Medicaid increases emergency-department use: evidence from Oregon's Health Insurance Experiment.
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ABSTRACT:
SUBMITTER: Taubman SL
PROVIDER: S-EPMC3955206 | biostudies-literature | 2014 Jan
REPOSITORIES: biostudies-literature
Publications
Medicaid increases emergency-department use: evidence from Oregon's Health Insurance Experiment.
Taubman Sarah L SL Allen Heidi L HL Wright Bill J BJ Baicker Katherine K Finkelstein Amy N AN
Science (New York, N.Y.) 20140102 6168
In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage by using a randomized controlled design. By using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we studied the emergency department use of about 25,000 lottery participants over about 18 months after the lottery ...[more]
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Project description:PurposeThere is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment").MethodsWe probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging.ResultsThe intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals.ConclusionsOur results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.
| S-EPMC4508170 | biostudies-literature
Project description:IntroductionIt is predicted that gaining health insurance via the Affordable Care Act will result in increased rates of preventive health services receipt in the U.S., primarily based on self-reported findings from previous health insurance expansion studies. This study examined the long-term (36-month) impact of Oregon's 2008 randomized Medicaid expansion ("Oregon Experiment") on receipt of 12 preventive care services in community health centers using electronic health record data.MethodsDemographic data from adult (aged 19-64 years) Oregon Experiment participants were probabilistically matched to electronic health record data from 49 Oregon community health centers within the OCHIN community health information network (N=10,643). Intent-to-treat analyses compared receipt of preventive services over a 36-month (2008-2011) period among those randomly assigned to apply for Medicaid versus not assigned, and instrumental variable analyses estimated the effect of actually gaining Medicaid coverage on preventive services receipt (data collected in 2012-2014; analysis performed in 2014-2015).ResultsIntent-to-treat analyses revealed statistically significant differences between patients randomly assigned to apply for Medicaid (versus not assigned) for 8 of 12 assessed preventive services. In intent-to-treat analyses, Medicaid coverage significantly increased the odds of receipt of most preventive services (ORs ranging from 1.04 [95% CI=1.02, 1.06] for smoking assessment to 1.27 [95% CI=1.02, 1.57] for mammography).ConclusionsRates of preventive services receipt will likely increase as community health center patients gain insurance through Affordable Care Act expansions. Continued effort is needed to increase health insurance coverage in an effort to decrease health disparities in vulnerable populations.
| S-EPMC4718854 | biostudies-literature
Project description:In 2008, a group of uninsured low-income adults in Oregon was selected by lottery for the chance to apply for Medicaid. Using this randomized design and state administrative data on voter behavior, we analyze how a Medicaid expansion affected voter turnout and registration. We find that Medicaid increased voter turnout in the November 2008 Presidential election by about 7 percent overall, with the effects concentrated in men (18 percent increase) and in residents of Democratic counties (10 percent increase); there is suggestive evidence that the increase in voting reflected new voter registrations, rather than increased turnout among pre-existing registrants. There is no evidence of an increase in voter turnout in subsequent elections, up to and including the November 2010 midterm election.
| S-EPMC8021132 | biostudies-literature
Project description:BackgroundThe rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown.ObjectiveWe evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED.Design, patientsThis was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n = 4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues).Main measuresWe analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics.Key resultsOverall, 65.0% (95% CI 63.0-66.9) of adults reported ≥ 1 acuity issue and 78.9% (95% CI 77.3-80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2% reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95% CI 0.79-1.40) and those with Medicare (OR 0.98; 95% CI 0.66-1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95% CI 1.06-2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95% CI 1.18-3.19) were more likely than those with private insurance to seek ED care for access issues.ConclusionVariability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.
| S-EPMC3965734 | biostudies-literature
Project description:Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.
| S-EPMC5682123 | biostudies-other
Project description:ObjectiveTo evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low-income populations.Data sourcesPrimary and secondary data on health care use and outcomes for participants in Oregon's 2008 Medicaid lottery.Study designWe used the lottery's random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care.Data collectionData were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in-person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646).Principal findingsMedicaid coverage significantly reduced the share of respondents who reported needing dental care (-9.8 percentage points, p < .001) or having unmet dental care needs (-13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti-infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out-of-pocket spending.ConclusionsExpansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services.
| S-EPMC6052006 | biostudies-literature
Project description:We develop a set of frameworks for welfare analysis of Medicaid and apply them to the Oregon Health Insurance Experiment, a Medicaid expansion for low-income, uninsured adults that occurred via random assignment. Across different approaches, we estimate recipient willingness to pay for Medicaid between $0.5 and $1.2 per dollar of the resource cost of providing Medicaid; estimates of the expected transfer Medicaid provides to recipients are relatively stable across approaches, but estimates of its additional value from risk protection are more variable. We also estimate that the resource cost of providing Medicaid to an additional recipient is only 40% of Medicaid's total cost; 60% of Medicaid spending is a transfer to providers of uncompensated care for the low-income uninsured.
| S-EPMC8081392 | biostudies-literature
Project description:The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010-June 2012) and after (January 2013-June 2015) the initiation of Oregon's Coordinated Care Organization (CCO) model (July 2012-December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014). Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25,454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.
| S-EPMC6205746 | biostudies-literature
Project description:BackgroundEmergency departments (EDs) nationwide are key entry points into the health care system, and their use may reflect changes in access and need in their communities. However, no studies to date have empirically and longitudinally studied how changes in a community's level of insurance coverage, a key determinant of access, affect ED utilization.ObjectiveTo determine the effects of changes in a community's rate of insurance coverage on its population's ED use.MethodsWe conducted a longitudinal analysis of all California counties between 2005 and 2010 using comprehensive ED visit data from the California Office of Statewide Health Planning and Development. Using Poisson regression with county and year fixed effects, we determined how changes in the rate of insurance coverage within a given county affect ED visits per 1000 residents.ResultsWe found that changes in the rate of insurance coverage within a county had a slight but significant inverse relationship with ED visits per 1000 residents for both adults and children. For example, if a county's rate of insurance coverage among adults jumped from the 10th (73.22%) to the 90th percentile (84.93%), an estimated 2 fewer ED visits would occur per 1000 adult residents.ConclusionsAs the rate of insurance coverage increased within California counties, overall ED utilization declined only slightly. Thus, expanding insurance coverage may not lead to significant decreases in overall ED use.
| S-EPMC4117395 | biostudies-literature
Project description:In the United States, health insurance is not universal. Observational studies show an association between uninsured parents and children. This association persisted even after expansions in child-only public health insurance. Oregon's randomized Medicaid expansion for adults, known as the Oregon Experiment, created a rare opportunity to assess causality between parent and child coverage.To estimate the effect on a child's health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage.Oregon Experiment randomized natural experiment assessing the results of Oregon's 2008 Medicaid expansion. We used generalized estimating equation models to examine the longitudinal effect of a parent randomly selected to apply for Medicaid on their child's Medicaid or Children's Health Insurance Program (CHIP) coverage (intent-to-treat analyses). We used per-protocol analyses to understand the impact on children's coverage when a parent was randomly selected to apply for and obtained Medicaid. Participants included 14409 children aged 2 to 18 years whose parents participated in the Oregon Experiment.For intent-to-treat analyses, the date a parent was selected to apply for Medicaid was considered the date the child was exposed to the intervention. In per-protocol analyses, exposure was defined as whether a selected parent obtained Medicaid.Children's Medicaid or CHIP coverage, assessed monthly and in 6-month intervals relative to their parent's selection date.In the immediate period after selection, children whose parents were selected to apply significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a nonsignificant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent's selection compared with children whose parents were not selected (adjusted odds ratio [AOR]=1.18; 95% CI, 1.10-1.27). The effect remained significant during months 7 to 12 (AOR=1.11; 95% CI, 1.03-1.19); months 13 to 18 showed a positive but not significant effect (AOR=1.07; 95% CI, 0.99-1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage (AOR=2.37; 95% CI, 2.14-2.64).Children's odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents' access to Medicaid coverage and their children's coverage.
| S-EPMC4918752 | biostudies-other