When You’ve Got It, Use It?

There are those who claim that since hospitals cannot turn emergency victims away, in the end no matter what we think, the general public is paying for indigent care… one way or another. Emergency rooms, therefore, have been viewed as the general medical office hours for the poor, who have no compunction using that level of entry into the healthcare system routinely for the smallest complaints. Arguments that expanding Medicaid (the federal healthcare program for the poor) would restructure that usage pattern and reduce the exorbitant cost of emergency room service with lower cost access to individual physicians.

Others argue that such Medicaid expansion, a state option under the Affordable Care Act, will simply accelerate that usage of the emergency room service because (i) those covered are now conscious that they won’t risk any charges from such practices and (ii) many of those added to the system haven’t got the faintest idea how to find the right individual doctors in the first place. Even when a primary care doctor is identified, they say, folks at the bottom of the economic ladder will feel the reigns and restrictions against using the system removed and will access healthcare more frequently. Who is correct?

In an overall policy review – Straining Emergency Rooms by Expanding Health Insurance by Raymond Fisman – published by Science Magazine (ScienceMag.org) on January 2nd – suggests strongly that emergency room usage goes up as Medicaid coverage increases. Specifically, Science Magazine published and cited results of a 2008 review of Oregon’s expansion of such Medicaid service –  Medicaid Increases Emergency-Department Use: Evidence from Oregon's Health Insurance Experiment by Sarah L. Taubman, Heidi L. Allen, Bill J. Wright, Katherine Baicker, and Amy N. Finkelstein. The abstract summarizes the results:

 “In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design. Using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we study the emergency-department use of about 25,000 lottery participants over approximately 18 months after the lottery. We find that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40 percent relative to an average of 1.02 visits per person in the control group. We find increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.” Wow!

The January 2nd Washington Post provides some additional observations from the study: “Medicaid coverage also increased the probability of having any visit to the emergency department by 7 percent. The researchers also looked at the types of visits and found no decline in use of the emergency department for primary care treatable conditions among those who had enrolled in Medicaid coverage.

“‘Part of what makes emergency department use interesting is there are different theories about what to expect,’ lead study author Sarah Taubman, also at the Harvard School of Public Health. ‘There's one theory that it increases, because insurance pays for emergency room care that would lead people to use more than if they faced the full cost. The other theory is that, by paying for primary care visits, insurance may lead to a decrease in emergency department use. We looked at this and, taken altogether, we see a net increase.’

“Twenty-five states and the District of Columbia expanded their Medicaid programs under the Affordable Care Act, extending coverage to all adults who earn less than 133 percent of the federal poverty line, about $15,000 for an individual and $31,400 for a family of four. Two more states, Indiana and Pennsylvania, are seeking to move forward with the health-care law program at a later date.

“Although the Affordable Care Act initially mandated that all states expand their Medicaid programs, the Supreme Court ruling in June 2012 found that provision to be too restrictive, allowing each state to decide whether to participate.” It does seem that if you want people to maximize their own health, someone has to pay for the resultant usage.

“‘I would view it as part of a broader set of evidence that covering people with health insurance doesn't save money,’ says Jonathan Gruber, a health economist at the Massachusetts Institute of Technology, who has also studied Oregon's Medicaid expansion but is not affiliated with this study. ‘That was sometimes a misleading motivator for the Affordable Care Act. The law isn't designed to save money. It's designed to improve health, and that's going to cost money.’” The Post.

In the end it costs more to add federally-subsidized support to those at the bottom of the earnings spectrum, a group that is growing as definitions of exactly who is and who is not really benefitting from the “recovery” our leaders tell us is taking place. So it does come down to whether or not relieving pain and suffering from as many Americans as you can is a value we are willing to support, a value that seems to be a basic tenet of every major organized religion on earth.

I’m Peter Dekom, looking and numbers and trends to keep living in the real world.