Increase seen in use of emergency departments by children in California, regardless of insurance type

Concerns regarding cost, continuity of care, and crowding continue to bring ED use under nationwide scrutiny. Although many hope that increasing insurance coverage through the Affordable Care Act will lead to decreases in ED visits, recent evidence in adults suggests that increasing access to specifically Medicaid insurance may actually be associated with increased ED use. Most prior research on trends in ED use in children, adolescents, and young adults predates the recent economic downturn and associated changes in insurance coverage, according to background information in the article.

Renee Y. Hsia, M.D., M.Sc., of the University of California, San Francisco, and colleagues analyzed data of ED visits by youths (children, adolescents, and young adults 18 years of age and younger) to acute care hospitals across California between 2005 and 2010. ED visits were grouped into 4 categories: Medicaid, private insurance, uninsured, and other.

The number of visits to California EDs by youths increased from 2.5 million in 2005 to 2.8 million in 2010, a change of 11 percent. Children covered by Medicaid accounted for 44 percent of all ED visits. The distribution of visits across payer groups changed significantly between 2005 and 2010, with Medicaid accounting for a larger share over time. After adjusting for population (given a 3 percent decrease in the pediatric population during the study period) to obtain ED visit rates, the rate of ED use increased across all insurance groups.

Uninsured youths living in California exhibited the fastest increase in ED visit rates, followed by those privately insured. The rate of ED use among youths covered by Medicaid exhibited the slowest growth, but remained the highest in absolute terms.

The authors write that even though Medicaid patients have the fastest-growing rates of ED use among adults, the largest increases in ED visit rates for youths are not among Medicaid beneficiaries but rather among those individuals who are privately insured or uninsured. "Shifts in insurance (from private and no insurance to Medicaid) during the recession (December 2007-June 2009) likely influenced the trends during this time."

"These findings suggest that the drivers for ED use differ significantly between youths and adults and that policies regarding insurance expansion may also have varying effects. The divergence from older trends in ED use among youths may also reflect the increasingly central role of the ED in the U.S. health care system, especially during a period of severe economic recession, and could signal an overall deterioration in access to primary care across payer groups, or that even privately insured youths with greater access to primary care physicians are being directed to the ED for care." (doi:10.1001/jama.2014.9905