Critics have pointed to this week’s study of emergency department use in the Oregon Medicaid program as the latest evidence of the ultimate – if not imminent – failure of health reform. In this examination of Oregonians who won the state’s 2008 health insurance lottery, and were thus able to enroll in Medicaid coverage, researchers from the National Bureau of Economic Research determined that newly-insured individuals used emergency departments 40 percent more often than similar, but uninsured, state residents. This conclusion, Obamacare critics allege, undermines a key argument for health reform, particularly for states that have not yet implemented expanded coverage under Medicaid – namely, that improving health coverage will reduce emergency department visits and, in turn, save money.
But not so fast. Leaving aside the absurdity of needing to participate in a lottery to get health coverage – a dehumanizing process that health reform will hopefully banish forever – the Oregon experience represents only one look at emergency department use after a Medicaid eligibility expansion. And this study only looks at the first 18 months after the lottery, which translates to an average of 13 months of coverage. In Massachusetts, which implemented health reform in 2006, emergency department use first grew (or continued to grow consistent with previous trends, depending on which study you look at) and then declined between 5 to 8 percent – with a significant drop in ED visits for problems that could be treated in a doctor’s office. Researchers attribute this decline to the reform’s expansion of coverage.
At the very least, the Oregon analysis isn’t the only take on what happens to emergency department visits when previously uninsured people have health insurance. But perhaps this paper doesn’t tell the whole story because it doesn’t track enrollees long enough. People who have gone without health insurance may have become accustomed to using the emergency room – the one place that can’t turn them away – for their health care problems. Once they have health insurance, they still need to find a regular doctor and figure out how to use their coverage. In the meantime, they may still turn to the emergency department. And it takes time to create new habits – months later, I am still working with my first-grader to wash her hands before her after-dinner piano practice.
The Oregon Medicaid lottery provided an unprecedented research opportunity to examine what happens to low-income people with new health insurance and to compare them to those who remain without health coverage. But it isn’t the last word on how the Affordable Care Act will work, whether for women and their families who are now newly eligible for coverage, or for the insurance programs that provide that coverage.