Now that 2014 and Obamacare are both here, there will be
plenty of stories about Affordable Care Act implementation. Some will be newsworthy; but others will just
be history.
Last week, we got our first history story characterized as exploding
news.
The Washington
Post reported on a newly-released Harvard study that analyzed the impact of
the 2008 Oregon Medicaid expansion on hospital emergency department visits. The study found that there was a 40
percent increase in the number of emergency department visits made by
the new Medicaid enrollees.
For the Post article, an MIT health economist (I guess no
Harvard ones were available!) commented that
he viewed it “as part of a broader set of evidence that covering people with
health insurance doesn’t save money,” something he went on to characterize as a
“misleading motivator for the Affordable Care Act.”
And Forbes went farther, claiming the study results are “undermining
[the] central rationale” for ACA.
But the Oregon expansion increase wasn’t really news by
itself, and it tells us nothing about the Affordable Care Act, either.
There are three reasons for this.
The first reason is
that Medicaid recipients, as a group, have always been the most frequent users
of emergency department care.
I learned about this up close when I was involved in a
community health project in Austin, TX, more than a decade ago.
We compared the use of emergency departments for non-emergent
reasons by privately insured, Medicaid-insured, and uninsured residents. About half the visits made by privately insured
or uninsured people were for non-emergent reasons. But 60 percent of those made by Medicaid
recipients were for non-emergencies.
The same thing was true when that analysis was repeated in
other hospitals in other parts of the country.
So the new study simply confirms what we have known to be
the case for years. Medicaid recipients use
hospital emergency departments for non-emergent care more frequently than those
who are not on Medicaid.
The second reason is
that we also know why Medicaid recipients have historically gone to emergency
departments for their non-emergency care.
It isn’t that emergency rooms are more conveniently located
than private doctors and walk-in clinics.
Or that some hospitals now use billboards, texting, or other mass media
to advertise shorter emergency department waiting times.
It is simply because – unlike many private primary care providers
– hospitals have historically been paid enough to take part in the Medicaid
system.
But there are new realities under the Affordable Care Act. More federally-qualified health centers are being
approved, and other
private primary care providers are seeing increased rates – rates comparable
to Medicare – for treating Medicaid patients.
While change won’t happen overnight, this means that over
time more private providers will be signing up for Medicaid in the expanded
Medicaid program, and more Medicaid patients will be choosing them over
hospital emergency departments because they can.
And that makes the results of an expansion program that took
place six years ago an interesting history lesson, but as poor a predictor of what
will happen in the future under a different set of rules as historical stock
market performance is of future returns.
The third reason is
that cost-savings was not a “misleading motivator” for supporting the Affordable
Care Act.
Despite the suggestion of the MIT economist and the Forbes
headliner, it wasn’t actually a reason at all.
When the Act was debated in 2009 and 2010, it was clear to all that it
was essentially cost-neutral.
Both the CBO and the Administration projected that we were going
to be spending about the same amount on health care overall for the next ten
years whether or not we passed the law. But
the law would distribute the costs and savings differently.
Medicare and Medicaid would take on a slightly greater share
of costs. Out-of-pocket costs not
covered by public or private insurance would go down (especially for those with
chronic diseases and conditions who could not afford insurance in the past). And private insurance would continue to pay
just about one-third of the nation’s health care bill.
While not everyone in the media may have known this at the
time, all the people voting on the law did.
That’s not news. That’s
history.
Just like the new Harvard study.
Paul Gionfriddo via email: gionfriddopaul@gmail.com. Twitter: @pgionfriddo. Facebook: www.facebook.com/paul.gionfriddo. LinkedIn: www.linkedin.com/in/paulgionfriddo/
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