Medicaid Malfunctions

More emergency room visits

When President Obama pitched his health care overhaul in 2008 and 2009, he repeatedly argued that the existing health system relied too heavily on emergency room usage by the uninsured, which drove up the cost of care for everyone else. "If there are affordable options and people still don't sign up for health insurance, it means we pay for those people's expensive emergency room visits," he said in one speech promoting the law.

But the argument that emergency room usage could be reduced by passing the health law never quite held up. After Massachusetts enacted a similar health law several years earlier, emergency room visits increased. Obama's health reform relied heavily on an expansion of Medicaid, the joint federal-state health program for the poor and disabled-but Medicaid recipients typically used the emergency room far more than other types of patients.

In 2012, the Supreme Court ruled that states could choose whether or not to expand Medicaid under the law without fear of losing their existing federal funding, creating a natural experiment. Some states have expanded the health program. Others haven't.

The results are clear: Emergency room visits are up significantly more in expansion states than in non-expansion states, according to a new study by the Colorado Hospital Association, which examined 450 hospitals in 25 states. Medicaid expansion states saw a 5.6 percent increase in emergency department visits in the second quarter of this year compared with the same period last year, an even greater increase than would have been predicted by recent trends. Emergency department usage in non-expansion states saw a smaller increase of 1.8 percent.

The newly covered Medicaid population, meanwhile, isn't like the old one. It's sicker, according to the study, and thus more expensive to treat and cover.