Majority of Medicaid ED Visits for Urgent or More Serious Symptoms

Study Dispels Myth that Medicaid Patients Often Use Emergency Departments (EDs) for Routine Care

News Release
July 11, 2012

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a national study released today by the Center for Studying Health System Change (HSC).

Two kinds of information from emergency department visits generally are used to explain ED use—patients’ symptoms as assessed by ED triage staff to determine how quickly patients need evaluation and patients’ diagnoses after evaluation by a physician.

About 10 percent of nonelderly Medicaid patient ED visits were for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people in 2008, according to the study funded by the Robert Wood Johnson Foundation (RWJF). In contrast, slightly more than half of Medicaid and private insurance visits were categorized as emergent—needing immediate attention—or urgent—needing attention within an hour, according to the study based on the most recent available data from the ┬áNational Hospital Ambulatory Medical Care Survey conducted by the Centers for Disease Control and Prevention.

Nonelderly Medicaid patients do use EDs at higher rates than nonelderly privately insured patients. In 2008, people aged 0 to 64 covered by Medicaid had 45.8 ED visits per 100 enrollees compared with 24.0 visits per 100 nonelderly privately insured people, the study found.

“Most of the difference in emergency department use between nonelderly Medicaid and privately insured patients results from more ED use by Medicaid patients for urgent and semi-urgent symptoms that need prompt medical attention,” said HSC Senior Researcher Emily Carrier, M.D., M.C.S.I., an emergency physician and coauthor of the study with Anna S. Sommers, Ph.D., a former HSC senior researcher; and Ellyn R. Boukus, M.A., an HSC health research analyst.

Nonelderly Medicaid patients were seen in EDs for emergent visits—needing immediate attention—at the rate of 5.6 visits per 100 enrollees vs. 3.6 visits per 100 privately insured people, according to the study. For urgent visits—needing attention within an hour—the rate for nonelderly people covered by Medicaid was 18.1 visits per 100 enrollees vs. 9.6 visits per 100 privately insured people. For semi-urgent visits—evaluation needed in 1 to 2 hours—the Medicaid rate was 10.4 visits per 100 nonelderly enrollees vs. 5.5 visits for privately insured people.

The study’s findings are detailed in a new HSC Research Brief—Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms—available online at

The study identified two types of conditions, or diagnoses, with the greatest potential to reduce ED use for both nonelderly people covered by Medicaid and private insurance if access to appropriate alternative care settings existed—first, acute respiratory and other common infections in children, and second, injuries among all nonelderly people.

For example, diagnoses of acute respiratory and other common infections in children and injuries together account for about 53 percent of ED visits by children aged 0 to 12 covered by Medicaid and almost 60 percent of ED visits by privately insured children aged 0 to 12, according to the study. While some infections and injuries will be too serious to treat elsewhere, lower-cost settings that can provide a moderate intensity of care and urgent response time likely could reduce emergency department use.

“Information on diagnoses supports the idea that patients who seek ED care for certain conditions could be treated in lower-cost settings, but primary care settings may not be a practical solution for all cases. Many primary care offices cannot see patients quickly enough to manage urgent problems or do not have the right equipment at the practice. Alternative care settings would need to provide prompt care for urgent cases and have appropriate services and equipment to diagnose and treat minor cases,” the study concludes.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is affiliated with Mathematica Policy Research.