Was the small overall 2014 increase an anomaly? Some see cause for hope that the trend can continue, while others are skeptical.


Aug. 8—Emergency department (ED) use increased at similar rates—about 3 percent—in 2014 in states that expanded Medicaid eligibility and those that did not, according to new research.

The findings, which were based on data from a cross-section of 478 hospitals in 36 states, ran counter to expectations that Medicaid expansion would drive large utilization surges among the newly enrolled.

“It was a surprise that it really had no impact,” Jesse Pines, a co-author of the study and director of the Center for Healthcare Innovation and Policy Research at George Washington University, said in an interview.

While Medicaid enrollees’ ED use jumped by nearly 26 percent at expansion-state hospitals, the increase was largely offset by a 33 percent drop in ED use by the uninsured. In non-expansion states, Medicaid enrollees’ ED use was little changed, while usage decreased by nearly 6 percent among the uninsured and increased by 7 percent among the privately insured.

Medicaid enrollment jumped 19 percent to nearly 70 million enrollees during 2014, according to a Kaiser Family Foundation tally, when 28 states and the District of Columbia expanded Medicaid eligibility, as authorized by the Affordable Care Act (ACA), while non-expansion states experienced increased enrollment among those who previously had been eligible.

The mild overall increase in ED use in expansion states ran counter to physician-reported greater volumes in surveys by the American College of Emergency Physicians (ACEP).

Jay Kaplan, MD, president of ACEP, said he personally has seen similarly sharp jumps in use among Medicaid enrollees and declines among the uninsured when working in a California hospital. But he worried that Medicaid enrollees’ ED use could have accelerated after 2014, when the ACA’s higher Medicaid pay rates for primary care physicians ended in all but 16 states.

“In most states, Medicaid paid so poorly that unless a doctor is in a federally qualified health center, many will not see Medicaid patients,” Kaplan said in an interview.

Kaplan also worried that short-term ED use may have been suppressed by the growing number of insurers that charged large copays for non-emergent ED use or required patients to pay high deductibles before covering most medical care.

“A large percentage of emergency physicians have seen patients who have delayed care because they were concerned about the cost,” Kaplan said.

A tame overall increase reported by the sample of hospitals also ran counter to some state-specific results, such as the much larger 9 percent increase in overall ED use in California hospitals in 2014, according to data from the Agency for Healthcare Research and Quality. That state had one of the most aggressive pushes to expand Medicaid, which grew enrollment by 30 percent in 2014. ED use by Medicaid enrollees increased by 43 percent that year.

Pines said his study’s approach was better able to isolate the Medicaid expansion’s effect by comparing results to hospitals in non-expansion states.

“Just looking before and after at Medicaid expansion in California is not a great way to isolate the effect of the Medicaid expansion on ED use because there is no control,” Pines said.

John Goodman, founder of the Goodman Institute for Public Policy, worried that the study is under-reporting the impact of the expansion on safety-net hospitals, where there are anecdotal reports of continued crowding by the uninsured and Medicaid patients and departures by newly-covered patients with private coverage. The study did not include some types of hospitals, the authors noted, including academic medical centers. Those losses also came amid rolling disproportionate share hospital cuts required by the ACA.

“They’re losing their support from the federal government under the assumption that with more insured they need would diminish but that is not what’s happening,” Goodman said in an interview. “The need has remained the same but people who pay, who are privately insured, are not going to those hospitals.”

The new study’s finding of declining ED use by the uninsured reflected other emerging data, such as a July analysis inHealth Affairs that used data from the National Health Interview Survey to conclude that annual ED use by the uninsured dropped from 18 percent in 2013 to 15 percent in 2014. However, the study differed in finding that the share of Medicaid enrollees seeking ED care also fell, from 39 percent in 2013 to 33 percent in 2014.

Even a relatively mild overall increase in ED use, as reported in the new study, could have major impacts nationwide. A 2.2 percent increase nationally in ED use, as projected by the Commonwealth Fund, would have added 1.1 million annual visits.

The increase reported in the George Washington study was similar to annual jumps in previous years, Pines said.

“Despite a lot of people getting health insurance, we didn’t see a disproportionate overall rise in the number of people coming to the emergency department,” Pines said.  

Accelerating Trend

The rates of both declining ED use by the uninsured and increasing ED use by Medicaid enrollees accelerated during 2014, according to the new study, and Pines expected the growing divergence to continue. By the latter half of 2014, Medicaid-paid ED visits had jumped 32.4 percent, uninsured visits had declined 37.5 percent, and privately insured patients’ visits had declined 8.2 percent.

“At some point they are going to level off, but I’m not exactly sure when that is,” Pines said.

Another trend that may continue was the 7 percent increase in privately insured ED visits in non-expansion states, which compared with a small decline in expansion states.

The authors theorized that the difference was driven by increased private insurance enrollment through the ACA marketplaces by people who would have been enrolled in Medicaid if their state had expanded the program.

“With the mandate to have health insurance and the rise of the exchanges, people need options to find health insurance if they can’t get insurance through the Medicaid expansion,” Pines said.

Causes and Challenges

Factors driving greater ED use by newly covered Medicaid enrollees include a lack of access to primary care providers, affordability challenges, and poor care coordination, according to previous research.

But research released this week in JAMA Internal Medicine offered hope that access to more appropriate sites of care may improve as the expansion matures. That study examined coverage results through 2015 in three southern states with high baseline uninsured rates—Texas, Arkansas, and Kentucky—and found larger coverage increases over time and increasing familiarity with ways to use coverage among the newly insured.

“By the end of 2015, we found marked increases in coverage and reduced cost-related barriers to care in the expansion states, with associated increases in preventive care, outpatient office visits, annual checkups, and chronic disease care, as well as decreased reliance on the ED (the subject of conflicting results in studies of prior coverage expansions),” the study authors wrote.

In that study, Medicaid expansion—which had been implemented in Arkansas and Kentucky, but not in Texas—was associated with a reduction of six percentage points in the likelihood of any ED visits, as well as a slightly increased likelihood of a checkup and blood glucose testing in the past year.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C. office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Monday, August 08, 2016