320 Emergency Department Utilization By Patients With Medicaid: Before and After the Affordable Care Act

Abstract

To investigate the trends in emergency department (ED) utilization among Medicaid patients after the implementation of the Affordable Care Act (ACA). This cross-sectional study identified all respondents within the IPUMS Health Surveys database who had at least one emergency department visit within the past year and provided at least one reason for their visit over a six-year period (2011-2017). To best demonstrate the impact of the ACA, results from 2011 and 2017 will be compared. The database is a publicly available, national data set based on over 50 years of the National Health Interview Survey (NHIS), which is a cross-sectional telephone-based survey. Participants provided the reasons for their most recent ED visits, which were separated into acute and nonacute categories, based on the authors’ clinical experience. Acute reasons include because the patient was sent by their doctor, because only the hospital could help, because it was too serious to go to another provider, and because they were brought by an ambulance. Nonacute reasons for coming to the ED were because their doctor’s office was closed, because the ED was the closest provider, because the ED is their usual place of care, and because they had no other place to go. Participants could select more than one option for their visit. Insurance status was self-reported. Bivariate statistics were done to describe the overall demographic characteristics of the patients and to assess significant associations between insurance status and reasons for ED utilization. A p-value of less than 0.05 determined significance. We identified 6753 patients in 2011 and 6750 patients in 2017 who fit inclusion criteria. The percentage of patients with Medicaid insurance did not change significantly, increasing from 24.6% (n=1661) in 2011 to 26.0% (n=1758) in 2017 (p=0.06). The percentage of uninsured patients almost halved, from 15.2% (n=1002) in 2011 to 8.3% (n=538) in 2017 (p<0.0001). At both timepoints Medicaid patients shared the most common reasons for ED visits with the overall insured population. In 2011, the most common reasons given were the doctor’s office was closed (62.2%, n=1033), only the hospital could help (49.3%, n=819), and they had no other place to go (48.7%, n=808). In 2017, a higher percentage of Medicaid patients reported ED utilization for each acute reason, and lower percentages were recorded for each nonacute reason. The largest change was an increase of 16.1% (95% CI 12.8%, 19.5%, p<0.0001) of patients who reported their complaint was too serious to go to another provider. The percentage of Medicaid patients who used the ED without an acute reason decreased from 35.8% (n=595) in 2011 to 26.1% (n=458) in 2017, a smaller decrease than the one seen in uninsured patients (12.6%, 95% CI 7.6%, 17.6%, p=0.0028) or the insured patients (11.7%, 95% CI 10.1%, 13.3%, p<0.0001). In 2017, 10.0% (n=176) of patients reported the ED as their usual place of care, and 40.7% (n=715) said they had nowhere else to go. Patients with Medicaid had similar ED usage patterns as the general population both before and after the implementation of the ACA. Though patients with Medicaid have trended towards using the ED for more acute reasons, these gains are smaller than both the insured and uninsured populations, indicating a possible lack of health care access among those with Medicaid.