One of the myths used to advocate for passage of the ACA was that the patients without health insurance were forced to seek care in emergency rooms, thus burdening the system with care that could be delivered elsewhere. As it turns out, providing people with insurance doesn’t decrease their emergency room use, in fact it may increase it. A study carried by Health Affairs further examines patterns of use by the uninsured. (HA Article) As the authors note, the Oregon Medicaid expansion experiment provided dramatic evidence that gaining coverage resulted in a persistent increase in ER use by the previously uninsured, and the increase applied to all types of visits for all kinds of conditions and across various subpopulations. The authors looked at data on ER use by working age adults who lacked insurance, using the Medical Expenditure Panel Survey and the National Hospital Ambulatory Medical Care Survey as their data sources. They analyzed health care utilization by insurance status, including ER visits, outpatient visits and hospital admissions. They also attempted to ascertain how necessary an ER visit might have been.
The results of their analysis are illuminating. The uninsured do not use the ER more than the overall insured population. In 2013, 13.7% of insured adults went to the ER, compared to 12.2% of adults lacking coverage. The average number of visits per capita was also similar; .2 visits per person per year for the insured versus .18 for the uninsured. But subsets of type of insurance are quite different; the rate for privately insured persons is .15 per capita per year, but for Medicaid it is .52, or three times greater. What is also striking is how much less of other types of care the uninsured use. Uninsured adults average two outpatient visits a year, compared to 6 for the insured population overall and 9 for people on Medicaid. The uninsured have half the hospital admissions of the insured and a fifth of those on Medicaid. While some people claim the uninsured are sicker and are just deferring needed care, that is not actually supported by the research. And it is hard to imagine that having so many fewer hospital admissions reflects deferral of needed care. And analyses done by these authors support that, even after adjusting for demographics and self-reported health status, the results are similar. And the visit types are almost identical; about 38% of the uninsured population’s visits to the ER were considered to be emergent or urgent, compared to 44% for all insured persons and 40% for the Medicaid population. The share of visits that were deemed potentially avoidable by better primary care was slightly lower for the uninsured.
Several lessons are evident here. One is that while there are undoubtedly some uninsured people who would like coverage and can’t afford it or aren’t eligible for free programs like Medicaid, the majority almost certainly just don’t think, and rightly so, that they need it. That is reflected in their very low use of care. Another lesson is that many people on Medicaid simply have very poor health-seeking behaviors–they are used to going to the ER, they find it convenient to go to the ER and so they keep doing it whether they have insurance or not; in fact if you give them insurance it only reinforces that poor behavior.