Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care?
Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine.
The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors' offices.
All eyes have been on Oregon to answer this question about ER use because, eight years ago, the state tried an experiment. It wanted to expand Medicaid, but it didn't have the money to cover every eligible resident.
So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like Bill Wright, director of the Providence Center for Outcomes Research and Education.
"You couldn't do this as a researcher," Wright says. You couldn't design a study that randomly gave some people insurance, but not others. It wouldn't be ethical to leave some people without coverage just to have a control group.
"As a researcher," Wright says, "you don't want to put someone in that position, just to study it."
But, since Oregon was already conducting the insurance lottery, that offered an invaluable chance to study the differences between people who have Medicaid insurance and similar people who don't.
It was the first randomized study on the impacts of health insurance, and it's one of the largest, surveying about 25,000 people.
The study's first findings, published a few years ago, showed that Medicaid was beneficial in many ways. It improved people's financial security. They went to the doctor when they were sick. And having the insurance correlated with a drop in rates of depression.
"These are all things that are really important benefits of Medicaid expansion," says Wright.
But the study also found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.
"That was a surprise to a lot of folks," says Wright.
It was widely believed that having insurance would encourage people to get routine medical care in doctors' offices or clinics, instead of waiting until they have more serious symptoms and have to head to the ER, where care is most expensive.
After those early findings were published, health care analysts scrambled to explain why the number of ER visits didn't decline. Some thought it was a reflection of pent-up demand from people who hadn't seen a doctor in years because they didn't have insurance.
Others thought some of these newly insured patients simply hadn't yet had time in that first 15 months to establish a relationship with a primary care doctor. As more time passed, that theory suggested, and more patients had primary care providers, their reliance on emergency rooms would drop.
But Wright, one of the study's authors, says he and his colleagues have now studied two years of data — and that's not what they're finding.
"There was no sign that this [ER] use went down," he says. "So this idea of pent-up demand sort of fading away — at least in the first couple of years, it didn't happen."
Quite the opposite.
"If your hope is that, in the short term — the first couple of years — you're going to see savings that come out of reduced [ER] use from Medicaid expansion alone, I don't think I'd be super optimistic about that," Wright says. "I think that it is going to cost money in the short term."
However, there may be savings in other areas, he says, like an increased use of preventive services that could stave off problems that would become more expensive later.
And, Leslie Clement, with the Oregon Health Authority, says over the past two years, Oregon has seen avoidable use of emergency rooms drop by 4 percent.
That's because the state is now coordinating care better, she says, by doing things like helping people get to their doctors' appointments and take their medication.
"It is not just a 'open up coverage and let people used health care services as they have done historically,' " she says. "It's reforming that system."
The researchers won't be able to tease much more information out of what's come to be known as the Oregon Health Insurance Experiment — the experiment had to stop once the state expanded Medicaid fully under the Affordable Care Act.
This story is part of NPR's reporting partnership with Oregon Public Broadcasting and Kaiser Health News.
ROBERT SIEGEL, HOST:
As Medicaid has expanded across the U.S., supporters hope that it would encourage people to stop using expensive emergency rooms for non-urgent care and go to primary care doctors instead. But the latest findings from a landmark study suggest that has not happened.
The study in The New England Journal of Medicine looked at Medicaid recipients in Oregon. It found their ER use stayed high two years after they gained health insurance coverage. Kristian Foden-Vencil of Oregon Public Broadcasting explains.
KRISTIAN FODEN-VENCIL, BYLINE: Eight years ago, Oregon tried an experiment, a Medicaid lottery. It didn't have the money to cover every eligible resident, so it covered as many as it could by picking them randomly.
BILL WRIGHT: Yeah, you couldn't do this as a researcher. You couldn't design a study that randomly gave some people insurance and some people wouldn't.
FODEN-VENCIL: It wouldn't be ethical. But Bill Wright with the Providence Center for Outcomes Research says it offered an invaluable chance to study the difference between people who have Medicaid and people who don't. The first findings were that Medicaid improved people's financial security, and it reduced rates of depression.
WRIGHT: These are all things that are really important benefits of Medicaid expansion.
FODEN-VENCIL: But another study found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.
WRIGHT: That was a surprise to a lot of folks.
FODEN-VENCIL: Some thought it was pent-up demand from a group that hadn't seen a doctor in years. Others thought people just hadn't had time to establish a relationship with a doctor and that when they did, emergency department use would drop. But now after looking at two years of data, that's not what the most recent studies found.
WRIGHT: There was no sign that this increase in ED use went down, so this idea of pent-up demand sort of fading away at least in the first couple of years - it didn't happen.
FODEN-VENCIL: Quite the opposite. The study found ER use stayed high even as more patients visited the doctor, says Wright.
WRIGHT: If your hope is that in the short term, the first couple of years, you're going to see savings that come out of reduced ED use from Medicaid expansion alone, I don't think I would be super optimistic about that. I think that it is going to cost money in the short term.
FODEN-VENCIL: But Leslie Clement with the Oregon Health Authority says over the last two years, Oregon's seen avoidable ER use drop by 4 percent. She says that's because the state is helping people do things like go to their doctors appointments and take their medications.
LESLIE CLEMENT: It is not just a - open up coverage and let people use health care services as they've safe done historically, but it's reforming that system.
FODEN-VENCIL: The Oregon study can't tease out much more information because the experiment had to stop when the state expanded Medicaid fully under the Affordable Care Act. For NPR News, I'm Kristian Foden-Vencil in Portland.
SIEGEL: And that story is part of a reporting partnership with Kaiser Health News and Oregon Public Broadcasting. Transcript provided by NPR, Copyright NPR.