Health Policy Journal Club, Health Policy, Advocacy

Health Policy Journal Club: Until Medicaid Arrived, Nowhere Else to Turn

What's missing from the Medicaid conversation?

Medicaid expansion has led to various discussions about its impact on emergency department (ED) utilization. Previous research has mainly focused on the numbers surrounding ED utilization as it relates to Medicaid expansion. The results from these studies have been mixed — some demonstrated increased volume while others did not show much change. As we continue to study the impact of Medicaid expansion, it is important to question if solely focusing on ED utilization misses part of the story.

This study examined the relationship between Medicaid expansion and the reason for ED visits in low-income patients. The authors identified 3 main reasons for ED visits among low-income patients:

  1. Perceived severity of illness
  2. Closed doctors' offices
  3. Barriers to outpatient care

A difference-in-difference analysis was performed to understand changes in outcomes before and after Medicaid expansion and in expansion vs. non-expansion states. The data, collected via the National Health Interview Survey from 2012-2017, included U.S. citizens 19-64 years old in families with self-reported income below 138% of the federal poverty level.

Significantly fewer people listed barriers to outpatient access as a reason for ED visits in Medicaid expansion states, compared with non-expansions states from the pre-expansion to post-expansion period. The study did not find significant changes in overall ED use, ED visits due to illness severity, or ED visits due to a doctor’s office closure. Furthermore, expansion states that implemented copayments for non-emergency ED visits had more low-income patients reporting barriers to access as reason for ED visit.

As the study notes, overall ED volume has not changed post-expansion. This is because most low-income patients come to the emergency department due to perceived acuity of illness and outpatient office closure. These are factors that are not modifiable by Medicaid expansion. What is modifiable by Medicaid expansion are barriers to outpatient care. After Medicaid expansion, fewer people coming to the ED mentioned barriers to outpatient care as being the reason for their visit.

Asking why patients visit the emergency department is an important part of understanding ED volume. This critical framework highlights the benefits of Medicaid expansion even when ED utilization remains unchanged. Advocates of Medicaid expansion may find such studies helpful in understanding the full effect of the policy on emergency health care.

Abstract: Chou SC, Gondi S, Weiner SG, Schuur JD, Sommers BD. Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care. Med Care. 2020; Jan. 29: ahead of print.

BACKGROUND: Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs.

OBJECTIVES: Examine the changes in reasons for ED use associated with Medicaid expansion

RESEARCH DESIGN: Difference-in-difference analysis

SUBJECTS: We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259).

MEASURES: We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and non-expansion states.

RESULTS: Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022].

CONCLUSIONS: Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

PMID: 32000172

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.