CHICAGO—Medicaid cutbacks in Tennessee were associated with an abrupt and sustained increase in emergency department use and hospital admission among the uninsured, research shows.
In August 2005, the state of Tennessee disenrolled approximately 171,000 individuals older than 18 years from TennCare, the state's Medicaid managed care program.
Between the predisenrollment period of Jan. 1, 2004, through July 31, 2005, and the postdisenrollment period of Aug. 1, 2005, through July 31, 2006, ED visits by the uninsured increased by 95,464, or 4.5%, and decreased among TennCare beneficiaries by 160,823, or 6%.
“This research shows that health policy decisions have real effects on the patients we see in America's emergency departments,” said Dr. Benjamin S. Heavrin, who presented the study findings at the annual meeting of the American College of Emergency Physicians. “The cost savings from disenrollment resulted in an increasing proportion of uninsured patients in Tennessee's EDs. This suggests an increasing financial burden on the newly uninsured and a possible ominous shift in their health status, based on our admission data.”
The uninsured represented 12.7% of all patients in the EDs in the predisenrollment period, compared with 17.2% in the postdisenrollment period, Dr. Heavrin and his associates reported.
The largest weekly correlation (−0.95) between ED visits among the uninsured and TennCare beneficiaries corresponded exactly to the time when disenrollment began.
When ED use was calculated by calendar year, the incidence of ED visits among the uninsured increased by a relative 34.5%, from 44 visits per 100 persons per year in 2004 to 59.2 visits per 100 persons per year in 2006.
Total ED visits in the state decreased by 74,178 during the study period, which is predictable given a Medicaid population's use of the ED, according to Dr. Heavrin, chief resident, department of emergency medicine, Vanderbilt University Medical Center in Nashville, Tenn. A recent study showed that Medicaid enrollees visited the ED about three times more often than the uninsured (Med. Care 2008;46:1099–107).
An evaluation of admission data by Dr. Heavrin and his associates revealed that the admission rate of uninsured patients increased from 7.5% to 9.3% between the predisenrollment and postdisenrollment periods, while decreasing slightly from 10.6% to 10.4% among TennCare beneficiaries. Higher admission rates among the uninsured may be related to the acuity of the illness, he explained.
“This is a very worrisome observation that should give states pause before they shed large numbers of people from the rolls of their Medicaid or Medicaid-equivalent program,” Dr. Arthur Kellermann, professor of emergency medicine and associate dean for health policy at Emory University in Atlanta, said during a discussion of the study. Dr. Kellermann called for additional analyses into the financial and health consequences of Tennessee's action.
Dr. Donald M. Yealy, professor of emergency medicine, University of Pittsburgh, concurred.
The challenge for emergency physicians is to integrate these outcomes into the broader health policy debate and describe “what really happens downstream and the cost of that, not just in dollars,” Dr. Yealy said.
The analysis, based on data from the Healthcare Cost and Utilization Project State Emergency Department database, supports recent findings from a similar study in which ED visits by the uninsured jumped 20% after Oregon disenrolled more than 50,000 Medicaid beneficiaries (Ann. Emerg. Med. 2008 April 15 [doi:10.1016/j.annemergmed.2008.01.335]).
Dr. Heavrin disclosed that the study was supported by a resident research grant from the Emergency Medicine Foundation.