Medicaid expansion increased ER visits overall, but lowered them among uninsured

States that expanded Medicaid eligibility saw emergency department (ED) use per 1,000 people increase by 2.5 visits in 2014, with the share of ED visits covered by Medicaid increasing by 8.8 percentage points compared to states that didn’t expand the program under the Affordable Care Act.

The study, published in the Annals of Emergency Medicine, showed the changes in payor mix for ED visits post-expansion. The share of visits by the uninsured decreased by 5.3 percent, while for commercially insured patients, their share of ED visits remained flat in expansion states while increasing in nonexpansion states, where gains in insurance coverage almost entirely owed to greater private coverage.

The results match up with what emergency physicians have been saying. 75 percent said patient volume in the ED had increased in a 2015 poll from the American College of Emergency Physicians (ACEP), with 68 percent saying the volume of Medicaid patients had increased.

“Medicaid expansion had a larger impact on the health care system in places where more people were expected to gain coverage,” lead study author Sayeh Nikpay, PhD, MPH, of Vanderbilt University said in a statement. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, as in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”

The study said further research would be needed to determine whether this increased use of the ED is permanent, how it can impact potential outcomes and whether providers have the capacity to meet the increased demand.

In an accompanying editorial, Ari Friedman, MD, PhD, emergency physician at Boston’s Beth Israel Deaconess Medical Center, said the fact the ACA didn’t break the long-term trend of increasing ED use is neither “clearly bad nor clearly good.”

“Insurance increases access to care, including emergency department care,” Friedman wrote. “We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients' care needs as patients themselves define them, the emergency department has a key role to play in a flexible system.”