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Tightening eligibility
requirements to reduce the size of the Medicaid patient population
forces more people into the ranks of the uninsured, impacting their
access to care and resulting in increased uncompensated care that puts a
significant strain on emergency departments, hospitals, and the state.
For example, when Oregon eliminated the state’s Medically Needy program,
Medicaid patient volumes in state EDs dropped 20% while uninsured
patient volumes increased 17%. The cuts resulted in a reduction in
undercompensated care but an increase in uncompensated care. (“Medicaid/SCHIP
Cuts and Hospital Emergency Department Use” Health Affairs, 2006)
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Imposition of
cost-sharing requirements on Medicaid populations has been proven to
increase uninsured populations. Survey results in Oregon indicated that
over two-thirds (67%) of poor adults who were disenrolled following
premium increases and tightened premium payment policies became
uninsured. A survey of the higher income disenrollees in Rhode Island
showed that just over half (51%) became uninsured. In Utah, nearly two
thirds (63%) of individuals disenrolled from the state’s Primary Care
Network Medicaid waiver program became uninsured. (“Increasing Premiums
and Cost Sharing in Medicaid and SCHIP: Recent State Experiences,”
Kaiser Commission on Medicaid and the Uninsured, May 2005)
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Following its Medicaid
coverage losses, Oregon saw an increase in emergency room use by
uninsured patients and increased pressure on clinics. After Washington
State attempted to transition a group of immigrant families from a
state-funded Medicaid look-alike program to its state-funded Basic
Health program that charges premiums and cost sharing, providers
reported a substantial increase in demand for charity care, emergency
department use and strains on clinic resources. (“Increasing Premiums
and Cost Sharing in Medicaid and SCHIP: Recent State Experiences,”
Kaiser Commission on Medicaid and the Uninsured, May 2005)
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Investing in
increased access to primary care for Medicaid patients (for
example, by expanding hospital clinics, outpatient clinics, or doctor
office hours) would result in a more efficient utilization of health
care dollars and help to decrease non-emergent use of the emergency
department by Medicaid patients who have no other place to obtain
primary care. This initial upfront investment may pay off in decreased
overall costs in the long run. This concept would also promote more
preventive care in the Medicaid population, leading to higher quality of
care and lower costs to the health care system.
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Providers of trauma
care and emergency medical care, by federal law, must see every patient
who presents at an emergency department, regardless of their insurance
status or ability to pay. Cutting reimbursement under the Medicaid
program does not change the legal requirement, known as EMTALA, and
simply exacerbates the serious problems related to uncompensated and
undercompensated emergency care.
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Unlike other physician
specialties, emergency physicians are required by state and federal law
to serve all patients and yet the Medicaid payment rates are grossly
inequitable for emergency care and often fall well short of covering the
per-patient costs for medical liability insurance, billing, overhead and
other costs associated with providing care.
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Emergency physicians
bear the brunt of uncompensated care. According to the American Medical
Association, individual emergency physicians average $138,300 annually
in lost revenue for providing EMTALA-mandated care. ("Physician
Marketplace Report: The Impact of EMTALA on Physician Practices" June
2003)
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More than one-third of
Medicaid/SCHIP patients report at least one emergency department visit
in the past year, far more than the average of 20% of both uninsured and
privately insured individuals. (“Medicaid/SCHIP Cuts and Hospital
Emergency Department Use” Health Affairs, 2006)
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