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Wednesday, January 8, 2014

What health care advocates should know about recent findings from the Oregon Medicaid study

Sanjay Kishore

Villers Fellow

Last week, Harvard researchers released the latest installment of the Oregon Health Insurance Experiment (OHIE) –a randomized control trial that examines the effects of Medicaid expansion on Oregonians who won a lottery for health insurance in 2008.  After analyzing hospital records for 18 months, the researchers discovered that Medicaid recipients visited the ER 41 percent more than those without insurance.

The release of the study has generated a lot of buzz. As Aaron Carroll, a writer for The Incidental Economist, and Seth Trueger, an ER physician who advises Rep. John Dingell (D-MI 12), point out, the results are not that surprising: access to care leads to access of care.  The individuals who won the Medicaid lottery were previously uninsured adults who likely viewed the ER as the only source of care; therefore, it seems intuitive they might return once covered. 

Austin Frakt, also of The Incidental Economist, later claimed that this trend of ER “overuse” reflects poorly on the broader structure of our health system itself. On the other hand, some commentators, like Avik Roy of the Manhattan Institute and Michael Cannon of the Cato Institute, have interpreted the latest findings as an indictment of the Affordable Care Act -- and Medicaid in particular.  

Advocates for Medicaid expansion in any state should be prepared to debate the implications of the OHIE’s latest results. Here are some key points:

  •  Though coverage may lead to initial increases in ER visits, evidence suggests it won’t be sustained. Though Massachusetts observed an increase in ER visits in the two years after it expanded coverage in 2006, studies documented a decrease in trips to the ER in the following four years, ranging from 4 to 8 percent. The findings from the OHIE highlight the need for robust education programs that inform Medicaid recipients when it is appropriate to visit the ER.
  •  Altogether, the vast majority of Medicaid patients across the country visit the ER for necessary care.  A 2008 study demonstrated that 74 percent of Medicaid ER visits were for “urgent, emergent, or semi-urgent” care.
  •  We need to know more about why individuals visit the ER to interpret the Oregon study’s most recent findings. The Center for Health Systems Change found that patients were visiting the ER unnecessarily because they perceived their conditions as urgent. Unfortunately, we can’t gain comparable insight from the OHIE study--the “appropriateness” of ER visits was based on diagnoses made after discharge-- not the patient’s initial evaluation during triage. As a case in point, a recent study questioned the value of this methodology, concluding that many ER patients eventually diagnosed with mild conditions initially presented with symptoms that seemed to warrant further examination.
  •  If reducing ER visits is a priority, we must focus on reforming the way health care is delivered—not just how we pay for it. And we know it can be done. For example, Oregon was able to reduce its Medicaid patients ER visits by 9 percent in just one year (in a period after this study was conducted). How? By discouraging unnecessary care through a combination of financial incentives and the use of trained community health workers in hospitals.

Overall, Medicaid remains an effective program that protects the health and financial status of low-income Americans. However, we can’t expect one program to “mask” the structural flaws of health care in America.  With focus and cooperation, we can reduce unnecessary spending in the ER and elsewhere, but we must also ensure those most vulnerable have access to vital treatment in the process.