Medicaid surpassed private insurance as biggest ER payer

Between 2006 and 2014, the number of emergency department (ED) visits paid for by Medicaid rose from 26.5 million to 44.1 million, making the program the most frequent payer in the ED over private insurance.

In a report on emergency room trends, the Agency for Healthcare Research and Quality (AHRQ) found the increase in ED visits covered by Medicaid (up 66.4 percent) and Medicare (up 28.5 percent) occurred at the same time privately insured ED visits decreased by more than 10 percent. In contrast, private insurance was the frequent payer in the ER in 2006, when it accounted for 35 percent of all visits (41.6 million total visits). There was also a drop in the number of uninsured ED visits, which fell by 9 percent from 20.7 million visits in 2006 to 18.9 million visits in 2014.

The shift in ER payers should come as no surprise considering the time period the data covered. Between 2006 and 2014, passage and implementation of the Affordable Care Act expanded Medicaid eligibility and decreased the number of uninsured, while an aging population began shifting the oldest of baby boomers away from employer-sponsored, private health coverage into Medicare.

The overall increase in ED visits over the time period of 14.8 percent—rising to 137.8 million visits in 2014—was driven in part by more visits among populations likely to be covered by Medicaid. Among patients living in low-income zip codes, the ED visit rate jumped 23 percent, from around 494 visits before 1,000 people to 607 visits per 1,000. In higher-income zip codes, however, the rate was virtually unchanged.

Additionally, Medicaid made up a greater percentage of ED visits by all types of first-listed diagnoses. It accounted for 27.6 percent of injury visits in 2014 (up from 17.4 percent in 2006), 32 percent of medical visits (up from 22.7 percent), 35 percent of mental health/substance abuse visits (up from 23.8 percent) and 58. 1 percent of maternal/neonatal visits (up from 49 percent). In all the same categories, the percentage of visits billed to private insurance and visits for the uninsured declined.

Outside of payer type, the report also listed the most frequently listed diagnoses for ED visits and which conditions saw the greatest increases and declines over the time period. Abdominal pain was the most commonly first-listed diagnosis, accounting for nearly six million ED visits in 2014. The sharpest increase in ED diagnoses was seen in “suicidal ideation and intentional self-inflicted injury,” which went from 44,000 ED visits in 2006 to more than 225,000 visits in 2014—a 414 percent jump.

The biggest decrease among all diagnoses was seen with contraceptive and procreative management, which was listed in only 4,400 ED visits in 2014, a nearly 79 percent drop from 2006.

Notably, out of all 15 first-listed diagnoses included in the mental health and substance abuse category, all of them saw an increase in ED visits between 2006 and 2014.