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Thu January 2, 2014
Shots - Health News

Medicaid Expansion Boosted Emergency Room Visits In Oregon

Originally published on Fri January 3, 2014 5:51 am

Giving poor people health insurance, the belief was, would decrease their dependence on hospital emergency rooms by providing them access to more appropriate, lower-cost primary care.

But a study published in the journal Science on Thursday finds that's not the case. When you give people Medicaid, it seems they use both more primary care and more emergency room services.

"Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations," says Amy Finkelstein, an economics professor at MIT and one of the authors of the study. "Including visits for conditions that may be most readily treatable in primary care settings."

In other words, people are going to the emergency department for things that aren't emergencies. This is exactly what policymakers hoped to avoid by giving people health insurance – including the huge increase in Medicaid coverage coming as part of the Affordable Care Act.

And the increase in ER use found in the study was significant – "about 40 percent," Finkelstein said.

This would be a good place to point out this is not just any study. It is the third major paper from something called the Oregon Health Insurance Experiment, which Finkelstein heads along with Katherine Baicker from the Harvard School of Public Health.

The experiment was a rare opportunity to create a randomized controlled experiment – the gold standard of scientific research. It came about almost by accident, thanks to Oregon's decision in 2008 to expand its Medicaid program via a lottery.

The result, said Finkelstein, was that the groups of people with or without insurance were identical, "except for the fact that some have insurance and some don't. You've literally randomized the allocation of insurance coverage."

And that gave researchers the ability to compare the effects of having health insurance — in this case, Medicaid.

The first paper from the research team, published in 2011, was mostly positive. It found that people who got Medicaid coverage were more likely to use health services in general, less likely to suffer from depression, and less likely to suffer financial problems related to medical bills than those who remained uninsured.

The results in the second paper, published last spring, were more equivocal. Researchers found no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes.

It's not clear that the emergency room results will translate nationwide: The study only lasted 18 months and the study population is both more while and more urban than the rest of the nation.

But that's not stopping critics of Medicaid expansion.

"When you make ER care free to people, they consume more of it. They consume 40 percent more of it," says Michael Cannon, head of health policy for the libertarian Cato Institute. "Even as they're consuming more preventive care. And so one of the main arguments for how Obamacare was going to reduce health care costs is just flat out false."

Cannon says the study will likely further hurt President Obama's credibility for vowing that expanding Medicaid would help get people out of emergency rooms. But what's likely to bother the administration even more, he says, is what it may do to the half of the states that have yet to adopt the Medicaid expansion.

"This study is going to make it less likely that the 25 states that decided not to expand Medicaid are going to change their minds and decide to expand Medicaid," Cannon predicts.

But this study doesn't come as much of a surprise to those people who actually run Medicaid programs around the country.

"This is not something that is unexpected and not something that we're not prepared for," says Kathleen Nolan. She's director of state policy and programs for the National Association of Medicaid Directors.

Nolan says most states are already working to help Medicaid recipients get care in more appropriate settings. "Things like nurse-advice lines, trying to work with the community clinics and community providers to expand hours and make sure that people who are working two and three jobs can get access to primary care after hours and on the weekends," she said.

Because Medicaid recipients are by definition low income, Medicaid doesn't use higher patient payments to deter emergency room use like many private insurers do, Nolan says.

But the key to getting inappropriate costs down for all patients, she says, is educating people about where they should go when it's not an emergency.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

RENEE MONTAGNE, HOST:

One of the great hopes for the Affordable Care Act was that it would bring down trips to emergency rooms, trips that are hugely expensive for hospitals. The theory was that people who don't have health care coverage end up in emergency rooms because they can't afford regular medical care.

Under Obamacare, about four million more of the poorest Americans are eligible for the newly expanded Medicaid, and a new study published in the journal Science has an ominous warning: Giving people Medicaid appears to increase, rather than decrease their use of hospital emergency rooms.

NPR's Julie Rovner reports.

JULIE ROVNER, BYLINE: The findings were pretty straightforward, said Amy Finkelstein. She's an economics professor at MIT, and one of the study's authors.

AMY FINKELSTEIN: What we found is that Medicaid coverage increases emergency department use both overall, and for a broad range of types of visits, conditions and subpopulations, including visits for conditions that may be most readily treatable in primary care settings.

ROVNER: In other words, visits to the emergency departments for things that aren't emergencies. This is exactly what policymakers hoped to avoid by giving people health insurance. The idea is that they will seek lower cost and more appropriate care in doctor's offices instead. And that increase in ER care was fairly significant, Finkelstein noted.

FINKELSTEIN: Medicaid increased the number of emergency department visits by about .41 visits, which is about 40 percent.

ROVNER: Now, this is perhaps were it would be good to point out that this isn't just any study. This is the third major paper from something called the Oregon Health Insurance Experiment. It was a rare opportunity to create a randomized, controlled experiment, the gold standard of scientific research. It came about almost by accident, thanks to Oregon's decision in 2008 to expand Medicaid by lottery. The result, said Finkelstein...

FINKELSTEIN: You have, literally, by construction, made the people with and without insurance identical, on average, except for the fact that some have insurance and some don't. You've literally randomized the allocation of insurance coverage.

ROVNER: Thus, they could compare people with and without insurance almost equally. The first paper from the research team was mostly positive. It found that people who got Medicaid coverage were more likely to use health services in general, less likely to suffer from depression, and less likely to suffer financial problems related to medical bills than those who remained uninsured. The second paper was more equivocal. It found no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes. It's not clear that the emergency room results will translate directly, nationwide. The study only lasted 18 months, and the population is more white and more urban than the rest of the nation. But that's not stopping critics of the Medicaid expansion. Michael Cannon heads health policy for the libertarian Cato Institute. He says he's not all that surprised by the findings.

MICHAEL CANNON: When you make emergency room care free to people, they consume more of it. They consume 40 percent more of it, even as they're consuming more preventive care. And so one of the main arguments for how Obamacare was going to reduce health care costs is just flat-out false.

ROVNER: Cannon says the study will likely further hurt President Obama's credibility for vowing that expanding Medicaid would help get people out of emergency rooms. But what's likely to bother the administration even more, he says, is what it may do to the half of the states that have yet to adopt the Medicaid expansion.

CANNON: This study is going to make it less likely that the 25 states that decided not to expand Medicaid are going to change their minds and expand Medicaid.

ROVNER: Perhaps ironic, however, is that this study doesn't come as much as a surprise to those people who actually Medicaid programs around the country.

KATHLEEN NOLAN: It is not something that is unexpected, and not something that we're not prepared for.

ROVNER: Kathleen Nolan is director of state policy for the National Association of Medicaid Directors. She says most states are already working to help people get care in more appropriate settings.

NOLAN: Things like nurse-advice lines, trying to work with the community clinics and other community providers to expand hours and make sure that people who are working two and three jobs can get access to primary care after hours and on the weekends.

ROVNER: Unlike private insurance, Medicaid doesn't deter emergency room use by charging people more. But the key to getting health costs down for all patients, she says, is educating people about where they can go instead when it's not actually an emergency. Julie Rovner, NPR News, Washington.

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