Setting the Record Straight on Medicaid Emergency Room Use

There are more than a few misconceptions in the health care world, including that many Medicaid patients are using hospital emergency rooms in place of family doctors. While that does take place in some cases, the percentage is not nearly as high as commonly thought. That is among several interesting findings in a new Center for Studying Health System Change report.

Policy makers and providers frequently point to Medicaid patients’ heavy reliance on hospital emergency departments as a problem that contributes to crowded emergency departments, long wait times and high costs, as well as poor management of chronic conditions. Recent research has dispelled misconceptions linking ED use to crowding, finding that most crowding results from emergency patients admitted to the hospital but waiting for an inpatient bed—so-called ED boarding—not a high volume of nonurgent ED visits. Other research has dispelled the mistaken belief that most ED users have Medicaid coverage, are uninsured or do not have a usual source of care. In fact, people with private insurance account for most ED use, and people with higher incomes and a private physician as their usual source of care are driving ED visit increases over time.

Other misconceptions about Medicaid patients’ ED use continue to drive policy. In response to state budget crises, some Medicaid programs have sought to cut ED use by denying payment for emergency care viewed as unnecessary, increasing patient cost sharing to discourage visits and penalizing patients for too many ED visits—all based on the assumption that Medicaid patients commonly use EDs to evaluate symptoms that could wait for a primary care clinician to treat. Media coverage of so-called frequent flyers—a small number of people with hundreds of ED visits—may have contributed to commonly held views that Medicaid and uninsured patients often use emergency departments inappropriately.

Nonelderly Medicaid patients do use EDs at higher rates than nonelderly privately insured patients. In 2008, people aged 0 to 64 covered by Medicaid had 45.8 ED visits per 100 enrollees compared with 24.0 visits per 100 nonelderly privately insured people, according to the most recent data available from the National Hospital Ambulatory Medical Care Survey (NHAMCS) (see Table 1 and Data Source). Across children and working-age adults with Medicaid, all age groups mirror a pattern of higher rates of ED use than the privately insured, including children aged 0-12, teens and young adults aged 13-20 and adults aged 21-64.5 However, this study’s findings indicate that Medicaid patients’ higher rates of ED visits are not disproportionately for minor health concerns when compared to privately insured patients.