Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix

Abstract

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.

Medicaid enrollment among previously uninsured Americans and associated outcomes by race/ethnicity—United States, 2008‐2014

“…Second, Medicaid enrollment was associated with significantly higher levels of ED use in sensitivity models that used entropy balancing. Our primary specification is consistent with prior work that indicated expansion of Medicaid was not associated with increased ED use, 36 but contrasts with findings from the OHIE which found higher levels of ED use after Medicaid enrollment. 17 A recent editorial on the issue noted, "the relationship between health insurance and emergency care isn't straightforward."…”

Ambulance diversions following public hospital emergency department closures

“…Furthermore, the mean number of diversion hours by hospitals that declare diversions has remained high and has not changed significantly since 2007 (2007: 688 vs 2015: 683 hours, P = 0.96) . Finally, diversions will likely continue to be an issue both in California and nationally, given research that suggests that ED use and crowding did not decrease after Medicaid expansion and might have increased …”

“…Our data do not permit us to measure the number of patients, degree of crowding, physician and nurse staffing patterns, and number of ED boarders at the moment a hospital declares a diversion. However, it is unlikely that these factors disproportionately dictate the observation hospital's decision to divert when the neighboring hospital that diverted was public vs private, particularly because patient acuity does not vary depending on Finally, diversions will likely continue to be an issue both in California and nationally, given research that suggests that ED use and crowding did not decrease after Medicaid expansion36 and might have increased 37. Our findings are based on data from California and in metropolitan or urban areas, which may be different from other markets.Finally, our study design relies on matching nonsafety net hospitals by size and distance to safety net hospitals.…”

Changes in hospital service demand, cost, and patient illness severity following health reform

“…Data that capture the direct effects of the ACA insurance coverage expansions on hospital utilization have been emerging. Studies using administrative data from the Healthcare Cost and Utilization Project (HCUP) found that Medicaid expansion led to shifts in payer mix from uninsured toward Medicaid for inpatient discharges and ED visits . Survey data from the National Health Interview Survey suggest increases in all‐payer inpatient utilization in Medicaid expansion states but no significant changes in ED utilization .…”

“…Studies using administrative data from the Healthcare Cost and Utilization Project (HCUP) found that Medicaid expansion led to shifts in payer mix from uninsured toward Medicaid for inpatient discharges 2,5 and ED visits. 6,7 Survey data from the National Health Interview Survey suggest increases in all-payer inpatient utilization in Medicaid expansion states but no significant changes in ED utilization. 8,9 A survey of lowincome adults in the 3 years following the ACA found better access to care, lower out-of-pocket spending, and improvements in preventive care for previously uninsured individuals gaining coverage.…”