Medicaid and non-emergency use of emergency departments

The Deficit Reduction Act gave state Medicaid programs the option of instituting higher copayments for non-emergency use of emergency departments. Some states accepted the option and imposed copays from $3 to $50 to Medicaid recipients for non-emergency ED use. An interesting article in Health Affairs from September/October 2010 found that these copayments did not reduce their non-emergency use of the ED.

According to the study, this effect is contrary to the findings of other studies that show that copays may reduce use for other services and pharmaceuticals. Also, other studies show that commercially insured populations are sensitive to small changes in copays in the use of ED services.

So what makes the emergency department utilization different for Medicaid enrollees? Assuming that the study was designed correctly (and there were some limitations to the study), what is going on? The authors suggest some explanations in their discussion.

1. Medicaid recipients face significant barriers to primary care due to a lack of PCPs that are willing to accept Medicaid insurance payments. Thus, the ED may be a location of last resort.
2. The 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires that the service be provided before the ED collects the copay. So, maybe the copay is not actually made to the hospital. (Does this add to the bad debt?) 
3. The Medicaid recipients may not have been aware of the requirement to pay a copay for nonemergency services in the ED. Therefore, the change in the law did not factor into their decision to seek non-emergency care in the ED.

Nonetheless, the contradictory findings underscore how little we understand about the causes of Medicaid recipients’ use of the ED for non-emergency services.