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Giving people Medicaid doesn’t reduce their number of ER visits

Giving people Medicaid doesn’t reduce their number of ER visits

According to a study of the Medicaid expansion program in Oregon, giving people Medicaid appears to increase their ER use, rather than decreasing it as Obamacare proponents had predicted.

Why on earth would this be any sort of surprise? I know, I know: the idea was that people without health insurance or Medicaid go to the ER so often because the law requires them to be treated there and they have no alternatives; if they were covered for doctor visits, the argument went, they would prefer to do that instead. But what the study found was that people who were newly-covered by Medicaid used both resources more, which makes perfect sense because, as Megan McArdle points out, “when you reduce the price of something, people usually want to consume more of it.”

Not only are they consuming ER visits at a faster clip, but they are consuming them more for lesser ills rather than greater ones. McArdle wrote “reduce the price,” but unless I’m mistaken, Medicaid doesn’t just reduce the price, it mostly eliminates it for the recipient as far as ER visits go. Any health care system involving no payments at all must do one of two things to keep cost and usage down: ration care, and/or start requiring co-pays of some sort.

Those who theorized otherwise were either just saying what they needed to say to pass the law, or truly believed that people would act in ways that they considered “rational” and reduce their ER use, preferring doctor visits and preventive care. But there’s nothing in the current Medicaid system (at least, not so far as I know) that incentivizes doctor visits over ER visits. In fact, I can think of a couple of things that do the opposite: it may be hard to get a doctor to accept Medicaid at all, and even if he/she does accept it there’s usually a wait to get an appointment, whereas an ER may make you wait a few hours but they will see you that day.

What’s even more important is a fact that’s become a bit lost in the shuffle, but which first came out last May in another study of the Oregon Medicaid-expansion situation (I wrote about it here): the Medicaid expansion didn’t appear to improve the new recipients’ health, either, in terms of basic markers such as blood pressure and cholesterol. McArdle points this out, too, “Only two large-scale random tests have ever been done on health insurance, and both have come back with the same surprising result: giving people Medicaid, or more generous health insurance, doesn’t seem to significantly improve clinical measures of good health.”

And yet health economist Jonathan Gruber, who was one of the Obamacare “architects,” had this to say in response to the Oregon study report on Medicaid and ER use:

I would view it as part of a broader set of evidence that covering people with health insurance doesn’t save money…That was sometimes a misleading motivator for the Affordable Care Act. The law isn’t designed to save money. It’s designed to improve health, and that’s going to cost money.

I don’t know whether Gruber himself was originally citing the “misleading motivator” of cost-saving back in the build-up to the passage of Obamacare. But I do recall—despite Gruber’s use of the passive voice in the quote above—that Obama and the Democrats were certainly touting cost-saving. However, Gruber’s emphasis on “improving health” is probably a “misleading motivator” as well.

[Neo-neocon is a writer with degrees in law and family therapy, who blogs at neo-neocon.]


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legacyrepublican | January 5, 2014 at 9:32 am

I am motivated to vomit again after finding out more of what is in the bill.

Death taxes, no interstate features, fewer doctors, more lawyers. Oh my, the list goes on.

I’m in the healthcare field, and it’s been a long-observed fact that many Medicaid patients use the ER as if it was simply an urgent care/walk-in clinic. This attitude stems from a couple of causative factors; 1) The law that required ERs to treat all patients, whether they had insurance or not – so Medicaid patients know they’re not going to be turned away, regardless. And 2) there is a sense of entitlement on the part of ‘some’ with Medicaid who think they’re entitled – without using any of the commonsense or rationalized thinking others do.

IMO, the more “free” stuff given out, the greater the sense of entitlement. People (human nature being what it is) don’t develop appreciation for things unless they have to ‘work’ for it or have some ‘skin the game’ so to speak.

Henry Hawkins | January 5, 2014 at 9:57 am

Medicaid patient: “OK, I have a very bad sinus infection and need an appt to obtain antibiotics. The nearest doc who’ll take Medicaid is 20 miles away and the next available appt is 3 weeks out. The ER is a 5 minute drive away. Hmmm… what to do, what to do?”

The above scenario is particularly true of rural Medicaid recipients. The ones I speak to don’t feel entitled so much as driven to the ER by circumstances.

    Chicklet in reply to Henry Hawkins. | January 5, 2014 at 12:13 pm

    Certainly an ER visit for an acute illness is understandable and most insurance underwriters have planned accordingly.

    However, when there is zero personal responsibility for cost (or anything else) many Medicaid beneficiaries visit the ER for reasons far less important than an acute infection.

    We see thrice-weekly visits for ‘pain killers’, new bandages for a laceration that occurred last month, ‘I lost my medications’, I need to make some phone calls, can I get a ride home to my cousin’s house, etc. Don’t forget, it’s free stuff and there is absolutely no reason why an Obamacare patient wouldn’t want to get their share.

    Any physician who works in an ER or takes Medicaid could have estimated these costs, none of them were consulted when the bill was being drafted. Bah!

    Lady Penguin in reply to Henry Hawkins. | January 5, 2014 at 12:50 pm

    Reply to Henry Hawkins, re:

    “Medicaid patient: “OK, I have a very bad sinus infection and need an appt to obtain antibiotics. The nearest doc who’ll take Medicaid is 20 miles away and the next available appt is 3 weeks out. The ER is a 5 minute drive away. Hmmm… what to do, what to do?”

    The above scenario is particularly true of rural Medicaid recipients. The ones I speak to don’t feel entitled so much as driven to the ER by circumstances.”

    Believe it or not, an acute sinus infection is not an emergency and that’s what we’re talking about here. Hospital ERs were designed for emergency care, the patient with chest pain, the trauma incident, the motor vehicle accident. Not the everyday stuff…And if a hospital is 5 minutes away, likely there are all kinds of urgent care/walk-in clinics available. Rural folks actually tend to be pretty on top of what their health care needs are, and avail themselves of their local doctors.

    I live in an urban area, abundant with medical providers, though primary care for Medicaid patients, Medicare and Tricare are all hard to come by. It still doesn’t change the fact that the urgent care centers are available. But I have seen first hand people who go to the ER because it’s more “convenient” for their schedule – but in no way is it an “emergency” and that is the issue.

      Henry Hawkins in reply to Lady Penguin. | January 5, 2014 at 2:18 pm

      I’m not an idiot and have been in the health industry for thirty years. I picked sinus infection precisely because it isn’t an emergent condition, but is one that carries significant pain and discomfort and can lead to worse problems if left untreated. I was pointing out that it isn’t just a sense of entitlement that takes Medicaid recipients to the ER. Often it is the *only* way they will receive care within a reasonable time frame, short of long waiting times for appts if they can find a doctor who will accept them at all.

      If the medical treatment delivery system tolerates patients who treat the ER as a walk-in clinic and operates as a walk-in clinic, whose fault is that? I understand the laws about having to treat people. The medical industry has long sat around whining and waiting for government to set the rules and solve the problems, more so than any other for-profit industry that comes to mind. The current paradigm is the price they pay for that, fairly or not.

        I get the idea that the hospitals don’t actually mind people using their EDs as a 24-hour walk-in clinic for non-emergent care. There must be something in it for their bottom line.

        It’s the medical staff who actually have to deal with some of the more annoying and entitlement-minded patients (while being careful to “please” them enough to keep their Press-Ganey scores up) who are more likely to complain about it.

    AZ_Langer in reply to Henry Hawkins. | January 5, 2014 at 1:19 pm

    A friend working in a rural area related the story of a lady who called 911 late one night because she was in severe pain and had no transportation to the ER. She wanted to go to one of the hospitals in the big city over an hour away, but the ambulance crew took her to the nearest hospital where my friend treated her ingrown toenail.

I agree with the comments above. Evidently no one who planned for the vast Medicaid expansion actually asked anyone who works in emergency room settings about the consequences of doing this. As a former emergency room physician, I knew this result was absolutely predictable.

One of the scandals of the ACA is the despicable legislative malfeasance on the part of the Democrats who passed this monstrosity with no knowledge as to what was in it – and they didn’t care!

    Uh Huh in reply to nomadic100. | January 5, 2014 at 11:05 am

    They didn’t care because they were told behind doors that this bill would destroy the insurance industry and help bring on single payer faster.

    Remember John Dingell’s famous comment after Obamacare passage.(He has been trying to get single payer in place for decades).” We had to get control of the people first in order to get single payer”.
    Obamacare is nothing but a trojan horse.

      gasper in reply to Uh Huh. | January 5, 2014 at 2:22 pm

      Calling Obamacare and its affects a “Trojan Horse” assigns them genius status. I totally reject that idea. THIS IS NOT A PLAN. Everything that has happened is the result of gross incompetence by a bunch of dolts. This is a major eff-up and to call it anything else is to compliment these ignoramuses who have failed at virtually everything they have attempted. Stop referring to them as geniuses.

Absolutely. I worked in the health care field and my state years ago began requiring Medicaid recipients to pony up five dollars for a exam appt. The idea was to place a value on the service so that the Medicaid recipient would actually show up, and would take the appt. seriously.

You can’t imagine the howls and screams from these people when they were told that the state required a copay. Sense of entitlement, ha, We would regularly be threatened with a lawyer, “I’m calling my case worker”, or the ever present, “I don’t have five dollars”. (Never mind that they had perfectly coiffed hair, nail extensions, and the kids had the latest athletic shoes, etc.)
We always wondered if they pulled that stuff on the bus/cab driver.

Is it any wonder that most doctors/dentists, etc. do not take Medicaid? Those that do, limit the number of them a day and just consider it charity work.

    Chicklet in reply to Uh Huh. | January 5, 2014 at 12:18 pm

    In the great state of New York our governor has declared Medicaid insurers place every recipient into ‘care management’. Insurance companies must follow up with each and every patient, and see them weekly/monthly as needed.

    Nobody would dare tell the patients about this, so we have the scenario of paying teams of ‘managers’ hundreds of dollars per month to ‘find’ the patients. Even when they might have 2 or 3 Obamaphones about 50% of them don’t want to be found. Every now and then you’ll find someone living in a mansion or even worse, a mansion in Florida! Bah!

    Estragon in reply to Uh Huh. | January 6, 2014 at 2:42 am

    $5 isn’t nearly enough of a minimum copay to be required. There should be NO “free” treatment or visits at all.

    Ask any health care worker in a doctor or dentist’s office or clinic, Medicaid patients treat appointments like suggestions and often argue loudly if not allowed to just show up and be treated. They should not only be required to pay copays as a minimum, but be assessed for those for missed appointments.

    If they can’t be responsible enough to keep their appointments, why should taxpayers see their own care increase in cost and decline in quality to provide them with freebies they don’t seem to appreciate?

One of the gratifying things about being conservative/libertarian is that research confirms your opinions and experience. I’m sure we all can cite examples of this very thing.

Last year while visiting my M-I-L she became very ill. She is aged 90 with many health problems. Her internist said meet me at the ER to admit her at local enormous hospital in south Texas. After having difficulty finding parking, my wife drops me off to go in and ask for a wheel chair to bring her in. They are all in use with people just sitting in them watching television in one of the largest rooms I have ever been in. It was the size of an auditorium. It was the waiting room of the ER. With my wife circling the parking lot, I found the internist who commandeered a wheel chair from the hospital proper and we brought her in.

Having been in this same very fine hospital to visit her previously, I was astounded at the size, noise, mayhem, picnicking (everyone there seemed to be eating), and temperature (it was freezing with the AC going full tilt) of the ER. I asked the internist (my wife’s second cousin) “what is that?”. “Oh that’s the TV room.” he said. “That is where the overflow from patient’s rooms and people who don’t have A/C in town and people who come to spend the day with a friend or relative who have a cold, splinter, indigestion, or broken toe come to hang. If they did not have the giant tv’s there would be a riot.”

I’m not sure how Obamacare is going to change a social gathering like that.

    Bruce Hayden in reply to Elliott. | January 5, 2014 at 12:20 pm

    My companion’s spine surgeon would have her get admitted through the ER, because somehow it was significantly cheaper for us with her insurance. It was the deductibles, I think with first dollar coverage with ER admissions. Inevitably, when we finally got to th ER doc, there would be a consult, she would be admitted, and then her spine surgeon would do his magic.

    It was bad, and worst was the large state teaching hospital in town. Huge lobby, with the long lines, some being in real pain, and many not. And, yes, some who appeared just to be hanging out. A lot of families. A lot of security though, with drunks and druggies on occasion thrown out. Next time, may try for an ambulance entry to avoid all of this. The other bad place there was the pharmacy, where the addicts go for their methadone. Standing in line with them with a script for pain meds is a bit unnerving. Still don’t know why we couldn’t have taken it across the street – would have been cheaper, safer, and far faster.

    genes in reply to Elliott. | January 5, 2014 at 12:33 pm

    Two reasons for the low temps in ER.
    Keep the germs down, and discourage people just hanging out.
    Hopefully it works better for the germs than it does in keeping the extra people out.

Gee, why was this a surprise! Free stuff leads to people over using it because there is no reason not to use it as much as possible. There are no personal consequences when someone else is picking up the tab. When expenses come directly out of the pockets of the consumer then that consumer thinks twice about going to an emergency room for a stubbed toe or a hangnail.

In what children’s fantasy world do you reduce use of a resource by increasing the number of users?

In what children’s fantasy world do you reduce the price of a product/service by artificially mandating a sudden increase in demand?

In what children’s fantasy world can obamacare make sense?

    MarkS in reply to Exiliado. | January 5, 2014 at 2:15 pm

    It all takes place in the fantasy world of the Liberal mind which IMO is indistinguishable from that of a child’s.

Those of us who have worked the ER could have told them what would happen. Those identification cards do increase the sense of entitlement, even among people who have used the ER for primary care prior to getting those cards.

Cases such as Henry Hawkins mentioned are understandable, but they’re far fewer than cases of overuse. When an assigned PCP’s office is within two blocks of the ER and could see the patient the same day, waiting until the office closes (despite no scheduling conflicts), then coming to the ER for a trifling matter happens all too frequently. In some cases it seems to be the family’s evening recreation plan. I have to credit the doctors who recognize their patients and chastise them for such abuses.

    Chicklet in reply to AZ_Langer. | January 5, 2014 at 12:24 pm

    In a study of a large hospital system in NYC it was found that 65% of ER visits occur Monday-Friday from 9-5, presumably when the local doctor’s office is open.

    However, hospital ER’s have free Wi-Fi, food and carfare to and from the place, the doctor you’ve never seen before will be easier to deal with than the office nurse and more ‘free stuff’ will come your way. Everyone who works in a hospital knows this, but nobody wanted to ask them because it’d ruin their blue sky assumptions!

the law requires them to be treated there

I’ve never understood how we got from the actual text of EMTALA to having to treat everybody for everything. The law only requires that the ER provide screening and stabilization for someone with an “emergency medical condition”. Then the hospital can transfer the patient.

…if any individual…comes to the emergency department…the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition…exists.

(1) If…the hospital determines that the individual has an emergency medical condition, the hospital must provide either–

(A) …such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

Hospital ERs are only required to treat emergency medical conditions under the law. I think the trial lawyers have managed to morph this limited role into “must treat all snotty noses and hangnails”.

    Henry Hawkins in reply to snopercod. | January 5, 2014 at 2:22 pm

    Exactly, which is why I said above: If the medical treatment delivery system tolerates patients who treat the ER as a walk-in clinic and operates as a walk-in clinic, whose fault is that?

    neo-neocon in reply to snopercod. | January 5, 2014 at 5:52 pm


    My best guess that the reason the law has morphed into ERs treating all comers, rather than just patients who represent a medical emergency, is the threat of lawsuits. Doctors and nurses probably have a hunch, just by glancing at a patient, who is a real emergency case and who is not. But exceptions happen, and if they were to turn away someone (for example) with a cough that turned out to be pneumonia that ends up becoming fatal, the hospital is in for a huge lawsuit. Since they can’t differentiate for certain whether it’s an emergency or not until they examine the patient, the end result is that they feel they need to treat (or at least examine) everyone. So although the law may only mandate emergency treatment, practically speaking it probably ends up causing them to treat everyone.

      Estragon in reply to neo-neocon. | January 6, 2014 at 2:58 am

      No meaningful reform of our health care delivery system is possible unless real tort reform is a critical part of it.

    LSBeene in reply to snopercod. | January 6, 2014 at 5:12 pm

    The trial lawyers make it a political death sentence for anyone to threaten their money.

    The simple solution is not caps or “tort reform” – but instead going to “loser pays”. Right now a law suit is like a lottery ticket, it costs little to file, and you cannot lose.

    Changing it to loser pays means if the lawsuit is frivolous then the loser pays the winner’s legal expenses.

    But, again, the trial lawyers will (out of a sense of financial survival) fight to the death to protect their pot of gold.

I’d like to clarify that the entitlement mentality isn’t limited to Medicaid recipients or ER visits. Private insurance with no and low co-pays increase office visits for self-limited conditions and problems that shouldn’t require professional care; and we can’t forget the Medicare patient with a sprained ankle who wanted paperwork for a power chair.

For the record, I’m old enough to remember affordable medical care, and we’re getting further and further away from it.

I say give the indigent an HSA account totaling a certain amount. If they remain healthy then add $200 every year they remain healthy. Cost and life savings as one with responsibility.

    David Yotham in reply to jennifer a johnson. | January 5, 2014 at 2:21 pm

    Another famous socialist just gathered the homeless up and placed them into work camps. They could work for their food and medical care — they even were award free burial benefits. That’s a hard combination to beat: food, housing, medical, gated community and burial services. The non-producers were transformed into wage earners, for a short time at least.

As a disabled veteran and the recipient of government medicine for over a decade, I just sit back and laugh! The American public voted this loon Obama in TWICE — I feel they deserve everything they’re going to get. They spit on Bush, Romney, etc., but find Obama acceptable. LOL

AND, FURTHERMORE, if I should live another 5-10 years, I fully expect there to be a national holiday celebrating his presidency. The first American president awarded a Nobel Peace Prize… Speaking of which, AQ has taken control of it’s second city in Iraq. Ghosts of Vietnam, eh?

I never did understand quite how adding an additional 17 million people to the Medicaid rolls was going to “bend the cost curve” of American medicine “down”. Yet the Democrats and the media (do I repeat myself?) just kept pressing that, along with a lot of other nonsensical talking points, as a matter of faith.

    LSBeene in reply to Amy in FL. | January 6, 2014 at 5:14 pm

    Amy – anyone who can do basic math knew this.

    It’s the same reason Team Obama and the RINOs and the (D)’s just agreed to cut veterans pensions while paying out illegal aliens: bigger constituency.

I would think it would increase it.