage. Often a bandage is all people care about.

ED has had to reach structural soundness because of unique exposure to litigation and EMTALA, which forbids denial of emergency treatment to the uninsured. Over the years the ED has become robust because of relentless and concentrated demands placed upon it. For many it is the most reliable element, a friend in need, in this fragmented health care system.

In the UK’s National Health Service (NHS), both primary care and ED are free at point of service for all, and access to PCPs is more certain and uniform than in the US. People still throng the ED. So much so that PCPs have been asked to open shop 24/7 to take pressures off acute services which are imploding because of limited budget and manpower.

For many in the US, the ED is the 24/7 de facto primary care that the UK so craves. Perhaps the Medicaid budget should follow the patient, and spending be directed away from regulatory waste and towards the emergency department so that it morphs in to a conjoined emergency-primary care service.

OHIE confirms several things. Having insurance increases utilization. Medicaid does not provide the level of access of private insurance or Medicare. The ED is perceived to be the best access for many and this will remain so for a long time. Expanding insurance will not shift burden from ED to primary care. Expanding health insurance will not reduce health care costs (that I think we all knew, deep down).

In a sense OHIE confirms reality. As opinions on health care can be highly polarized, presenting a reality that we can all agree on is a ground-breaking achievement.

Saurabh Jha is a radiologist. He can be reached on Twitter @RogueRad.

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