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ED Visits Up, Uninsured Patients Down in States That Expanded Medicaid

In states where Medicaid was expanded under the Affordable Care Act (ACA), the news was both good and bad in terms of emergency department usage.

ED visits went up, but the percentage of uninsured ED patients dropped, according to a report in Annals of Emergency Medicine.

Researchers at Vanderbilt University found that in 14 states with expanded Medicaid, ED visits increased 2.5 per 1,000 after 2014, but the share of uninsured fell 5.3%.

“Medicaid expansion had a larger impact on the healthcare system in places where more people were expected to gain coverage,” said lead author Sayeh Nikpay, PhD, MPH, of Vanderbilt. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, than in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”

The study analyzed 25 states—14 that expanded Medicaid coverage and 11 that did not. Researchers determined that while the portion covered by private insurance remained steady for expansion states and increased by several percentage points for non-expansion states, almost all the gains in insurance coverage in non-expansion states were from private policies, not Medicaid.

The greatest increase in ED visits appeared to be for injuries, according to the report, which also noted significant changes in payer mix for ED dental visits. Mental health visits also experienced a large change in both the total number and the share covered by Medicaid, study authors noted.

“If the ACA’s Medicaid expansion increased total use of the ED, an important question is whether the existing capacity of providers will be sufficient to meet increased demand,” the researchers asked. “Although the existing supply of primary care providers is expected to be sufficient to meet increased demand for primary care, less is known about ED capacity.”

The study calculated that 1.13 million ED visits in 2014 could be attributed to Medicaid expansion in these states, given their total population of 112.7 million, 4.7% of total 2014 visits in expansion states.

“If the change is permanent, future research must also consider the effect of greater ED volume associated with the ACA on quality of care and other potential outcomes,” study authors said. “One possibility is that the Medicaid expansion could result in ED crowding. Existing research suggests that ED crowding increases hospital mortality, length of stay, and costs.”