Category: Medicaid

It is well established that Medicaid patients use emergency rooms more than either uninsured or privately insured patients. What has been debated is whether their use of the ER is necessary or unnecessary. Well, it turns out that that depends on how you look at it. Obviously, not many people go to the ER because they enjoy the experience and have nothing better to do. However, medical problems that cause them to go to the ER could often be dealt with in a doctor’s office.

The Medicaid and CHIP Payment and Access Commission (MACPac) has just published a review of articles examining why Medicaid patients frequent the ER so much:

The majority of ED visits by non-elderly Medicaid patients are for urgent symptoms and serious medical problems that require prompt medical attention…

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Medicaid, which provides health-related welfare benefits to low-income individuals, is jointly financed by the federal and state governments. Before Obamacare, the split was 50/50 for rich states, but low-income states got more dollars. This mechanism is called the Federal Medicaid Assistance Percentage (FMAP). So, if California spent $50 on Medicaid, the federal taxpayer would chip in $50. However, for West Virginia, the split is 28.65/71.35. That is, for every hundred dollars spent on Medicaid, only $28.65 is spent by the state, and $71.35 comes from federal taxpayers. These dollars are not appropriated by Congress: They just roll out on auto-pilot, as calculated by the FMAP.

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Medicaid “crowd-out” is the hypothesis that enrolling more people in Medicaid will cause some people to drop private coverage in favor of Medicaid. Historical analyses of this effect come to a wide range of estimates, as Linda Gorman discussed in a recent blog entry.

Now courtesy of the Robert Wood Johnson Foundation (RWJF), we have evidence that the entire effect of Obamacare so far is to crowd out private coverage. The RWJF report further confuses the consequences of Obamacare on coverage and access to care. This is not the RWJF’s fault: The emerging evidence on Obamacare is a jumble of contradictions. In this instance, the report insists that physicians saw no increase in patient demand after Obamacare, as demonstrated in Figure 2. More sophisticated metrics showed that the complexity of patients’ needs also did not increase after Obamacare.

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To paraphrase John Wayne, evaluating health care is hard. It is even harder if you use percentages.

A 2011 report on whether or not Wisconsin’s BadgerCare’s coverage of childless adults affected their utilization of services concluded that people in a sample of about 10,000 very low income childless Milwaukee adults increased their total emergency department visits by 39 percent when they were newly enrolled in Medicaid coverage.

Seventeen percent of visits resulted in a hospital admission before Medicaid was expanded to cover the group. After expansion, 9.5 percent of emergency department visits resulted in a hospital admission.

The report spins this like it was a good outcome: “This significant 45% decline is notable in that Wisconsin Medicaid payment policy considers an ED visit ‘appropriate’ when it results in a hospital admission.” Later on, the report reminded readers that “the percentage of hospital admissions from the emergency department declined dramatically.”

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Claims about Medicaid’s effectiveness should be approached with caution simply because the population covered by Medicaid differs from that covered by private insurance in ways a variety of ways that are likely to affect overall health.

For example, Medicaid patients are more likely to be no-shows for medical appointments. No-shows are typically defined as either not showing up at all or calling to cancel on the same day. In one orthodontic practice, Medicaid patients accounted for almost 40 percent of missed appointments but only 27 percent of all appointments. Children most likely to miss dental visits were those with lots of cavities, poor behavior, multiple missed appointments, and no phone.

Broken appointments translate into a reimbursement rate of zero. Surveys of dentists suggest that they are even more important than low reimbursements in dentists’ refusal to participate in Medicaid.

The pattern does not change for more involved procedures like cochlear implants. At Children’s Hospital in Cleveland, Ohio, access to cochlear implants is the same whether patients are covered by Medicaid or by private insurance. But medical complications do vary with a patient’s insurance status. From 1996 to 2008, 133 children received unilateral cochlear implants. Complications in Medicaid-insured children were 5 times those in privately insured patients with 10 complications in 51 Medicaid-insured patients and 3 complications in 61 privately insured patients. Medicaid patients missed 35 percent of follow-up appointments. Privately insured patients missed 23 percent of follow-up appointments.

Given that behavioral differences exist for something as simple as keeping an appointment, challenges to getting high-quality care to Medicaid patients cannot be solved by just expanding Medicaid budgets.

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