Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care?
Not in the first years, said a study published Wednesday online in the New England Journal of Medicine.
The study found ER use among Medicaid patients in Oregon stayed high even two years after people gained coverage, and even as more patients visited doctors’ offices, too.
All eyes have been on Oregon to answer this question because eight years ago, Oregon tried an experiment. It wanted to expand Medicaid, but it didn’t have the money to cover every eligible resident.
So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like Bill Wright, director of the Providence Center for Outcomes Research and Education in Portland. “You couldn’t do this as a researcher,” Wright said. “You couldn’t design a study that randomly gave some people insurance and some people[none], because as a researcher, you don’t want to put someone in that position, just to study it.”
It wouldn’t be ethical to leave some people without coverage just to be a “control group.” But, since the state was doing it, it offered an invaluable chance to study the differences between people who have Medicaid and people who don’t.
It was the first randomized study on the impacts of health insurance, and it’s one of the largest, surveying 25,000 people.
The first findings reported earlier were that Medicaid was beneficial in many ways: it improved people’s financial security; they went to the doctor when they were sick and it reduced rates of depression.
Bill Wright (Kristian Foden-Vencil/Oregon Public Broadcasting)
“These are all things that are really important benefits of Medicaid expansion,” said Wright.
But another earlier study found Medicaid enrollees increased their Emergency Department visits by 40 percent over the first 15 months.
“That was a surprise to a lot of folks,” said Wright.
It was widely believed that having insurance would encourage people to get primary care in doctors’ offices or clinics, instead of waiting until they’re really sick and heading to the ER, where care is most expensive.
After that study, experts scrambled to explain what was happening. Some thought it was pent-up demand from a group that hadn’t seen a doctor in years because they didn’t have insurance.
Others thought people just hadn’t had time to establish a relationship with a primary care doctor. And that when they did, emergency department use would drop.
But now, after looking at two years of data, that’s not what this latest study found, said Wright, who is one of the researchers.
“There was no sign that this ED use went down. So this idea of pent-up demand sort of fading away, at least in the first couple of years, it didn’t happen.”
Quite the opposite.
“If your hope is that in the short term, the first couple of years, you’re going to see savings that come out of reduced ED use from Medicaid expansion alone. I don’t think I’d be super optimistic about that. I think that it is going to cost money in the short term,” he said.
Wright said there maybe savings in other areas, like an increased use of preventive services that could stave off problems that would become more expensive later.
And, Leslie Clement, with the Oregon Health Authority, said during the past two years, Oregon has seen avoidable emergency room use drop by 4 percent.
She said, that’s because the state is coordinating care better, by doing things like helping people get to their doctors’ appointments and take their medication.
“It is not just a ‘open up coverage and let people used health care services as they have done historically,’ ” she said. “But it’s reforming that system.”
The Oregon study can’t tease out much more information because the experiment had to stop when the state expanded Medicaid fully under the Affordable Care Act.
This story is part of a reporting partnership that includes NPR, Oregon Public Broadcasting and Kaiser Health News.