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Medicaid Expansion and Avoidable Emergency Department Use—Implications for US National and State Government Spending

1 School of Medicine, Department of Emergency Medicine, University of Washington, Seattle
2 School of Public Health, Department of Health Systems and Population Health, University of Washington, Seattle
3 Evans School of Public Policy & Governance, University of Washington, Seattle
Original Investigation Association of Medicaid Expansion With Emergency Department Visits by Medical Urgency Theodoros V. Giannouchos, PhD, MS; Benjamin Ukert, PhD; Christina Andrews, PhD JAMA Network Open

Expansion of Medicaid through the Affordable Care Act has been one of the most consequential health and social program reforms in recent decades. Since 2014, approximately 14 million low-income US individuals, most of whom were uninsured before, have gained health insurance coverage through Medicaid expansion alone. 1 Beyond increasing health insurance enrollments, Medicaid expansion has resulted in a net savings for participating states overall (largely owing to enhanced federal cost-sharing) and numerous economic and health benefits for enrollees. 2 However, there are lingering concerns about the ramifications of using a publicly funded coverage mechanism for a large proportion of the population for state and federal budgets.

A crucial question for many policy makers is whether Medicaid expansion offers value over alternative pathways to expand coverage, such as greater investment in subsidized insurance exchanges. However, answering this question largely hinges on the extent to which Medicaid expansion improves the efficiency of health care use and spending. Giannouchos and colleagues 3 examine whether Medicaid expansion was associated with improvements in the use of what is often one of the most expensive health care settings: the emergency department (ED). Their simple yet revealing study further contributes to the literature by noting that Medicaid expansion is a good value for states and is likely to reap long-term benefits in the form of better population health and lower health care spending.

In this study, the authors examined 80.6 million outpatient ED visits from the Healthcare Cost and Utilization Project State Emergency Department Databases and a difference-in-differences design to evaluate changes in the rate of outpatient ED use in 2 Medicaid expansion states (New York and Massachusetts) vs 2 nonexpansion states (Georgia and Florida) from 2011 to 2017. 3 Emergency department visits were stratified by severity using the New York University algorithm, which classifies visits based on their likelihood that the primary diagnosis will fall into 1 of 4 subgroups: (1) emergent, not preventable, (2) emergent but potentially preventable, (3) emergent but primary care treatable, and (4) nonemergent. Emergency department visits related to injuries and behavioral health conditions are also classified (or classified separately). Although no clear consensus exists on what proportion of ED visits are unnecessary, it is generally believed that a substantial number could be avoided with either better access to timely and high-quality ambulatory care (such as in the case of preventing exacerbations of chronic illness), greater attention to mitigating social determinants of health or, at least, shifting care to a less costly venue (such as an urgent care center).

The investigators found that Medicaid expansion was associated with a significant reduction in overall ED use by 4.7 visits per 1000 population. 3 Furthermore, this reduction was associated largely with changes in the subgroups of ED visits that are potentially avoidable, with greater decreases noted for the least severe conditions that are likely to be most avoidable and smaller decreases for higher severity conditions. Visits classified as nonemergent decreased by 1.5 visits per 1000 population, those classified as primary care treatable declined by 1.1 visits per 1000 population, and those classified as emergent, but potentially preventable declined by 0.3 visits per 1000 population (all statistically significant declines). Conversely, the authors noted no associations with visits classified as injuries and emergent, not preventable, which would not be expected to change owing to insurance coverage alone. Although the present study was limited to ED use, the apparent disproportionate reductions in nonemergent and primary care–treatable conditions are highly suggestive of greater access to alternative and less-costly sources of care. Accordingly, these results are largely consistent with the preponderance of studies that show increased access to preventive care, better continuity of care and management of chronic disease, and an overall decrease in unmet health care needs among low-income adults in states that expanded Medicaid vs those that did not. 4 , 5

Reducing unnecessary ED use has been a longstanding priority for state policy makers. Medicaid enrollees use the ED at higher rates than those with private insurance or who are uninsured. 6 Although Medicaid coverage clearly improves access to essential services relative to having no insurance, many Medicaid enrollees still experience persistent barriers in accessing high-quality and coordinated services and face poor social determinants of health, both of which are associated with avoidable ED use. Moreover, unlike private insurance, most Medicaid programs do not impose cost-sharing requirements for health care services used by enrollees, which lowers the opportunity cost for using the ED for Medicaid enrollees compared with individuals with private coverage. This situation may be why many studies on Medicaid coverage expansions demonstrate increased ED use. For example, the Oregon Health Insurance Experiment, a randomized clinical trial under which Medicaid coverage was expanded via lottery to a subset of low-income individuals in Oregon, found that ED visits increased by 40% in the first year and a half following enrollment. 7 It is, therefore, understandable that the outcomes of the ACA’s Medicaid expansion on ED use have been an area of intense study.

Although Giannouchos et al 3 found encouraging patterns of ED use, other studies have found the opposite. In particular, a 2019 study by Garthwaite et al, 8 which also used Healthcare Cost and Utilization Project data, but included 20 states and all ED visits (both outpatient ED visits as well as those leading to inpatient admission), found that ED use for deferrable conditions increased in expansion states relative to nonexpansion states, whereas those for nondeferrable conditions did not. The authors defined deferrable conditions as those that a panel of physicians believed were likely to be at the patient’s discretion, and nondeferrable conditions as those that were truly emergent and not likely to be discretionary. This latter study only examined data through 1 year postexpansion and, thus, may have observed an early uptick in ED use owing to pent-up demand. The study by Giannouchos et al 3 incorporates a 4-year time horizon but a more limited set of states, which could explain the variable results.

So, where does this study leave us on the question of whether Medicaid expansions improve value for states with respect to ED use? It appears that for some states, expanding Medicaid improves the efficiency ED use, resulting in fewer ED visits for conditions that may be prevented with better access to primary care. In other states, especially those that may have less ambulatory capacity to meet increased demand from newly enrolled Medicaid beneficiaries, ED visits may increase (at least initially). However, it is important to consider that better access to care and management of chronic disease may take years to manifest in the form of improved health and lower rates of avoidable ED visits. As a result, the long-term outcomes of Medicaid expansion associated with avoidable ED use should remain an area of ongoing inquiry as a meaningful indicator of the effectiveness of the ambulatory care system for Medicaid enrollees, as well as the overall health of the Medicaid population.

Published: June 14, 2022. doi:10.1001/jamanetworkopen.2022.16917

Corresponding Author: Amber K. Sabbatini, MD, MPH, School of Medicine, Department of Emergency Medicine, University of Washington, 1705 NE Pacific St, Box 357235, Seattle, WA 98195 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

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Sabbatini AK , Dugan J. Medicaid Expansion and Avoidable Emergency Department Use—Implications for US National and State Government Spending. JAMA Netw Open. 2022;5(6):e2216917. doi:10.1001/jamanetworkopen.2022.16917

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