The Emergency Room Myth

In March 2012, a study found that Medicaid patients were more likely to visit emergency rooms than patients with private insurance. In a ten-year span, less than 18% of privately insured patients visited the ER while nearly 40% of Medicaid recipients did.

Tom Suehs, the executive commissioner of Texas’s Health and Human Services commission, cites this as a reason for not expanding Medicaid in his state. And in Washington State, lawmakers tried to limit Medicaid payments for ER visits that turned out not to be emergencies.

But, are Medicaid patients really visiting the ER for non-emergency conditions?

It turns out they aren’t.

A study of more than 34,000 ER medical records in the National Hospital Ambulatory Medical Care Survey found that even though more Medicaid patients visit the ER, it isn’t nor non-emergency conditions.

In fact, 75% of Medicaid patients treated in emergency rooms suffered from conditions categorized as semi-urgent, urgent, or very urgent. Compare this to privately insured patients at 78% and the truth of things starts to come out.

The Straight Facts

Only 10% of Medicaid patient’s ER visits were for non-urgent care. However, research did confirm that these patients are more likely to go to the ER than patients with private insurance.

Why’s that?

According to Dr. Adit Ginde, the author of the March study, Medicaid recipients may be typically in poorer health than their privately insured counterparts.

Other research suggests he may be right. A 2010 study looked at what changed when Medicaid patients were made to pay co-payments for ER visits. The goal was to reduce unnecessary visits, but the study found no change in the frequency of ER use.

Everyone seems to know that the ER is for emergencies. Patients who need care now are not likely to think about co-payment costs when their life may be on the line.

On top of that, Oregon had a Medicaid expansion lottery in 2008. A random selection of people gained coverage. When researchers compared ER visits among those with and without this coverage, they found no difference.

However, patients lucky enough to win a place in the program did report feeling better physically and mentally than those who did not.

Is the ER the Place to Worry About Cutting Costs?

When policy makers want to cut costs by slashing the ability of people on Medicaid to use the emergency room, today’s research suggests that this slashing may not work at all. All it could do is force millions of people to forgo urgent care.

New parents on a budget may have to make some really tough decisions about their children. Is my child’s condition urgent enough to qualify for Medicaid coverage? Is it worth the risk of going to the ER and maybe racking up a huge medical bill I cannot afford to pay?

Just 10% of Medicaid ER visits were for non-emergencies. A good 90% of Medicaid patients know what the ‘e’ in ER stands for.

And while more research still has to be done, some experts have suggested that Medicaid patients are just not as healthy, since they don’t have as much access to catching conditions early.

Why the “Doughnut Hole” Exists (and what it really does)

It’s 2003. The Medicare Modernization Act hits and starts to cover drug prices for seniors. For many, this is a blessing for people on fixed incomes who juggle medication, housing, utilities, and food and all the rest.

Then, some of those seniors found themselves in the so-called “doughnut hole” and faced a nasty surprise at the pharmacy. Thanks to the coverage gap, those seniors would have to pay full price for their prescriptions when they entered the “doughnut hole.” That was all pre-2011.

New laws then aimed at slowly closing the gap. They’ve reduced the amount of out-of-pocket costs seniors pay during this period: in 2012, for example, Medicare recipients received a 50% discount on brand name drugs and a 14% discount on generic alternatives. But still, if you’re on a fixed income, these discounts may not make prescriptions much easier to afford.

For example, the antidepressant Lexapro costs $370 for a 3-month supply. No generic is available. Medicare beneficiaries in 2012 would still be required to pay $185 out-of-pocket for this prescription.

That doesn’t sound too bad. But on average, each senior takes five different prescriptions. Every day.

If all other medications cost the same as Lexapro, three months worth of medication totals to $925. That’s an extra $300+ per month that many Medicare patients do not have.

So, what happens when patients can’t afford to pay for all of their medication?

In a recent study, researchers found 12% of Medicare patients stopped using their anti-depressants while they were in the “doughnut hole.” Of those who stopped their drug therapy, about 75% were on brand name drugs. The numbers are similar for heart failure and diabetic drugs too.

Was the coverage gap meant to encourage people to stop taking their prescriptions? Actually, yes, in a way.

Why the Coverage Gap Exists

The coverage gap was meant to encourage Medicare patients to make smarter choices about their medication. For example, maybe they choose the generic over the brand name drug to reduce out-of-pocket costs and lower Medicare’s expenses.

While generics do save money, some physicians say that they’re not always as effective. Reduced effectiveness can be a big problem when it comes to severe depression or heart failure.

On top of that, not every available brand name medication has a generic alternative on the market.

In tough situations, the coverage gap leaves some people out in the cold instead of actually promoting smart buying.

A Political Battle or a Long Wait

Supporters of the coverage gap provision point out that Medicare Part D (the prescription benefit portion) plans are available to pay for medications once patients reach the “doughnut hole.”

While such plans do exist, their monthly premiums cost twice as much. When you’re on a fixed income, that can be a stretch on top of other premiums, co-payments, and living expenses.

Still, the coverage gap is on its way to being closed by 2020, which is good news for many seniors. That is, unless “doughnut hole” supporters get their way. And unless 8 years (2012 to 2020) is too long to wait.