The Enid News and Eagle, Enid, OK

January 10, 2014

Obamacare surprise: More Medicaid means more trips to the ER

Taylor Armerding
CNHI News Service

Editor's note: CNHI newspapers that are not weekly subscribers to Taylor Armerding's column may publish this one if they notify him at t.armerding@verizon.net.

The latest “surprise” in the world of Obamacare is that people do not always behave logically.

That should be obvious. But apparently it is not to experts and political leaders who have championed the expansion of Medicaid to cover adults with earnings less than 133 percent of the federal poverty line.

Turns out the promise that it would save money because those people would stop using emergency rooms in favor of doctors’ offices is, like so much in the new law, illusory. Those people don’t use the ER less, they use it more.

The Medicaid expansion was supposed to be mandatory under the new health care law, until the courts rejected it, leaving the decision up to the states. Since then 25 states and the District of Columbia have signed on, with Indiana and Pennsylvania planning to do so, seduced in part by a promise that the feds will pay for the first three years of it, and 90 percent from then on.

But the other sales pitch has been that if poor people are covered by Medicaid, they will no longer get most of their care at emergency rooms, where it is more expensive and where they are likely to have more severe problems that might have been addressed more easily and inexpensively if they had insurance coverage.

Health and Human Services Secretary Kathleen Sebelius used that line during the debate over Obamacare in 2009.

“Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need,” she said in a statement. “We cannot wait for reform that gives all Americans the high-quality, affordable care they need and helps prevent illnesses from turning into emergencies.”

Michigan’s Republican Gov. Rick Snyder is among those who swallowed that story. In a “fact” sheet, he claimed that, "by expanding Medicaid, those without insurance will have access to primary care, lowering costs and improving overall health."

No, it won’t. Sadly, as Sebelius, Snyder and President Obama himself are discovering with the rollout of his signature legislation, logic does not prevail in this situation. If they had bothered to do some homework on the issue, they would have known it never has.

Poor people covered by Medicaid still use emergency rooms – more, not less.

Supposedly, this is a surprise. There has been a mini-explosion of stories about a study recently published on the website of the journal Science, which analyzed the use of ERs in Oregon by people newly enrolled in Medicaid. The study found that ER use spiked by 40 percent.

The real surprise ought to be that anybody is surprised. I could have told the Harvard people this before they started the study, because health care professionals were telling me about it back in the 1980s.

They had made the same assumption at first – that if people without health insurance were given access to it, they would no longer have to treat every medical need as an emergency. They would see their doctor regularly enough to manage chronic conditions, and keep minor problems from becoming major ones. And that would “bend the medical cost curve”  – something we heard constantly during the campaign to sell Obamacare.

If only. What they found was a population, in general, that needs more than a health insurance policy. They need someone to function as a surrogate parent – to remind them to do things that the experts had thought they would do on their own.

They found a population that does not plan ahead. They described them as people with “a short time horizon.”

“A lot of them don’t have a steady job, they don’t have a steady place to live, they may have drug or alcohol problems, and about all they can think about is getting through the day. They don’t make appointments. Thinking about next week or next month might as well be 10 years from now,” one hospital executive told me. That was about 30 years ago.

Jonathan Gruber, a professor of economics at the Massachusetts Institute of Technology and one of the architects of Obamacare, has apparently been aware of this all along. He told the Washington Post recently that promises of savings made by people like Sebelius were, “sometimes a misleading motivator for the Affordable Care Act. The law isn't designed to save money. It's designed to improve health, and that's going to cost money."

Gee, nice of him to acknowledge that now. I don’t recall him disputing either Sebelius or the president during the intense debate over whether Obamacare was going to save money.

Oregon officials contend that since 2008, when the patient sample was studied, they have cut the use of ERs with better patient management. But that has required putting “community health workers” – in essence, health-care babysitters – in hospitals to divert patients with non-emergency problems to a less costly setting than the ER. This, they say, will “train” them to do it on their own. Good luck with that.

Meanwhile, there isn’t much discussion about what happens if they get diverted to a doctor who doesn’t take Medicaid.

Everybody should be provided with health care. But in some cases – millions of them nationwide – handing them an insurance plan is not the best way to do that. It certainly is not the way to save any money.

That is something people like Gruber knew – and should have acknowledged – up front.

Taylor Armerding is an independent columnist. Contact him at t.armerding@verizon.net