Hospital emergency departments (EDs) provide lifesaving care for millions of people each year. However, around one-third of ED visits are for conditions that are not emergencies or for conditions that are preventable.
Research has found that a lack of health insurance coverage plays a role in whether a person seeks ED care, and the expansions of state Medicaid programs through the Affordable Care Act could have affected ED visits. However, research has not been fully conclusive and the understanding of how Medicaid expansions affect different types of ED visits remains unclear.
Results of a new study in the journal JAMA Network Open suggest that expanding Medicaid might reduce ED visits for conditions that could be treated in a doctor’s office. Benjamin Ukert, PhD, assistant professor at the Texas A&M University School of Public Health, and colleagues from the University of South Carolina studied outpatient ED visits between 2011 and 2017, focusing on two states that have expanded Medicaid (New York and Massachusetts) and two states that have not (Georgia and Florida). They analyzed data on more than 80 million ED visits by 26 million people between the ages of 18 and 64 during the study period.
The researchers measured total ED visits and ED visits broken down into five categories of medical urgency: not preventable and injury-related, emergent but preventable, emergent but primary care treatable, not emergent, and mental health and substance use disorders. In addition, the study included data on gender, race and ethnicity, age, unemployment rate and percentage of the population under 200 percent of the federal poverty level.
Prior research on Medicaid expansions has found increases in access to primary care and preventive medicine services and decreases in ED visits among those who had faced barriers to care before. However, other studies have found increased ED use following Medicaid expansions due to reduced cost barriers. These seemingly contradictory findings point to the complex relationship between Medicaid expansions and ED visits, which this study aims to clarify by looking into varying degrees of medical urgency.
Ukert and colleagues found that Medicaid expansion was associated with a decrease in ED usage of 4.7 visits per 1,000 people in the two states that expanded Medicaid programs. The analysis also found that most of the decreases were in less urgent conditions. This suggests that better access to preventive services and primary care providers through Medicaid coverage could have played a role. Possible mechanisms include substitution of primary care visits for ED visits and improved health leading to less need for ED visits. However, even after Medicaid expansions, more than 40 percent of ED visits were for non-emergent, preventable and primary care treatable conditions. This points to the possibility of other social and economic factors that act as barriers to care.
These findings add to prior work by shedding light on ED visits of varying levels of medical urgency and by covering more post-expansion years. With this greater understanding, researchers and policy makers can better address Medicaid expansion effectiveness and the possible role of other factors in access to quality medical care. Improving access to routine care promises to reduce the burden on EDs, which are expected to provide more emergency care as the country’s population continues to grow.