Emergency Room Usage is Way Up in Medicaid Expansion States



When President Obama pitched his health care overhaul in 2008 and 2009, one of the arguments he often made was that the existing 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 a major speech promoting the law in September, 2009. In multiple speeches, Obama suggested that excess emergency room visits added almost $1000 a year to the average family's medical insurance costs.

But the argument that emergency room usage could be reduced by passing the health law never quite held up. In Massachusetts, which several years prior had enacted a similar health law, emergency room visits had 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.

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

And 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. Emergency department usage in non-expansion states saw a 1.8 percent increase, possibly because of people who were previously eligible for Medicaid getting covered and using emergency rooms more.

The increased utilization in the expansion states is not only significantly higher than in states that didn't expand, it's more than what might have been expected based on data from the previous two years.

The problem with emergency room usage is that it's expensive and inefficient—which is why it's supposed to be used mainly in emergencies. So what the Medicaid expansion has done is put millions into a health system that encourages this kind of expensive, inefficient care.

The newly covered Medicaid population, meanwhile, isn't like the old one. It's likely sicker, according to the study. Which means they're even more expensive still.

We've seen similar results in studies looking at a randomized experiment expanding Medicaid in Oregon. Overall, Medicaid looks likely to increase utilization throughout the health system. What it doesn't seem to do, as the Oregon experiment found, is increase physical health in a measurable way. That randomized controlled study, the single best examination of Medicaid's effects, found no statistically significant improvement in objective health outcomes. So we're sending people to the emergency room a lot more, and spending billions on expanded coverage in the process. But we may not be helping them get any healthier. 


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  1. Emergency rooms are also a major way in which illegal aliens get free medical treatment through Medicaid: 1, 2.

  2. Without any basis, I’m going to float the explanation is that people without insurance avoid going to the ER because the cost is uncertain and possibly high but once they go on Medicaid, it’s a known fixed amount. Also, once they’re enrolled, the state floods them with pamphlets and letters telling them all about the services they’re now eligible for. Why not show up in the ER?

    1. The other thing is that GPs who will accept new Medicaid patients are few and far between.

      1. Even if you find a GP, they are usually open 40 hours a week. The ER is open 168 hours a week.

        1. But you’d think that people with jobs would be even more likely to be pushed to ER’s by their primary care physician’s schedule.

          So why would skewing the population poorer make ER visits rise?

          The Medicaid population has PLENTY of time and opportunity to go to regular doctor visits. They just don’t. They go to ER’s because the whole concept of going to a normal doctor’s office requires foresight, the ability to keep a calendar schedule, and a certain degree of civilization – and the Medicaid population lacks all of those things.

  3. In multiple speeches, Obama suggested that excess emergency room visits added almost $1000 a year to the average family’s medical insurance costs.

    The problem with emergency room usage is that it’s expensive and inefficient?which is why it’s supposed to be used mainly in emergencies.

    I don’t believe either you or President Obama. Frankly, emergency room usage is very likely one of the cheapest ways to get nonemergency care.

    First, emergency rooms have to be open for emergencies. So resources are sitting there unused except in emergencies. Of course they can handle nonemergency care. Second, ERs can triage the daylights out of the population that visits them. No emergencies will go untreated because someone came in with a cough.

    But the greatest evidence that emergency room use for nonemergency care is not a big problem is that there isn’t a door next to the Emergency Room that says NonEmergency Room. Collapsing these two services is clearly what most hospitals find most economical.

    Emergency rooms look expensive for nonemergency care only because the hospitals are averaging the standing costs required to handle emergency cases over nonemergency cases. This likely makes sense for the hospital that is trying to maximize its revenue. But it is soundly not true that nonemergency use of emergency rooms costs American families $1000 per year.

  4. By the way, this notion that treating the uninsured in emergency rooms results both in (a) high costs for the medical system and (b) bad results for the uninsured compared to preventative care is the biggest of the big lies behind Obamacare.

    Obamacare costs a fortune compared to the pittance of compensating hospitals for emergency room care delivered to the uninsured, and preventative care costs more than acute care in all but the narrowest of conditions.

  5. Problem of excessive emergency room visits is due to people on Medicaid having difficulty of seeing a doctor due to the lower payments Medicaid makes for medical services.

    Solution is the creation of a clinic staffed with nurse practitioners who can deal with the great majority of medical problems at less cost. Leaving the actual ER for those who need that level of medical services. Of course this will be opposed by the MD’s who hate the thought of “competition” for their services. This type of opposition to using lesser qualified people is endemic among the professions, who behave much like unionized workers who believe that they “own” their jobs thanks to the union.

    The entire history of the professions has been one of organizing themselves into politically powerful “unions” to do the exact same thing that ordinary labor unions do for their members. We have reduced the power of organized labor through “Right to Work” legislation. We need to do the same thing with the professions who have effectively organized themselves into legal monopolies able to charge the rest of us far higher fees than what they could obtain in a true free market.

  6. Of course they’re using the emergency room more. If you or I go to the ER, we have a nice copay or deductible that will come out of our pockets. If you’re on Medicaid, it’s completely free.

  7. This article was published in September 2014, and today the situation is about the same; a significant portion of these Medicaid covered populations are turning to Emergency Departments for mild to moderate urgency conditions, such as abdominal pain, coughs and mild fevers.

    Still, the biggest cost among Emergency Room visits remain the high risk frequent “fliers” – the few and often, the homeless. Although some CCO’s are reaching out to them, connecting them with adequate or optimal resources such as housing, there is more work to be done.

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