The New Hampshire Union Leader misleadingly used the findings of a study on Oregon's Medicaid expansion to attack the program, claiming it did not improve the health of patients and led to increased emergency room visits, and warning that New Hampshire "must not fall into that trap." However, contrary to the Union Leader's assertion, studies of Oregon's expansion show improvements in preventable diseases and mental health, and while ER visits were shown to rise initially, the number of people using the ER has dropped as people become more educated about their insurance coverage.
In a January 7 editorial, the Union Leader, which has a history of misinforming the public on Medicaid expansion, said Medicaid expansion is an effort to "move working-class and eventually middle-class Americans into government dependency." The paper claimed this would have a devastating effect on New Hampshire because the program is "poorly designed" and "does not even achieve its stated goals," using a recently released Harvard study of Oregon's 2008 Medicaid expansion experiment to show how the program "did not improve health outcomes or reduce health care costs" and "even increased visits to hospital emergency rooms."
But the Union Leader's claim that Medicaid did not improve health outcomes is inaccurate and fails to tell the whole story. A digest of the study published by the National Bureau of Economic Research contests the Union Leader's claims, saying the report found "higher healthcare utilization, lower out-of-pocket medical expenditures and medical debt, and better self-reported health." Past reports on Oregon's Medicaid experiment have also shown improvements in mental health and chronic disease detection among those covered by the expansion.
The Union Leader and other local conservative voices have been eager to highlight a finding in the Harvard study which found that those who were covered by Oregon's 2008 Medicaid expansion increased their visits to the ER by 40 percent to about 1.4 visits per person compared to the control group, or those who did not receive expanded coverage, who only visited emergency rooms approximately 1 time over the 18-month period.
While there is no disputing that ER visits increased during the period covered by the Harvard study, it is vital to note that utilization of many health care services increased immediately following expansion, suggesting people were eager to use their recently received health insurance. As Katherine Baicker, co-author of the report, explained in an interview on PBS Newshour, those who received insurance coverage not only went to the ER more, but also visited their primary care doctors more, which also increased the use of prescription medication. However, Baicker also noted that people without insurance may have been more reluctant to access healthcare because they were concerned about the cost.
In addition, the spike in ER visits seems to have been temporary. A snap shot of data from January to June of 2013 shows Oregon has reduced ER visits by 9 percent when compared to 2011 measurements. Oregon's Coordinated Care Organizations (CCO) -- a provider network that services Medicaid patients -- attribute the decline to educating patients on the appropriate use of emergency services and by encouraging better management of chronic conditions. As Sarah Kliff reported for The Washington Post's Wonkblog:
One way that Oregon's CCOs have hit their targets is by reducing the exact same type of medical care that's at the heart of the Science study: primary care delivered in an emergency-department setting. In year one, the CCOs saw a 9 percent reduction in emergency-department visits among Oregon's Medicaid population.
One way that Oregon's CCOs are cutting down on emergency-department use is by stationing community health workers in the hospitals themselves, to divert less urgent patients to less costly settings. I asked Kolmer whether these workers faced challenges, whether patients were at all resistant to being told to get their care elsewhere.
"Absolutely. We're talking about changing behavior at every level," he responded. "It's behavior change for the provider, being allowed to do different things. And it's behavior change for the patient. Everyone has got to start changing. Members have to engage and be accountable for their own care."
In the first six months of 2013, Oregon had an 18 percent decrease in emergency room spending when compared to 2011, and has seen reductions in hospital admissions for congestive heart failure, chronic obstructive pulmonary disease, and adult asthma.