Medicaid expansion's impact on ER visits has complex causes

Friday, January 24, 2014 | 6:00 a.m. CST; updated 5:29 p.m. CST, Thursday, February 20, 2014
Hospital visitors leave University Hospital in Columbia on Wednesday. A study released earlier this month says Medicaid expansion in Oregon is responsible for a 40 percent increase in emergency room visits.

COLUMBIA — Carolyn Colburn, 38, was on Medicaid when she was pregnant with her son but was dropped soon after he was born 14 years ago. She later had insurance through her employer but went on Medicaid again after losing her job because of an accident at work.

Even when she had Medicaid, Colburn had trouble finding doctors who were accepting Medicaid patients, she said. Nor could she find any urgent care clinics that accepted Medicaid. In any case, urgent care centers often close before she leaves work.

Medicaid expansion not dead yet in Missouri

Medicaid expansion in Missouri is a major issue in the current legislative session. The Affordable Care Act expanded eligibility for Medicaid to adults between ages 18 and 65 and who make up to 133 percent of the federal poverty level. The expansion was voluntary for states, however, and Missouri opted out.

"The most significant improvement we could make to the health and well-being of our state is Medicaid," said Gov. Jay Nixon in Tuesday night's State of the State address. He has described Medicaid expansion as a top priority.

Expanded Medicaid eligibility would improve immediate access to health care for nearly 260,000 Missourians and that number would later increase to more than 300,000, according to a 2013 study funded by the Missouri Foundation for Health.

Republican legislators have said they would not support Medicaid expansion until the current system is reformed. Rep. Caleb Rowden, R-Columbia, said early in the session that he was open to expansion if it is part of a larger reform package.

Members of the Columbia delegation, including Reps. Chris Kelly and Stephen Webber, have co-sponsored a bill to expand eligibility for Medicaid in Missouri, referred to as MO HealthNet, in accordance with the federal expansion. Under the Affordable Care Act, state expansion would be supported with money from the federal government.

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“When you’re working the regular Monday to Friday thing, and you have the flu really bad and you can’t go in, instead you have to go to the emergency room,” she said.

So she found herself going there a lot.

“You have to work,” she said.

Colburn is one of almost 800,000 Missouri residents without health insurance, according to the U.S. Department of Health and Human Services. She's in what has been called the "coverage gap" by the Kaiser Family Foundation. One component of the Affordable Care Act allows individuals to purchase private insurance though exchanges, while those whose income is below a certain point would receive Medicaid. The federal government would pay 100 percent of Medicaid expansion, with that amount dropping to 90 percent by 2020. After 2020, the states would pay the remaining 10 percent.

People are eligible for Medicaid if their household income is below the federal poverty rate as calculated by the U.S. Census Bureau. The poverty threshold for 2013 was an income of $23,550 a year for a household of four. Under the Affordable Care Act's Medicaid expansion, households of four with an income up to $32,499 a year — or 138 percent of the poverty threshold — would be eligible.

However, several states sued the federal government over the new law. In 2012, the U.S. Supreme Court allowed most of the law to stand, but ruled that forcing states to expand Medicaid was unconstitutional. That ruling allowed states to opt out of Medicaid expansion.

Missouri opted out. Today, Colburn cannot afford a private policy, and because Missouri is not expanding Medicaid, she can't easily get on the program.

“To get on Medicaid in Missouri, you need to be pregnant or dying,” she said with a chuckle and shake of the head.

According to a 2011 Missouri Foundation for Health document, different groups had different eligibility requirements for Medicaid, also referred to as MO HealthNet. In 2011, pregnant women were eligible for benefits if they made less than 185 percent of the federal poverty level, or $41, 348 a year for a family of four.

The lowest eligibility threshold in the document is for parents and is calculated based on the 1996 Aid to Families and Dependent Children standard, not the federal poverty level. In 2011, it worked out to about 18 percent of the federal poverty level, or an annual income of around $4,000 for a family of four.

In 2011 MO HealthNet in Missouri, the state’s Medicaid program, provided medical coverage to more than 900,000 low-income Missouri residents. Eligibility for Medicaid is calculated differently for families, children and individuals with disabilities based on their annual income and family size. Missourians falling within the colored areas of the chart were eligible for coverage in 2011. Graphic by Elizabeth Scheltens

Keep job or take care of health

Dave Dillon, vice president of media relations at the Missouri Hospital Association, which supported the expansion of Medicaid in Missouri, said ER overuse is a complicated problem with numerous causes. The Oregon study, which found that a Medicaid test group visited the emergency room more than the uninsured, does not take those causes into account.

“In many cases, what isn’t factored in is socioeconomic status,” he said. "We have to figure out what the drivers are here.

“We agree that the Oregon study is the gold standard for reporting the differences in how the uninsured use the emergency department versus how those on Medicaid use it,” he said. “But we believe it’s too early to state anything for sure.”

The association is conducting its own research to understand and improve how Missouri residents use the state’s emergency departments, Dillon said.

Dillon believes that in many cases, people don't get primary care because they can't afford co-pays and don't have transportation or sick time. In many cases, Medicaid recipients are faced not only with the cost of seeing a doctor and filling prescriptions but losing income because most work low-paying jobs with fewer benefits, such as paid sick time.

According to a U.S. Bureau of Labor Statistics report, 39 percent of American workers in private sector jobs do not have paid sick time, and 75 percent of workers who make $10.50 per hour or less do not have paid sick time. Unlike every other industrialized nation in the world, the U.S. does not have a federal law requiring employers to offer paid sick days, nor does federal law protect workers from being fired for illness related absences, according to a report published by the Center for Economic Policy Research.

Andy Quint, medical director at Family Health Center in Columbia — which provides medical, dental and mental health services with an emphasis on underserved populations — said that taking time off for health care during working hours is a major problem for some of his patients.  

“Primary care is not open 24 hours a day,” he said.

“I’ve had people tell me that they have to wait until they get off from work to go in to be seen,” he said. "Our last appointment is at 4:30, so if it’s after that, they’re going to the ER.”    

“For a lot of people, the emergency department is the most available place to get care,” Dillon said.


When Colburn moved to St. Louis after living in the Columbia area to take care of her mother, she had to call more than 160 doctors before finding one who was still accepting Medicaid patients. When she finally found one, she waited five months for her first visit.

Quint is familiar with this problem.

“Just because you get Medicaid doesn’t mean you have primary care,” he said.

He pointed to Massachusetts, where, under former Gov. Mitt Romney, the state passed a law very similar to the Affordable Care Act. When insurance coverage was greatly expanded, people often waited months to see a primary care physician, he said.

“There aren’t enough doctors out there for the number of people who, if they had insurance, would need a primary care doctor,” Quint said.

Of 114 counties and the independent city of St. Louis, only five counties statewide are not considered a health professional shortage area, according to statistics published by the U.S. Department of Health and Human Services. Boone County is considered a health professional shortage area in primary, dental and psychiatric care for low-income people.

As health insurance access is increased, there will be a shortage of about 45,000 primary care doctors in 2020, the American Association of Medical Colleges estimates.

Colburn has yet to find an urgent care clinic that accepts Medicaid, she said. "I had a really bad toothache, I was not feeling well at all," she said. "I went up there (to the urgent care) and asked if they would let me make payments, something like that, and they said no. They turned me away."

"So, at that time, the ER is the only way to go," she said.

Educating patients

After Massachusetts passed health insurance reform, researchers in the state noticed an increase in emergency room visits, according to a study published in the Annals of Emergency Medicine in 2011. Eventually, however, the numbers of emergency room visits attributed to non-emergency issues began to decrease, according to the study.

Quint said he thinks that's a result of educating patients about when an ER visit is truly warranted, building of relationships between primary care physicians and patients, and better long-term management of chronic issues.

"That doesn't happen right away," he said. "That takes time, that takes building a relationship with their primary care provider."

"Educating people about what can be provided by their primary care physicians, what we can do for them, what we can't do for them" is important, Quint said.

While many people have chronic issues like asthma and heart disease, proper preventive care can help reduce the number of trips to the emergency room for flare-ups of these illnesses, he said.

Dillon of the hospital association believes educating patients about how to navigate and use the health care system is also important.

"There are many tools to use the system properly," he said, "and we need to empower people to use them."

"Patients must be taught to follow though with care, and given a means by which to do so," he said. "When patients visit the ER, they are usually given a set of instructions on what to do, to see a primary care physician and what prescriptions to get. ... We need to find ways to make sure those instructions are followed."

Colburn said when she was accepted into the Medicaid program, there was no training about how to navigate the system.

"They mail you a packet in the mail with information," she said. "But it's not like anyone sits down with you to help you find a primary care doctor and tell you what sorts of things they can do for you."

She said emergency room staff has referred her to primary care physicians in the past, but so far, no one has been able to help her find one.

Looking forward

Data collected by the Centers for Disease Control and Prevention in 2010 indicate that overall, Medicaid patients' emergency room visits are very similar to their privately insured counterparts.

Medicaid patients use the nation's emergency rooms for non-urgent and semi-urgent care more often than the privately insured. The percentage for Medicaid patients visiting the emergency room for non-urgent care is 8 percent, according to the CDC; for the privately insured, that rate is 5.3 percent. The percentage of Medicaid patients visiting the emergency room for semi-urgent care is 35.1 percent, compared to 31.4 percent for the privately insured. The privately insured lead Medicaid patients by a slim margin in ER visits for cases considered immediate, emergent and urgent, according to the data.

According to CDC statistics, the most common reasons for all emergency room visits for patients between 15 and 64 years old is stomach and abdominal pain for women and chest pain and related symptoms for men.

When patients are admitted to the emergency room, the severity of their condition determines how quickly they are seen by the doctor. In 2010, 8 percent of emergency room visits from individuals with Medicaid or the Children’s Health Insurance Program (CHIP) were deemed “nonurgent,” compared to about 5 percent of visits from individuals with private insurance. However, the Centers for Disease Control stipulates that the figures have a 0.9 and 0.6 standard error of percent, respectively. Graphic by Elizabeth Scheltens

"To say that expanding Medicaid led to more ER usage, that's a very simplistic thing to say," Quint said.  "Of course you give people money to cover their cost of going to the emergency room, and yeah, they're going to go to the emergency room.

"That's a no-brainer," he said.

"When it's 3 a.m. on a Sunday, and your child is having an asthma attack, going to the ER is the rational thing to do," Dillon added.

Colburn is left wondering what the future holds. Missouri legislators decided not to expand Medicaid under the Affordable Care Act, even though the federal government would pay all costs until 2020, when they would cover 90 percent. Researchers at MU said in a study that Medicaid expansion would have brought $9.6 billion to the state's economy between 2014 and 2020. 

Colburn is still several months away from the end of her probationary period at the grocery store where she works part time. Once she makes it past her probation, she can join the union and find out if she qualifies for the company's health insurance plan.

But she's not sure it will happen. “They schedule you for just enough hours per week to keep you from qualifying,” she said. “I think after 180 days I can join the union, and maybe I can get it then.”

For now, she mostly goes without health care but still relies on the emergency room when she's very ill, she said. Between ambulance rides and emergency room visits, she has defaulted on her hospital debts and has credit problems.

According to a recent report issued by the Missouri Hospital Association, she’s not alone. Missouri hospitals lost $1.17 billion on uncompensated care in 2012 — the last year for which complete data are available. Of that amount, $493 million is bad debt that patients were responsible for but did not pay. Hospitals wrote off the other $680 million as “charity care,” according to the report.

She's still not planning to apply for Medicaid again.

“I don’t know if I want to be on that," she said. "There are so many others who need it more than I do."

Supervising editor is Katherine Reed.

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Michael Williams January 24, 2014 | 10:51 a.m.

"...said ER overuse is a complicated problem with numerous causes."

But, you said nothing about "complicated" and "numerous" before now. Instead, you said it was supposed to FIX the problem. That's how you sold it!

"Laws of Unintended Consequences" strikes again.


Laws of lies.

Admit it.....liberals didn't (and don't) have the foggiest idea how to translate ivory-tower fixes into practical solutions. Not the foggiest. Utterly incompetent.

PS: Of course, many of us saw this train wreck well down the track. Long ago, we saw doctors slowing their acceptance of medicaid/medicare patients. Long ago, we saw that folks would not pay (or be unable to pay) premiums or co-pays. Long ago, we saw not enough primary care physicians. Long ago, we saw the ACA and medicaid expansion would not change the habits/necessities of visits to the ER. Long ago, we knew expanded medicaid was NOT free from the federal gov't....taxpayers all over the US pay for it. The "hope" barrel is empty.

(Report Comment)
Ellis Smith January 24, 2014 | 11:32 a.m.

Of course ER usage is a complex situation, because emergencies themselves are complex issues. On any given day does the emergency facility and its staff KNOW what will show up at their facility? Certain assumptions can be made based on a history of ER usage, but that won't guarantee what will occur on any given day.

It's not difficult draw a parallel between an ER and a municipal fire department. How often does the fire department know in advance where the next fire will occur, but the fire department is there for when the next fire DOES occur.

As for liberals, I'm reminded of my late wife's oft-made comment that if liberals had brains they would probably take them out of their heads and play with them.

(Report Comment)
Michael Williams January 24, 2014 | 1:02 p.m.

Ellis: True, but you used "usage" and the article used "overuse".

The ACA promised to rid us of ER "overuse", not "use".

PS: You'll next be asked to pay premiums and deductibles. I'm also expecting taxpayer-supported open-all-night clinics. In short, you'll be asked to solve/pay for ALL the not-new-but-never-acknowledged problems in this article.

(Report Comment)
Michael Williams January 24, 2014 | 2:21 p.m.

First I've heard of this:

Anyone know anything about this? The gov't can recover Medicaid expenses from your estate? How would this affect Missourians?

(Report Comment)

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