Health Policy Journal Club, Health Policy, Health Care Administration

Health Policy Journal Club: Medicaid and the Expansion of ED Crowding

Does Medicaid Expansion Significantly Impact ED Wait Times?

In 2014, Medicaid coverage was expanded to include individuals under 65 with incomes below 133% of the federal poverty line. At that time, the impact of Medicaid expansion on Emergency Department (ED) crowding was unknown. Many theorized that the increased access to medical care would encourage patients to pursue lower-cost healthcare options, thus removing some burden from EDs.

Unfortunately, the solution to crowding is not as simple as increasing access to medical coverage, which otherwise might enable patients to seek care outside the ED. The issue of crowding can, ultimately, be broken down into three contributing factors:

  1. Input
  2. Throughput
  3. Output

Expansion of Medicaid may have contributed to increased ED crowding via an increase in patients seeking care (input), the enhancement of ED clinicians' workup for greater reimbursement (throughput), and increased boarding (output).

A recent study examined how Medicaid expansion affected ED crowding. Data from 2012 to 2017 were collected from the Centers for Medicare and Medicaid Services (CMS) and four measures of ED wait times were compared between states that expanded Medicaid and states that did not.

The researchers found that wait times to see an ED provider increased by approximately 3 minutes (10%) after Medicaid expansion. Time to discharge increased by 7.5 (5.3%) minutes and boarding time increased by 3.8 minutes (3.4%). Finally, the percentage of patients that left without being seen increased by 15.3% after expansion.

Despite the statistical significance of these findings, the clinical significance remains to be seen. This study was limited by its inability to stratify wait times based on illness acuity. This is important because whereas a 3-minute wait time may mean life or death for a patient with a cardiopulmonary event, the small increase in wait time may not alter the course of illness for the vast majority of ED patients. Overall, this study suggests that Medicaid expansion may have worsened crowding in EDs, however the exact mechanisms for this still unknown. Future studies must investigate what factors are contributing most to ED crowding in the age of Medicaid expansion for us to find the best ways to mitigate the issue and better serve our patients.


Article: Allen L, Gian CT, Simon K. The impact of Medicaid expansion on emergency department wait times. Health Serv Res2021. doi:10.1111/1475-6773.13892. Online ahead of print.

To estimate the impact of Medicaid expansion on emergency department (ED) wait times. Data Sources: We used 2012–2017 hospital-level secondary data from the CMS Hospital Compare data warehouse.

We used a state-level difference-in-differences approach to identify the impact of Medicaid expansion on four measures of ED wait times: time before being seen by a provider, time before being sent home after being seen by a provider, boarding time spent in the ED waiting to be discharged to an inpatient room, and the percentage of patients who left without being seen. We compared outcomes in states that expanded Medicaid to those in states that did not expand Medicaid.

Our sample included all U.S. acute care hospitals with EDs in states that did not ever expand Medicaid or that fully expanded Medicaid in January of 2014.

Principal Findings: Medicaid expansion was associated with a 3.1-minute increase (SE: 0.994, baseline mean: 30.8 minutes) in the time spent waiting to see an ED provider, a relative increase of 10%. Patients who were eventually sent home after being seen by a provider experienced a 7.5-minute increase (SE: 1.8, baseline mean 142.1 minutes) in wait time. Boarding time rose by 3.8 minutes (SE 1.9, baseline mean 111.4 minutes). The percentage of patients who left without being seen rose by 0.3 percentage points (SE: 0.09, baseline mean 2.0), a relative increase of 15.3%.

This study provides multi-state evidence that the Medicaid expansion increased ED wait times for patients, indicating that ED crowding may have worsened post-expansion.

PMID: 34636421

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.