A study of Oregon’s 2008 Medicaid expansion has been touted as a huge blow to President Obama’s claims that Medicaid expansion through the ACA would reduce ER visits, but a parallel study of California’s 2010 Low-Income Health Program suggests that the situation is not so simple.

Oregon: Medicaid expansion drives up costs

The Oregon study, published in Science by economists Amy Finkelstein of MIT and Kate Baicker of Harvard, measured emergency room visits of more than 20,000 residents living in the Portland area – one group of patients without insurance, and one group newly enrolled in Medicaid. Researchers determined that the Medicaid patients visited emergency rooms 1.4 times over 18 months, while the uninsured group visited 1.02 times in the same period. They further determined that nearly half of the increased visits were for complaints that could have been treated by a primary care physician (PCP), or were for emergency complaints that could have been prevented by PCP care.

Overall, ER spending in the Oregon study was estimated to have increased by $120 per covered patient. The researchers attribute this to a structural flaw in Medicaid’s design that reduces cost-sharing for covered patients to zero or near-zero, encouraging more unnecessary visits and raising state spending for Medicaid claims. State governments have responded by drastically reducing their reimbursements to medical providers, and PCPs have further responded by turning away new Medicaid patients.

Their conclusion is that Medicaid patients are more likely to visit the ER than to search for a PCP who will accept them, which then raises the cost of care even more.

San Diego: ER visits appear to be falling – with patient education

However, Paul Sisson of the San Diego Union-Tribune reported yesterday that a similar expansion of California’s Medicaid programs in 2010 has resulted in a two percent decrease of emergency room visits from July 2011 to September 2012. Nearly 50,000 San Diego-area residents enrolled in California’s Low-Income Health Program from mid-2011 to the end of 2013. There is only about a year of available data, and ER administrators have not noted significant changes in visits, but the results thus far are encouraging to doctors and health care researchers in the state.

A key difference between San Diego’s program and Portland’s is the access enrolled patients have to PCPs. In San Diego, new patients in the LIHP were counseled about their healthcare options and connected to a local PCP with whom they had a preliminary visit. These visits were designed to build a relationship so the patient would visit their doctor instead of the emergency room in the event of an illness.

In addition, county employees reached out to the community clinics where they sent their patients to make sure they were able to make same-day appointments. The UCLA Center for Health Policy Research studied ER use by LHIP participants and noted that their ER visits decline as they become accustomed to having insurance.

In Oregon, on the other hand, there is no record of patient education to suggest that patients knew about or had access to alternative healthcare options. As stated by UCLA Center for Health Policy Research director Gerald Kominski,

That behavior of seeking primary care in the ER has been reinforced for a period of years,
and it doesn’t change immediately just because you give somebody an insurance card.

Long-term effects of Medicaid expansion remain to be seen (as do short-term effects in states that have just implemented their own expansions), but these two contrasting studies make a compelling argument that patient education is necessary to fully reap the potential benefits of expanded low-income insurance programs.

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