Emergency visits seen increasing with health law
By Sabrina Tavernise
The New York Times, January 2, 2014
Supporters of President Obama’s health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.
The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance. …
In remarks in New Mexico in 2009, Mr. Obama said: “I think that it’s very important that we provide coverage for all people because if everybody’s got coverage, then they’re not going to the emergency room for treatment.” …
“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard … and one of the authors of the study….
Comment:
By Kip Sullivan, JD
Last Friday the New York Times, the Wall Street Journal and other media outlets trumpeted the news that a recent study shows that low-income people newly insured through Medicaid use 40 percent more emergency room services than a control group of low-income people who remained uninsured. In a sane world, this finding would not have deserved any coverage, much less headlines on front pages. The conditions that would cause Medicaid enrollees to visit the ER more than the uninsured have been known for a long time, and it’s well known that some of these conditions have been getting worse. The conditions include:
• the uninsured use roughly half as many health care services as the insured,
• the uninsured are in worse health than the insured and have more unmet medical needs, and
• Medicaid enrollees have much more trouble finding primary care doctors and specialists who will take Medicaid than the privately insured.
Anyone familiar with these facts could have predicted that if the State of Oregon were to offer Medicaid coverage to 10,000 of its poor people those people would make more visits to emergency rooms than an uninsured control group. But the media’s fascination with this paper suggests the study’s results were indeed surprising to “many in the [health] policy debate,” as Ms. Baicker asserted.
How do we explain the surprise? I nominate the overuse myth – the conventional wisdom that the main reason America’s per capita health care costs are double those of the rest of the industrialized world is that doctors order, and patients demand, great volumes of unnecessary medical services. The overuse myth has led far too many policymakers on the left and the right to think that emergency rooms are vastly overused. Liberals like Obama use the myth to claim better coverage will reduce all that unnecessary ER use and free up money to insure the uninsured. Conservatives use the myth to decry more coverage. According to conservatives, better coverage will just encourage poor people to consume even more unnecessary care. As conservative blogger Avik Roy wrote on the Forbes blog about the new study, “Because Medicaid was nearly free to the program’s enrollees, those enrollees ended up seeking – and receiving – lots of inappropriate care.”
http://www.forbes.com/sites/theapothecary/2014/01/02/new-oregon-data-expanding-medicaid-increases-usage-of-emergency-rooms-undermining-central-rationale-for-obamacare/
In fact, researchers have determined (with the luxury of hindsight, it should be noted) that only 10 percent of Medicaid enrollees go to emergency rooms for non-urgent matters, which is close to the 7 percent rate seen in the privately insured http://www.hschange.com/CONTENT/1302/.
Like all sturdy myths, the overuse myth has a kernel of truth to it – some overuse of medical services does occur. But underuse is far more common than overuse, even among the insured, possibly four times worse according to a 2003 study by Elizabeth McGlynn et al. in the New England Journal of Medicine. Even for some expensive procedures like heart surgery underuse is far worse than overuse.
The media’s surprise at the new study’s finding and reporters’ and right-wing bloggers’ eagerness to report the political winners and losers of this story concealed the real problems, notably:
• Because America sequesters its poor people in a separate program called Medicaid, it has never found the political will to pay the providers who care for poor people anywhere near as much as we pay providers for taking care of everyone else;
• this policy has made it difficult for Medicaid recipients to find doctors;
• this difficulty is further aggravated by the widespread use of managed care in Medicaid programs which forces recipients to pick doctors from “preferred” lists; and
• Despite these facts, Oregon sought to increase coverage under Medicaid while doing little to increase the supply of primary care providers or the resources available to those who treat Medicaid enrollees.
In a sane world, we wouldn’t be debating whether a rich nation should be attempting to insure a minor portion of its uninsured through a separate and underfunded program for the poor. But if we must debate whether to do that, the least we can do is focus on the real issues, not promises of cost containment based on a false assumption, in this case, that overuse is our main problem and underuse, high prices and excessive administrative costs are nonexistent or trivial.
The truth is we are going to need to put more money into primary care in this country, and it will have to come from somewhere. Single-payer supporters propose that it come from reduced prices and reduced administrative waste. By clinging to their pet version of overuse, managed-care and high-deductible advocates dodge the issue. Managed care advocates claim that even within the underfunded world of Medicaid greater access to primary care can be paid for without harm to patients by reducing overuse via capitation, report cards, pay-for-performance, ACOs and other vaguely defined “changes to the delivery system.” High-deductible advocates claim consumption of medical services by poor people can be reduced without harm (because the foregone services weren’t necessary), and the savings can be directed to lower taxes or a lower deficit. Neither claim is credible.