Many uninsured in ERs don't know they're eligible for Medicaid

Nearly 80% of 13,069 uninsured patients in the ERs of four San Diego hospitals over an 11-month period were eligible for some form of government insurance, yet weren't enrolled, according to a Point-of-Service ER Survey conducted by the San Jose, CA-based Foundation for Health Coverage Education (FHCE).

Researchers also analyzed data from the FHCE's National Eligibility Survey, which found 61.7% of 180,250 CoverageForAll.org visitors seeking information on their health care options were also unaware of their eligibility government coverage.

These results were "startling," according to Phil Lebherz, FHCE's executive director.

"To realize that 80% of the patients who received care at these four busy ERs were actually qualified for government programs, but not enrolled, indicates that the enrollment system is not working," he says.

Mr. Lebherz also notes while the hospitals will make an effort to get reimbursement for their "treat and admit" patients, it is often very difficult to get payment for the care provided to patients discharged from the ER.

Given that the nation's health care reform act mandates moving millions more Americans into the Medicaid program, Medicaid directors are seemingly being placed in a "no-win situation," says Mr. Lebherz.

"The Medicaid program has created a situation where it's providing care to a large segment of its qualified members at the highest cost venue possible — the emergency department," he says. "In the process, the government is avoiding its responsibility to provide needed reimbursement to hospitals and doctors giving care."

Hospitals nationwide reported that they incurred $36.5 billion in uncompensated care losses in 2009, according to the American Hospital Association. Mr. Lebherz hypothesizes that "much of the responsibility for that figure is the result of the Medicaid enrollment inefficiencies across the nation."

Mr. Lebherz says his hope is that the government will someday see Medicaid as a health care program, not a health insurance program. "The principle behind insurance is to protect oneself against loss of assets in case of a financial disaster," he says. "People with few assets don't need an insurance program. They need health care."

For this reason, says Mr. Lebherz, a "point of care" eligibility and provider reimbursement system is needed. Since a person's annual income and current year quarterly estimates can be identified through the Internal Revenue Service, a patient could theoretically qualify on the spot for Medicaid, he explains.

"This is important, because each state's budgetary spending for qualifying and monitoring Medicaid recipients has grown exponentially, reducing the amount used for direct health care," says Mr. Lebherz.

Within the 2010 budget, the California Department of Health Services included employment of a staff of 27,300 to enroll the state's Medicaid, food stamp and welfare recipients with total costs exceeding $3 billion, notes Mr. Lebherz.

"This money did not provide care or funds to those in need, just administrative expenses," he says. "Through technology, we can improve access for all Medicaid eligible recipients at the point of care."

The fact that uninsured but eligible individuals continue to be identified in the ER points out the value of doing outreach and enrollment assistance in the ER, says Beth Morrow, director of health information technology initiatives for The Children's Partnership, a child advocacy organization with offices in Washington, DC and Santa Monica, CA.

"While in the ER, families often sit and wait for long periods of time," she says. "They are well aware of their health needs at that time. Thus, they are highly motivated to figure out their insurance options."

Furthermore, says Ms. Morrow, hospital staff can assist families in completing the application and obtain immediate, presumptive eligibility for Medicaid and the Children's Health Insurance Program, where state law allows.  

"As we move forward with health reform, all available channels of entry should be explored to reach uninsured individuals, including emergency rooms," says Ms. Morrow.

Contact Mr. Lebherz at (800) 234-1317 or fhceinfo@coverageforall.org and Ms. Morrow at (718) 832-6061 or bmorrow@childrenspartnership.org.