Medicaid expansion has driven significantly more patients to hospital emergency departments for non-urgent conditions, according to a new Brookings Institution study by health economists.
This finding, which follows a deep dive into states’ widely varied Medicaid expansion programs under the Affordable Care Act, represents another rebuttal to the initial predictions that people with health coverage would stop relying on emergency departments for non-emergency care. By law, hospital emergency departments must take any patient regardless of ability to pay.
The analysis also follows an April study from JAMA that came to similar conclusions.
Healthcare economist Craig Garthwaite authored the paper along with collaborators including fellow economists John Graves and Tal Gross. For their analysis they looked at the number of hospital visits by each person who gained Medicaid insurance after the expansion, and where those visits were concentrated. Overall, the new Medicaid patients visited hospitals 20% more than they did before they got coverage, and they mostly opted for emergency departments.
This result isn’t surprising, the authors said, given one often-ignored aspect of the emergency care mandate on hospitals known as EMTALA. Even though an emergency department can’t reject someone who can’t pay, the hospital can still bill that patient after treatment.
“Existing evidence suggests that hospitals do not recover all — or even most — of the costs of providing this service, but they do enact meaningful financial and psychic costs on those from whom they attempt to collect,” they wrote. “Non-profit hospitals enjoy tax-exempt status because they provide ‘community benefit,’ including charity care to the uninsured. But even those non-profit hospitals have been shown to go to great lengths — including litigation and wage garnishment — to recover unpaid bills.”
Patients under Medicaid don’t have to fear debt collection, removing one big barrier that could deter someone from a hospital visit. Those visits may be perceived as more convenient than a regular doctor’s office visit even if they’re more expensive to Medicaid, since the patient doesn’t have to find a physician who accepts his or her plan.
Additionally, the study’s authors did not find an increase in actual emergency or “nondeferrable” visits to hospital EDs.
“This pattern of estimates is intuitive,” they wrote. “Medicaid expansion effectively lowers the price of an ED visit for the patient, and so we would expect for an increase in visits for those that are discretionary.”
Overall, the authors noted that Medicaid expansion programs did appear to vary significantly over the 20 states they studied. Some states saw big shifts in hospital utilization rates, while others saw very little. The researchers concluded that states’ ability to target medical coverage to people who need it most “varied meaningfully.”
In general, people who qualified for Medicaid under the expansion went to doctors or hospitals at higher rates than the people who didn’t qualify. The authors said that suggests basing the expansion on income rather than specific categories of need “successfully targeted” the people most in need of medical care.
That suggestion held in non-expansion states as well. The people in those states who bought plans on the individual market exchanges with the aid of income-based subsidies were also those who most needed medical care.