Medi-Cal Patients Flocking To ERs More Than Before ACA -AND- California ER use jumps despite Medicaid expansion

CAL/AAEM News Service at
Sat Jul 1 21:01:33 PDT 2017



June 12, 2017


Medi-Cal Patients Flocking To ERs More Than Before ACA 



52995346> California Healthline



By Kellen Browning


Medi-Cal patients are swamping California emergency rooms in greater numbers
than they did before the Affordable Care Act took effect, despite
predictions that the health law would ease the burden on ERs.


Emergency room visits by people on Medi-Cal rose 75 percent over five years,
from 800,000 in the first quarter of 2012 to 1.4 million in the last quarter
of 2016, according to data recently released by the state's Office of
Statewide Health Planning and Development.


The most dramatic increase began roughly around the time the ACA expanded
health care benefits in January 2014. More than 5 million Californians have
gained coverage under the ACA, either through the expansion of Medi-Cal,
California's version of the Medicaid program for low-income people, or by
purchasing health plans from Covered California, the state's Obamacare
insurance exchange.


The architects and proponents of Obamacare had argued that once people got
health coverage they would stop going to the ER so much, because they could
visit primary care doctors instead. But in reality, people who were
uninsured before the ACA were actually reluctant to go to the ER unless they
were "about to die," because they would be saddled with big bills, said
state Sen. Richard Pan (D-Sacramento), a pediatrician. Under Medi-Cal,
though, patients aren't worried about those expenses.


And old habits die hard: A newly-insured patient accustomed to visiting the
ER for treatment might not immediately switch to a primary care doctor who
is, "just a name - not somebody you know," Pan added.


Still, experts believe fewer Medi-Cal patients would be visiting the ER if
there were more doctors willing to treat them.


Though "we have seen a very strong increase in the number of Medi-Cal
patients . the number of doctors willing to see Medi-Cal patients has not
increased accordingly," said Jan Emerson-Shea, vice president of external
affairs for the California Hospital Association.


Dr. Marc Futernick, the immediate past president of the California American
College of Emergency Physicians, agreed that "there aren't adequate
providers for the demands." He said he believes Medi-Cal's low payment rates
for physicians play a role.


Historically, doctors across the country have been reimbursed less for
treating Medicaid patients than those on private insurance or Medicare -
especially in California, which ranks 47th in the country in fee-for-service
reimbursement rates.


This means the state's doctors are less likely to accept Medi-Cal patients,
who will then seek treatment wherever they can get it, Futernick said. The
ER is always open and cannot legally turn people away, even though many of
the Medi-Cal patients' ills could be treated by primary care providers,
Emerson-Shea said.


California doctors have long lobbied to increase Medi-Cal reimbursements.
They are pushing hard to use some revenue from California's recently passed
tobacco tax to increase Medi-Cal rates. But Gov. Jerry Brown wants to use it
more broadly for overall Medi-Cal spending.


Pan, the state senator, noted other factors that could explain the surge in
ER use.


Health clinics, which see many Medi-Cal patients, generally cannot provide
specialty care on site, he said. "What's the quickest way to see a
specialist? Send them to the emergency room."


Moreover, many Medi-Cal patients work jobs without flexible hours or sick
leave, which means they are not able to make appointments or visit health
care providers during regular hours, Pan said.


"When I worked in the emergency room," he recalled, "people would show up
early in the morning with their kids who had an ear infection or cold or
something and the parents would tell me, 'Well, I have to go to work today
or I'll get fired.'"


California is not the only state where the ACA has failed to produce a drop
in ER use. A study published in 2014 found that Oregon residents who won
Medicaid coverage in a 2008 lottery made 40 percent more trips to the ER in
the first 18 months they were covered than those who entered the lottery but
were not selected.




June 16, 2017


California ER use jumps despite Medicaid expansion 



mpaign=financedaily> Modern Healthcare



By Virgil Dickson


California is the latest state to report that emergency room usage is up
despite expanding Medicaid eligibility.


Emergency room visits by people on Medi-Cal, the state's Medicaid program,
rose 75% over five years from 800,000 in the first quarter of 2012 to 1.4
million in the last quarter of 2016, according to California's Office of
Statewide Health Planning and Development.


Similar findings have also been noted in studies on Illinois, Massachusetts
and Oregon. The trend contradicts what policy experts thought would happen
if people gained more insurance coverage. They could also give Republican
lawmakers the ammunition they need to dramatically overhaul Medicaid, as
they propose in the American Health Care Act that passed the U.S. House of


>From 2013 to 2016, enrollment in Medi-Cal grew by 57%; 5 million new members
were added, bringing current enrollment to 13.5 million. Medi-Cal now covers
more than one-third of all Californians, leading some to claim that it's the
closest to universal coverage of any state.


California health officials couldn't explain the rise, but providers think
they have an answer.


"There has not been an increase in physicians willing to see Medi-Cal
patients, mostly because the payment rates are so low," said Jan
Emerson-Shea a spokeswoman for the California Hospital Association.
Therefore, newly enrolled Medi-Cal patients continue to seek care in
hospital ERs because they cannot access primary care in physician offices
and clinics.


California ranks 47th in the nation for payment rates for providers,
according to the CMS.


Republicans have already used reports of increased ER usage in expansion
states and rising spending in the program as reasons to convert Medicaid
into a per capita cap system.


Medicaid spending jumped 4.3% to $575.9 billion in 2016 with the federal
share growing 4.5% to $363.4 billion, according to the CMS.


"Despite these significant investments, one-third of doctors in America do
not accept new Medicaid patients," HHS Secretary Tom Price told the Senate
Appropriations Committee on Thursday. "We need structural reforms that equip
states with the resources and flexibility they need to serve their unique
Medicaid populations in a way that is as compassionate and as cost-effective
as possible."


Price supports President Donald Trump's budget proposal that includes a $600
billion cut to Medicaid over the next decade.


The trend in rising ER visits could also support Republican's rationale for
imposing co-pays on those services, according to Josh Archambault, senior
fellow at the Foundation for Government Accountability, a conservative think
tank. Wisconsin recently submitted a waiver for such a requirement.


"Hopefully these kinds of reports grant urgency to change Medicaid and the
health system it operates in," Archambault said.


High ER use in expansion states also gives Republicans some political cover
as they seek to roll back Medicaid expansion.


"The argument that expanding coverage would reduce ER use was always a bit
of a canard used to sell the ACA," said Charles Blahous a senior research
fellow for the Mercatus Center, a conservative research organization, adding
that while the information would have been useful when crafting the ACA, the
findings could still be useful to discount the notion that any decrease in
Medicaid coverage would lead to more ER visits.


Dr. Larry Stock, president of the California chapter of the American College
of Emergency Physicians, worries how Medicaid cuts and ER visit co-pays
could affect patients.


"We don't want to scare people from coming into the emergency department if
they need to," he said.


In California, provider groups have lobbied for new taxes that could
increase reimbursement for providers and boost the number of residency slots
in the state.


Insurers say in order to affect the number of ER visits, patients need to be
better informed about their options in healthcare especially since many who
enrolled under expansion had never before had coverage.


Mary Ellen Grant, a spokeswoman for the California Association of Health
Plans, said plans will continue to work with providers to lower ER overuse.




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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