More insurance may lead to more care, though not more efficient care, researchers report in the journal Science as a publicly financed push to expand insurance moves to enroll millions of Americans in health plans. The study, which found an increase in unnecessary emergency room use among the newly insured, raises questions about how the expanded coverage will affect healthcare demand and cost.
Emergency room use for conditions that did not need immediate care or could be treated in primary-care clinics increased for uninsured working-age adults in Oregon
who gained Medicaid
coverage, researchers reported in Science. That's compared to adults who were excluded from Medicaid under the state's lottery for safety-net insurance.
“We see increases in visit types that are most readily treatable in primary care settings,” said Sarah Taubman, a research fellow at the National Bureau of Economic Research and the study's lead author.
Indeed, emergency room use was higher among the newly insured overall, by about 40%, at an estimated additional cost of $120 per insured person, per year, said researchers Sarah Taubman, Heidi Allen, Bill Wright, Katherine Baicker and Amy Finkelstein.
The report comes as the Obama administration released new enrollment figures for the expansion of Medicaid under the Patient Protection and Affordable Care Act. About 3.9 million newly eligible enrollees for Medicaid and the Children's Health Insurance Program have gained coverage since October.
The rising use of costly emergency services among Oregon's newly insured raise the question what other interventions may be necessary to eliminate avoidable emergency room visits—and better control costs. An answer could help contain costs as Medicaid expansion increases spending and states and providers face mounting pressure to control spending.
The ACA expansion is projected by the Congressional Budget Office to raise federal spending for Medicaid and CHIP by a projected $642 billion through 2022. States, which jointly finance Medicaid, do not pay any expansion costs through 2017, after which state financing increases to 10% by 2020. Not all states chose to expand Medicaid; 23 opted out. Regardless, states have sought to better control Medicaid budgets with managed-care contracts and accountable care initiatives, both of which introduce the risk of financial losses—or missed bonuses—if healthcare spending grows rapidly.
Policymakers have limited and mixed research to draw on to suggest how Medicaid expansion may affect use of the emergency room, the authors said. Theories suggest conflicting possibilities. The insured no longer face the financial barrier to emergency rooms that may prevent the uninsured from seeking care, they noted. But the newly insured also gain access to primary care as an alternative to the emergency room. They may also need fewer necessary trips to the emergency room with better primary care, the researcher said.
The results combined with the researchers' prior work suggest increased unnecessary use of the emergency room among the newly insured even as they gained greater access to primary care.
Oregon adults who gained Medicaid coverage under the lottery and who were surveyed previously for a separate study reported greater use of primary and preventive care and easier access, the researchers said.
Indeed, the only category of emergency room visits that was not higher among the newly insured compared with the uninsured were those that required an unavoidable trip to the ER for immediate medical care. Follow Melanie Evans on Twitter: @MHmevans