Unpacking the Emergency Rooms?

One of the common arguments for insuring the uninsured is that they will get the opportunity to use care at the proper times and thereby reduce reliance on the emergency room, meaning better care (it’s better to get something early, generally speaking) and cheaper care. A study written up in the Huffington Post (via @HEALTH_NOTES) suggests that that’s true. They looked at a case study of patients in Richmond, VA, and this is what they found:

The study -- which focused on uninsured people in Richmond, Virginia who fell 200 percent below the poverty line -- found that over three years, health care costs fell by almost 50 percent per participant, from $8,899 in the first year to $4,569 in the third after they received insurance. Participants who enrolled in health coverage made fewer trips to the emergency room, which are notorious for running up patient bills. Instead, insured participants went for more primary care visits.

Overall, they suggest a decline of .26 visits to the ER per year from year one to year three of tracking.

Mitt Romney made a version of this argument right after Massachusetts passed its version of health care reform, except he suggested that the uninsured were irresponsible rather than unfortunate (“Why pay for something when you can get it for free?” Romney wrote, of the uninsured’s usage of emergency room care.) So it’s probably appropriate to look at Massachusetts’s ER utilization—a New England Journal of Medicine article did just that, and their comparison of the number of ER visits in Massachusetts, Vermont and New Hampshire suggests that, in fact, there’s no difference in trend of ER use at all. (It also has one of the biggest caveats ever: “Our findings underscore the problem with evaluating policies by looking only at single trends and not examining simultaneous countervailing trends or comparable trends that cannot be attributed to the policies in question.” They go on to explain this stuff is hard, which is true. It is hard.) (On the other hand, this paper from University of Illinois-Chicago Ph.D. student Sarah Miller suggests that Massachusetts health care reform substantially reduced ER usage—the paper actually compared things in-state on a per-capita basis, unlike the NEJM paper, which simply compared the number of pre-health reform visits to post-health reform visits.)

Interestingly, there’s a quote from Nancy Turnbull in Boston Globe about this very issue that states: “I don’t think the increase [in emergency room visits] has anything to do with health care reform. It’s much more reflective of [primary care] access problems.” Well, if you wanted to be critical about it: could this be a natural consequence of increasing the number of insured and hence the amount of demand? If the supply of primary care remains constant, then you’re bound to have shortages…