Yesterday the Center for Studying Health System Change released a report on emergency department usage by Medicaid enrollees. The common strain of thinking, even among the informed, is that Medicaid patients frequent the emergency room primarily as a substitute for general care. Which is to say that they mainly use it for non-urgent care and that phenomena has somehow translated into increased health care cost growth.
According to the report, though, that’s a bunch of health policy bull:
Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments (EDs) for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a new national study by the Center for Studying Health System Change (HSC). About 10 percent of nonelderly Medicaid patient ED visits are for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people.
And the accompanying graph:
As you can see Medicaid patients actually use emergency rooms at slightly higher rates than those privately insured for non-urgent care, but not by much. Three-quarters of Medicaid visits to the ER are for, well, emergency reasons. This has important policy implications because many recommendations for Medicaid reform include increased cost-sharing for ER visits, something that would prove counter-intuitive (for health reasons) if the goal is to reduce non-urgent visits. At the very least such schemes would be largely ineffective given that it would only affect a small percentage of Medicaid visits.
Now in terms of raw numbers Medicaid participants do use the ER much more often:
In 2008, Medicaid enrollees had 45.8 emergency room visits per 100 enrollees, compared to 24 visits for the same number of privately insured individuals.
[the higher numbers] could have something to do with the fact that Medicaid tends to cover higher-risk patients, like the disabled and pregnant women […] It may also reflect a lack of access to primary care, as some surveys show a shrinking number of doctors who accept new Medicaid patients. If health problems go untreated, the thinking goes, they could become worse and ultimately result in an emergency room visit.
But, again, the percentage of usage is similar. My amateur conjecture would be that it’s the high-risk attributes that result in a greater number of visits. Low-income people tend (for whatever reason) to have more serious health issues, and specifically those that produce the type of acute symptoms that require ER visits. To the extent that you see a slightly higher percentage for non-urgent care is probably where the lack of primary care access comes into play. Irrespective of that aspect it’s just simply important to note that any Medicaid reform should reflect reality, which make studies like this one all the more important.