Health Policy Journal Club, Health Policy, Health Equity, Health Care Administration, Social EM


Medicaid Expansion Decreased Non-Emergent Emergency Department Care

Since the passage of the Patient Protection and Affordable Care Act (ACA), 39 states have adopted Medicaid expansion, covering most adults with incomes up to 138% of the federal poverty line, resulting in roughly 14 million uninsured individuals gaining health coverage. Additionally, due to an enhanced federal matching rate (FMAP), states have generally had net savings since expansion. However, there is concern that ED usage for nonemergent conditions would increase following Medicaid expansion, as fewer patients would face cost-related obstacles.

A recent study analyzed 80.6 million ED visits across four states. Two of the states (NY, MA) had adopted the Medicaid expansion, while the others (FL, GA) did not. In the two states that did not expand Medicaid, ED visits increased by 2.4 per 1000 while ED visits decreased by a mean of 2.2 visits per 1000 in the states that did expand Medicaid. Overall, this equates to a difference in ED visits of 4.7 per 1000 patients between nonexpansion and expansion states. Additionally, using the NYU ED algorithm, the authors found that there were significant decreases in visits for conditions classified as "non-emergent," "primary-care treatable," and "potentially preventable" in Medicaid-expanded states. This may indicate that when patients have access to Medicaid, they gain access to primary care physicians who can manage patients' non-emergent concerns and routine medical care instead of relying on the ED for these services.

The high costs of health care services and insurance is often the primary barrier limiting access to primary care for many patients in the United States, leading to ED use for non-emergent concerns. This study indicates that non-emergent ED use may decrease with Medicaid expansion; however, roughly 40% of all ED visits were still for "non-emergent" conditions in the expansion states. Therefore, health coverage is likely not the only factor impacting ED usage throughout the country, and it is important to compare alternative methods such as marketplace subsidies to Medicaid expansion. This study indicates that Medicaid expansion, and resulting increased access to primary care, may allow EDs to more efficiently allocate resources and focus on caring for patients with emergent needs.


ARTICLE: Giannouchos TV, Ukert B, Andrews C. Association of Medicaid expansion with emergency department visits by medical urgency. JAMA Netw Open. 2022;5(6):e2216913.

IMPORTANCE: Relatively little is known about the association of the Medicaid eligibility expansion under the Patient Protection and Affordable Care Act with emergency department (ED) visits categorized by medical urgency.

OBJECTIVE: To estimate the association between state Medicaid expansions and ED visits by the urgency of presenting conditions. Design, setting, and participants: This cross-sectional study used the Healthcare Cost and Utilization Project State Emergency Department Databases from January 2011 to December 2017 for 2 states that expanded Medicaid in 2014 (New York and Massachusetts) and 2 states that did not (Florida and Georgia). Difference-in-differences regression models were used to estimate the changes in ED visits overall and further stratified by the urgency of the conditions using an updated version of the New York University ED algorithm between the states that expanded Medicaid and those that did not, before and after the expansion. Data were analyzed between June 7 and December 12, 2021.

EXPOSURE: State-level Medicaid eligibility expansion. Main outcomes and measures: Emergency department visits per 1000 population overall and stratified by medical urgency of the conditions.

RESULTS: In total, 80.6 million ED visits by 26.0 million individuals were analyzed. Emergency department visits were concentrated among women (59.3%), non-Hispanic Black individuals (28.3%), non-Hispanic White individuals (47.8%), and those aged 18 to 34 years (47.5%) and 35 to 44 years (20.4%). The rates of ED visits increased by a mean of 2.4 visits in non-expansion states and decreased by a mean of 2.2 visits in expansion states after 2014, resulting in a significant regression-adjusted decrease of 4.7 visits per 1000 population (95% CI, -7.7 to -1.5; P = .003) in expansion states. Most of this decrease was associated with decreases in ED visits by conditions classified as not emergent (-1.5 visits; 95% CI, -2.4 to -0.7; P < .001), primary care treatable (-1.1 visits; 95% CI, -1.6 to -0.5; P < .001), and potentially preventable (-0.3 visits; 95% CI, -0.5 to -0.1; P = .02). No significant changes were observed for ED visits related to injuries and conditions classified as not preventable (-1.4; 95% CI, -3.1 to 0.3; P = .10), as well as for substance use and mental health disorders (0.0; 95% CI, -0.2 to 0.2; P = .94).

CONCLUSIONS AND RELEVANCE: The findings of this study suggest that Medicaid expansion was associated with decreases in ED visits, for which decreases in ED visits for less medically emergent ED conditions may have been a factor.

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 physicians, 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.  

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