What should happen to ED visits after health care reform?

Earlier this year, people got into a tizzy because the Oregon HIE found that giving people Medicaid led to increased ED use. Was this “counter-intuitive”? I didn’t think so, because I still hold that giving people more access leads to more access. But don’t take my word for it. What happened after we increased access in Massachusetts? Here’s a study to help. “Increased Use of the Emergency Department After Health Care Reform in Massachusetts”:

Study objective: With implementation of the Patient Protection and Affordable Care Act, 30 million individuals are predicted to gain access to health insurance. The experience in Massachusetts, which implemented a similar reform beginning in 2006, should provide important lessons about the effect of health care reform on emergency department (ED) utilization. Our objective is to understand the extent to which Massachusetts health care reform was associated with changes in ED utilization.

Methods: We compared changes in ED utilization at the population level for individuals from areas of the state that were affected minimally by health care reform with those from areas that were affected the most, as well as for those younger than 65 years and aged 65 years or older. We used a difference-in-differences identification strategy to compare rates of ED visits in the prereform period, during the reform, and in the postreform period. Because we did not have population-level data on insurance status, we estimated area-level insurance rates by using the percentage of actual visits made during each period by individuals with insurance.

Researchers examined more than 13 million visits to emergency departments from 2004-2009. They found that Romneycare was associated with increased use of the ED, across all domains.

The study wasn’t designed to say why this was so, but the authors speculated that it might be due to decreased financial barriers to getting care in the ED, or due to the fact that the shortage of primary care options was worsened by increased numbers of insured people. I think it could be due to both. But this study confirms what many wonks already knew to be true. Giving people insurance will not obviously decrease people’s use of emergency department care. In fact, it’s likely to increase it. That’s true of both commercial insurance (Massachusetts) and Medicaid (Oregon).


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