Oregon Pilot Finds Expanding Medicaid Led to Increase in ED Use

Low-income Oregon residents who obtained Medicaid coverage in 2008 under an expansion-like pilot program visited emergency departments 40% more often over an 18-month period than other residents, according to a new analysis published Thursday in the journal Science, the Los Angeles Times' "Science Now" reports (Morin, "Science Now," Los Angeles Times, 1/2).

According to the New York Times, the study raises questions for supporters of the Affordable Care Act and the Medicaid expansion. Advocates have long argued that expanding coverage to low-income earners will reduce costly ED visits since they would seek care from primary care physicians.

The analysis is part of a larger, continuing examination of the so-called Oregon Health Insurance Experiment, which opened up the state Medicaid program to low-income adults through a lottery system (Tavernise, New York Times, 1/2).

Findings

For their latest analysis, researchers compared ED use by 25,000 lottery applicants in the Portland area (Cooper, AP/Sacramento Bee, 1/2).

Although the analysis found an increase in PCP visits, the researchers also found that newly enrolled beneficiaries made, on average, 1.43 ED visits during the 18-month period, compared with an average of 1.02 visits among unsuccessful lottery applicants, the Washington Post's "Wonkblog" reports (Kliff, "Wonkblog," Washington Post, 1/2).

The authors noted that outpatient visits made up the bulk of the visits and that there was no corresponding increase in actual hospital admissions ("Science Now," Los Angeles Times, 1/2).

They also found that 42% of the new beneficiaries visited an ED, compared with 35% of the unsuccessful applicants (AP/Sacramento Bee, 1/2). Through an analysis of the reasons for the visits, the researchers found that there was no decline in ED use among the new beneficiaries for conditions that could have been treated by a PCP ("Wonkblog," Washington Post, 1/2).

Reaction

In an accompanying editorial, Raymond Fishman -- an economics professor at Columbia Business School -- wrote, "These findings explode the myth that health insurance access will reduce the strain on emergency services and thus undermine the hope that expanded coverage will put an end to this particular inefficiency in America's bloated health care market" ("Science Now," Los Angeles Times, 1/2).

Heidi Allen -- an assistant professor at Columbia University, who was involved in the analysis -- noted that many of the new beneficiaries used EDs for non-urgent reasons as they could not get same-day appointments with their PCPs (New York Times, 1/2).

Jonathan Gruber -- a health economist at MIT, who was not involved in the analysis but has examined the Oregon initiative -- argued that the ACA was not "designed to save money. It's designed to improve health, and that's going to cost money." He added, "For those who want to argue that expanding Medicaid is a free lunch, this is bad. But that was never the right argument" ("Wonkblog," Washington Post, 1/2).

Tara McGuinness -- a spokesperson for the Obama administration -- said the time frame for the analysis is too short to expect substantial change in ED use and expressed confidence that utilization would drop over the longer term. She noted that a study of Massachusetts's expansion of health services in 2006 found an 8% drop in ED use over several years. She said, "Medicaid saves lives and improves health outcomes," adding, "Plenty of studies show that" (New York Times, 1/2).