As I've noted before, the Oregon Health
Experiment is a randomized control group design, far superior to most
health care research. In 2008, Oregon hoped to expand Medicaid, but
didn't have enough money, so they held a lottery. They invited
everyone who was eligible to apply. Of the 90,000 applicants, 30,000
were randomly selected to receive Medicaid, while the losers became
eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the
control group. They visited primary care physicians (PCPs) and were
admitted to hospitals more often, and spent more on prescription
drugs. They were also healthier and freer of financial worries,
although most of the health differences are not statistically
significant due to insufficient sample sizes in the study.
A new analysis by the Oregon research group reports that the Medicaid participants were also more likely to visit the emergency room (ER). Specifically, during their first 18
months on Medicaid, they made an average of 1.43 ER visits compared
to 1.02 in the control group—a 40% difference.
This should not have been a surprise.
If you reduce the cost of a service, people are more likely to use
it. However, some ACA proponents claimed that Medicaid expansion
would save money by reducing ER use. Although the ER accounts for
only 4% of health care spending, an ER visit is more expensive than
visiting a doctor. The pro-ACA argument was that if patients
established a relationship with a PCP, they would have a place to go
for medical care and these doctor visits would prevent potential
emergencies. For example, Health and Human Services Secretary
Kathleen Sebelius said in 2009:
Our health care
system has forced to many uninsured Americans to depend on the
emergency room for the care they need. We cannot wait for reform
that gives all Americans the high quality, affordable care they need
and helps prevent illnesses from turning into emergencies.
It is important to note that these
results are not due to the fact that Medicaid provides health
insurance for poor people. Private health insurance patients are
also more likely to use the ER than the uninsured.
Increased ER use might not be seen as a
problem if the visits were real emergencies. However, the study
found ER use to be higher even for non-urgent care that should
ideally have been treated by a PCP. These results could be used by
the opposition to suggest that single-payer might cause an massive
influx of people outside the ER waving torches and pitchforks and
demanding free care.
There are several considerations that
may place these results in clearer perspective.
- The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.
- Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.
- Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.
This study is one of a growing number
that show that providing health insurance to the uninsured alone
does not save money. The ACA contains some cost controls, such
as the Independent Payment Advisory Board, which may eventually
reduce costs. Single payer eliminates the cost of private insurance,
which will save much more. Other changes may be needed. One of them
may be asking PCPs to become more consumer-friendly by seeing more
patients on evenings and weekends.
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