Are Medicaid patients overusing the ER?

Co-authored by Josie Phillips, policy intern.

Note: This post has been updated to correct the number of ER visits by Medicaid enrollees reported in 2019 and to clarify that the declining trend of ER utilization is unlikely to cause health care costs to increase in the near future. [5/5/21]

As part of a larger pattern of demonizing the social safety net, critics of the Medicaid program frequently claim that patients overuse emergency rooms for non-emergency care and that the state must address this problem to contain Medicaid spending. However, there is little evidence to support this claim. In reality, Oklahoma’s SoonerCare enrollees use the emergency room at rates comparable to the general population, and emergency services represent a small fraction of total SoonerCare expenditures. Legislators concerned about rising health care costs should worry less about the health care practices of individual SoonerCare members and more about how we can most effectively provide health care for all Oklahomans through the SoonerCare program.

SoonerCare patients aren’t overusing the emergency room 

ER usage by SoonerCare members is nowhere near as pervasive or as serious a problem as many assume, according to data from the Oklahoma Health Care Authority (OHCA). In fact, ER utilization rates have significantly decreased in recent years. In the fiscal year ending in 2019, nearly three in four Medicaid patients (73 percent) made no emergency room visits at all. Another 22 percent visited the ER once or twice. Only 11,073 individuals, or 1.1 percent of those insured by Medicaid, had six or more ER visits. Even when accepting the premise that some Medicaid patients use the emergency room at a higher rate, it is clear that the hypothetical misusers make up a tiny proportion of all SoonerCare members.

Additionally, although differences in demographic make-up and data sources make direct comparison difficult, ER utilization for Medicaid patients appears to be stable — with annual visits ranging from 0.52 to 0.62 per member since 2007 — and comparable to the overall population. All Oklahomans (regardless of health care coverage) had 492 ER visits per 1,000 people in 2019, and that number was 533 visits per 1,000 Medicaid enrollees. ER usage among SoonerCare members has steadily declined in recent years, making it unlikely that this will cause health care costs to balloon in the near future.

It is also not apparent that ER visits are a major expense in the Medicaid program. In fiscal year 2019, total emergency department costs for SoonerCare members were $139 million, which represented less than 3 percent of the total SoonerCare expenditures of $5.6 billion. (If we also include additional ancillary services, the total cost was $177 million, or 3.2 percent of total expenditures.) If Oklahoma policymakers are looking for ways to decrease health care spending, demonizing a group that accounts for a tiny fraction of total spending would be an ineffective place to start. 

Medicaid expansion could temporarily increase ER usage, but managed care won’t solve that problem 

Oklahoma’s decision to expand Medicaid this year may change the situation, although not in any meaningful magnitude. ER usage may increase slightly following the implementation of Medicaid expansion but will likely decline over time as individuals receive more preventative care. Any increase in ER visits will likely be small, based on evidence from other states. After Medicaid expansion, Kentucky saw a one percent increase in ER visits, and Maryland did not see any increase at all. Another study of 14 states that expanded Medicaid found an increase of only 2.5 visits per 1,000 people. Either way, any increase will likely be temporary, with ER usage declining after a few months, possibly even to levels lower than the pre-expansion period

No matter what, it’s unlikely that the state’s push to privatize the Medicaid program will help address ER usage. Research suggests that managed care doesn’t impact ER utilization. Instead of pushing this substantial change to privatized managed care, OHCA could instead adopt practices that increase access to primary care outside of normal work hours, such as increasing funding for community health centers. This would provide a non-emergency room path to care for Oklahomans who work during the day and might otherwise rely on the ER for primary care because they are unable to take leave to see a doctor. 

Oklahoma’s approach to health care should be informed by data, not by political talking points

OHCA’s efforts to monitor and prevent inappropriate emergency room usage are important in ensuring responsible use of taxpayer dollars. However, the idea that many Medicaid members make unnecessary trips to the ER seems to reflect myths and anecdotes rather than being based in reality. Instead of shaming the people who are insured by SoonerCare, Oklahoma policymakers should adopt and fund targeted actions that will reduce reliance on the emergency room, such as ensuring a robust and accessible Medicaid expansion and providing pathways to more accessible primary care.

 

About the Co-Author

Josie Phillips is a policy intern for OK Policy. She graduated from the University of Oklahoma with a double major in Economics and International & Area Studies. She is an alumna of OK Policy’s Summer Policy Institute.

ABOUT THE AUTHOR

Emma Morris serves as the Health Care and Revenue Policy Analyst at OK Policy. She graduated from the University of Oklahoma in fall 2019 with dual degrees in Women’s and Gender Studies, and Public and Nonprofit Administration. She is an alumnus of OK Policy’s Oklahoma Summer Policy Institute.

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