June 25, 2018
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More Medicaid, more ER use. No surprise, and no reason to deny expansion

A patient waits in the hallway for a room to open up in the emergency room at Ben Taub General Hospital in Houston, Texas, in this July 2009 file photo.


Predictably, the results of a newly released study on Medicaid expansion ’s effect on emergency room use in Oregon are becoming another flashpoint in the debate over Medicaid expansion, which about half the states are implementing this year under the federal Affordable Care Act.

Now that the Legislature is returning to Augusta, the debate over whether Maine should also participate will only intensify. A public hearing on the latest attempt to extend Medicaid coverage is scheduled for Jan. 15.

The findings throw a wrench — though not an unexpected one — in the oft-repeated talking point of Medicaid expansion proponents that extending public health insurance coverage to more low-income residents helps to keep those residents from seeking care in the emergency room.

In 2008, Oregon carried out a limited expansion of its Medicaid program, extending coverage to 10,000 low-income adults selected by lottery from a waiting list of 90,000. The lottery essentially offered researchers a well designed, randomized experiment to help them compare the effects of Medicaid coverage on those who received it versus a similar socioeconomic group that did not.

In the 18 months following the 2008 lottery, Medicaid recipients visited the emergency rooms of hospitals near Portland, Ore., 40 percent more often than their uninsured counterparts, often for conditions that could have been treated more efficiently elsewhere. Medicaid coverage, after all, offered those low-income adults a tool to pay for care. The study also found Medicaid recipients more often visited primary care doctors. Basically, they used more health care because they had a way to pay for it.

This shouldn’t come as a surprise, and we shouldn’t be surprised this year if hospitals see more emergency room use as more gain coverage through the Affordable Care Act. The increase in visits won’t only come from Medicaid recipients. Uninsured people who purchase private insurance through Obamacare’s online exchanges are also likely to increase their use of health care, both in the emergency room and the doctor’s office. During their time without insurance, they’re likely to have gone without checkups and, potentially, had chronic conditions go undiagnosed.

The prospect that emergency room use could increase following an expansion of Medicaid isn’t a reason for Maine not to extend coverage to more than 70,000 low-income residents, including more than 20,000 who either lost coverage on Jan. 1 or will lose it in the coming months.

Rather, it should strengthen the resolve of policymakers to design a Medicaid program that delivers high-quality care — that keeps people out of the hospital for care that can be provided more efficiently elsewhere — at the lowest possible cost.

Maine has long had a need to confront excessive emergency room use. In 2006, Maine’s overall emergency room use was 30 percent higher than the national average, and Medicaid recipients were more likely than those with private insurance and the uninsured to visit the emergency room for care.

There’s reason to believe the right mix of reforms can ultimately lead to reduced emergency room use among Medicaid recipients. Some of that evidence, in fact, comes from Oregon. In 2012, well after the 2008 Medicaid coverage lottery, the state struck a deal with the federal government, pledging to save the Medicaid program money if the federal government helped the state fill a gaping budget hole.

At the core of the money-saving effort was the formation of 15 coordinated care organizations that are essentially paid to keep their local Medicaid populations — as well as their broader communities — healthy. Now, those organizations are delivering results in the form of reduced emergency room use among Medicaid recipients, lower emergency room spending and fewer hospital admissions.

Obamacare’s expansion of health insurance coverage coupled with the right mix of reforms to the way health care is provided can pay off in the form of improved care, better health and lower costs.

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