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No Drop in ED Usage Over Time With Expanded Oregon Medicaid

BOSTON – Expanding Medicaid rolls was touted as a way for patients to visit personal physicians instead of getting most or all of their care at more expensive emergency departments.

If the experience in Oregon is typical, that hasn’t happened, according to a new study.

A Perspective article published in the New England Journal of Medicine notes that visits to hospital EDs increased by 40% in Oregon after Medicaid coverage was expanded there in 2008 and also stayed at that level for at least two years.

In fact, the study, led by health economists at the Massachusetts Institute of Technology (MIT) and Harvard T.H. Chan School of Public Health, found no evidence that the newly insured are more likely to substitute primary care provider visits for trips to the ED. Instead, the authors report, Medicaid beneficiaries appear to be more likely to use both types of care.

"Our finding that Medicaid increased ED visits generated a lot of debate about whether this might just be a temporary spike; now we know that the increase in ED visits persisted for at least the first two years of Medicaid coverage," explained lead author Amy Finkelstein, PhD, of MIT, who was involved in previous research on the issue.

For this study, the researchers examined new evidence from the Oregon Health Insurance Experiment, a unique, randomized, controlled evaluation of the effects of Medicaid expansion.

While previous results from the Oregon Health Insurance Experiment indicated that extending Medicaid coverage led to increased healthcare use across a range of settings, such as physician office visits, prescription drugs used, and hospitalizations, they also showed a 40% increase in ED use in the first 15 months after coverage was gained. That study also suggested that while Medicaid substantially improved financial security and reduced depression, it had no provable effect on physical health or on employment.

“This finding was greeted with considerable attention and surprise, given the widespread belief that expanding Medicaid coverage to more uninsured people would encourage the use of primary care and thereby reduce ED use,” study authors point out.

The higher rate of ED use was expected to decrease over time as more newly insured patients gained access to primary care doctors, but the new study documents that the drop in usage did not occur.

"For policymakers thinking about expansions, our results suggest that a typical Medicaid program will increase health care use across settings — including the ED — for at least two years, and that it won't lead people to go to the doctor instead of the ED," said co-author Katherine Baicker, PhD, of Harvard.