More ER visits result from complex factors, says UB medical policy expert

BUFFALO, N.Y. – Reports that people newly insured through Medicaid in Oregon made more emergency room visits than the uninsured may reflect regional issues, says Nancy Nielsen, MD, senior associate dean for health policy at the University at Buffalo School of Medicine and Biomedical Sciences and past president of the American Medical Association.

While the recent studies based in Oregon found that the newly insured made more emergency room visits than those without insurance, Nielsen says that Massachusetts did not see a rise in emergency room use after instituting its statewide health insurance mandate.

“It remains to be seen where increases in services will occur, and it may be different in different regions,” says Nielsen. “The issue is more complex than obtaining insurance for the first time, although we know that alone results in people seeking medical services. For example, if there is ready access to primary care, those will be the services that are sought by the newly insured who aren't acutely ill.

“If there is a shortage of available primary care or specific specialty areas in a region, then indeed the emergency department of hospitals may initially show an influx of patients. Hopefully those folks can then be linked with more appropriate settings for follow-up care.”

Nielsen has served as senior advisor at the Center for Medicare and Medicaid Innovation (CMMI) in the Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services.

She notes that it is instructive to look at the behavior of uninsured people who are aging into Medicare; for example, a retired 63-year-old.

“It’s well known that these people will typically delay seeking health services until Medicare coverage begins, and then there is an increase in services received for the first year afterward,” she says. “After that, the demand for health services returns to a more normal level. That would predict a similar initial uptick in demand from those newly insured under Obamacare, with a return to more typical levels fairly soon afterward.”

She adds that several other factors should be taken into account when assessing the Affordable Care Act.

“Prior to the implementation of Obamacare, acutely ill people without insurance got hospital care that all the rest of us paid for,” Nielsen says. “Now there will be a third-party payer, which takes the burden from hospitals for uncompensated care and from everyone else who paid higher premiums to cover care rendered to the uninsured.”

She adds that for those who obtain private insurance through state or federal exchanges, there are hefty co-pays, especially for emergency rooms, for the plans that have lower monthly premiums.

“Those hefty co-pays will cause people to pause before going to a higher cost site like a hospital emergency room unless it's really necessary,” Nielsen says.

She adds that it also isn’t yet known as to what proportion of the newly insured have chronic conditions.

“Once that becomes clear in about six months (since insurance has to be obtained by March to avoid the tax penalty), we can better evaluate the pressure points in a region's health care service network,” she says.

“But the real news is what has been shown over and over again: lacking health insurance is hazardous to your health, so the 2.1 million newly insured Americans are in a much better place now, despite problems that will surely arise, than they were before Jan. 1.”