Obamacare and ER Visits: Another GOP Talking Point Falls Apart

For five years now, President Obama has been in office. And for five years, Republicans have had two objectives: sabotage the economy, and fight health care reform at all costs. Over last month, we've had news that the economy is really starting to pick up steam, and millions of Americans decided to ruin the GOP's Christmas by signing up for Obamacare. On top of that, total health care spending as a percentage of GDP actually went down last year for the first time in, like, forever.

But you can always count on naysayers to naysay. Last week, a study was released showing that new enrollees in the expanded Medicaid program under the Affordable Care Act increased their emergency room visits by 40%. Conservatives latched onto the study as proof that expanding coverage to the poor would raise health care costs instead of lower them, and as their next shiny object they hope will undermine Obamacare and help them attack the president for yet another imagined broken promise.

As usual, the Republicans' house of cards is collapsing. First of all, the study was conducted on 25,000 low-income Oregonians who won coverage through a lottery system, not on the overall population of those who gain coverage now that the program is open to anyone who is low-income. It was conducted over 18 months, and participants were observed for an average of only a year, a time period too short not only to observe long term behavioral changes but to have set up normal treatment regimens after diagnosis. The Obama administration pointed to a longer term study in Massachusetts, showing a decline in emergency room visits.

The narrow scope of the study does not allow it to account for a key truth in health care: Having health insurance long term does allow individuals to seek regular care and therefore reduce the need for ER visits, but the biggest reason expansion of coverage reduces overall expenses is better health and timely treatment. Even in the ER, people who have insurance can easily schedule a follow-up visit with their physicians if needed. For those without, their only option for a "follow-up" is to come back to the emergency room - which they do as sporadically as possible considering the medical bills that they know are sure to follow. The visits drop over time, as the insured begin to rely on the primary care system.

Yeah? How do I know this is the case? After all, I could be just running off my mouth and being my usual happy clappy Obamabot. Do I have data bearing out anything I claim above?

Funny you should ask. Why, yes I do. In 2010, certain counties in California instituted a similar program to what Oregon did, except not through a lottery. UCLA's Center for Health and Policy Research studied the local program in Los Angeles county and obtained longer term data than the study on Oregon's system. Here is what they found:
Researcher Dylan Roby says preliminary results show that in the California program’s first year, emergency room use spiked much the way it did in Oregon. But in the second and third years, "we’ve seen a reduction that’s quite substantial."

Roby says one explanation for the initial jump in ER use is pent-up demand: Once insured, these patients rushed to emergency rooms to take care of ailments they had put off treating because they didn’t have insurance.
And what is accounting for the drop in subsequent years? It isn't that people do not need care after the first year. It is just that by that time, they discover that the primary care system is a lot more efficient in delivering the care that they need.
Roby says ER visits diminished in the second and third years of the program because counties took on an important task: "They were redirecting them from the ER into primary care."
Even in Oregon, while the time period to study long term drop in ER visits weren't enough, the health and financial benefits of expanded coverage was undeniable. In the same report that outlines increased ER use, the National Bureau of Economic Research observes the following outcomes of the Oregon experiment:

  • Medicaid decreased the possibility of having unpaid medical bills by 25%.
  • Medicaid coverage increased the likelihood of being in good or excellent health by 25%.
  • Medicaid decreased the rate of depression by 30%.
  • Medicaid coverage virtually eliminated out-of-pocket catastrophic medical bills, and reduced the possibility that one will skip paying other bills in order to afford medical expenses by an astounding 50%.
In the final analysis, expanded coverage in general and the vast expansion of Medicaid in particular for states that accept it are doing three things: vastly improving quality of life and quality of care for the previously uninsured, vastly reducing personal and family economic upheaval due to health care costs, and yes, over the long term reducing ER visits. These three outcomes fit exactly what the president has promised through health care reform: reduce costly emergency room visits for ailments that can and should be treated through the primary care system, relieve the constant fear of families that they live one medical catastrophe away from being out on the streets, and give people the care that they need.

Now that this talking point has been debunked, Republicans can return to howling about Benghazi...