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Repeat emergency department users changed how they used EDs after gaining Medicaid coverage

Patients in Medicaid expansion states shifted their ED usage toward more critical injuries and illnesses.

Jeff Lagasse, Associate Editor

The Affordable Care Act expanded health insurance coverage, including eligibility for Medicaid, and states have the ability to decide whether to expand eligibility for Medicaid coverage. As of earlier this year, 36 states and the District of Columbia had adopted Medicaid expansion, and other states are still debating whether to do so.

Against this background, a new study seeks to determine how the nature of visits to emergency departments changed for previously uninsured patients who gained Medicaid insurance expansion under the ACA in 2014, and who went to the ED at least once before and once after expansion.

It found that compared with patients who remained uninsured in states where Medicaid was not expanded, these patients shifted their use of the ED toward conditions that required subsequent hospitalization, and predominantly for illnesses that were not easily avoided by robust outpatient care.

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The study, by researchers at Carnegie Mellon University and U.S. Acute Care Solutions, appears in Medical Care Research and Review.


The findings suggest that newly insured patients may be relying more on outpatient care for less severe conditions, affecting utilization by avoiding unnecessary ED visits -- effectively freeing up hospital EDs for their intended purpose.

The researchers looked at data on patient visits from 30 EDs in seven states -- Illinois, Nevada, North Carolina, Ohio, Oklahoma, Rhode Island and West Virginia -- from April 2013 through September 2015. Of these seven states, 19 EDs were in five states (Illinois, Nevada, Ohio, Rhode Island, West Virginia) that expanded Medicaid in January 2014, and 11 were in two states (North Carolina and Oklahoma) that did not expand Medicaid before the end of 2015. ED visits in the facilities examined are comparable to ED visits nationally.

Visits to the ED were nearly 29% more likely to result in hospital admission for newly insured patients in expansion states, compared with those visiting the ED who remained uninsured in non-expansion states.

Researchers also found a similar increase, 31 percent, for conditions for which hospital admissions may not be avoided by robust treatment in an outpatient setting. The authors point to these findings as important for the patients studied because using the ED for less severe conditions is of particular concern.

One of the implications is that ending Medicaid expansion may increase the use of EDs for less severe cases, negatively affecting ED efficiency when it comes to treating critically ill patients, a trend both policymakers and clinicians would rather avoid.


Among private health plan enrollees in recent years, there has been a substantial shift from EDs to urgent care centers when it comes to patients receiving care for low-acuity conditions, at least according to a 2018 Brigham and Women's Hospital study.

Treatment for new health problems, or acute care visits, encompass over one-third of all ambulatory care delivered in the U.S. Given the high costs of EDs, many insurance plans have created incentives to encourage patients to receive that care elsewhere.

In response to patient expectations for more convenience, and to long wait times at traditional physician outpatient practices, alternative care facilities such as urgent care centers, retail clinics, and telemedicine have rapidly emerged.

Twitter: @JELagasse

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