No Place to Call Home — Policies to Reduce ED Use in Medicaid

One goal of Medicaid expansion under the Affordable Care Act (ACA) is to provide low-income, medically vulnerable adults with a source of care outside the emergency department (ED) and the means to pay for that care. Yet Medicaid expansion alone may not reduce ED use among new enrollees. Although some research suggests that Medicaid coverage is associated with reduced ED use, a lottery-based, controlled study from Oregon found that newly enrolled beneficiaries actually increased their ED use, at least temporarily. This finding is not surprising, since health insurance reduces financial barriers to being seen promptly, and the newly enrolled Medicaid population has pent-up demand for care and a high burden of chronic disease. Although the contribution of ED use to cost growth is sometimes exaggerated, it remains a substantial source of health care costs, representing at least 5 to 6% of U.S. health expenditures.2 Medicaid alone spends $23 billion to $47 billion annually on ED care, and some of the sickest Medicaid enrollees are seen in the ED.

Broadly speaking, two approaches have been proposed for reducing use of the ED in this population. One focuses on making the ED more costly for patients to use; the other, on creating more robust alternatives to the ED. Although not incompatible, these approaches reflect different beliefs about why Medicaid beneficiaries use the ED for medical issues that could potentially be addressed elsewhere.

At the core of this alternative approach to reducing ED visits are key components of the patient-centered medical home model, including care coordination, case management, extended hours, and walk-in visits. Medical-home initiatives emphasize prevention and post-acute care, and preliminary studies have shown these models to be effective in reducing ED use among Medicaid beneficiaries.