Study links insurance coverage to access to hospital care

Patients who are uninsured or on Medicaid are more likely to be transferred, discharged, or not admitted when seeking care in hospital emergency departments.
A stethoscope, calculator, and stack of money arranged on top of medical insurance documents.


Compared to privately insured patients, individuals who lack insurance or use Medicaid are more likely to be transferred to another hospital after receiving initial treatment in the emergency department (ED). The uninsured are also at greater risk of being discharged from an ED and not admitted to the hospital. These findings reveal disparities in access to hospital care linked to insurance coverage, said Yale researchers.

Their study was published in JAMA Internal Medicine.

Prior research suggests that uninsured and underinsured patients were more likely to be transferred from the ED to another hospital, especially if they needed specialized care for an emergency. But other studies failed to account for differences in the ability of hospitals to provide those specialized services, such as intensive care.

To explore the issue further, the Yale researchers analyzed data from a national sample of EDs for one year. They included only hospitals that offered critical care to treat three conditions commonly seen in the ED: asthma, pneumonia, and chronic obstructive pulmonary disease.

The research team reviewed more than 200,000 ED visits and found significant differences – linked with insurance status – in whether patients were transferred, discharged, or hospitalized. “Patients who are uninsured or on Medicaid were more likely to be transferred than patients with commercial or private pay insurance,” said lead author Arjun Venkatesh, M.D., assistant professor of emergency medicine. The uninsured also had half the admissions rate of privately insured patients.

While the study did not examine the cause of these disparities, financial incentives for hospitals could play a role, said Venkatesh. Hospitals are not reimbursed for admitting uninsured patients and they receive lower payments for Medicaid, he noted.

Patients have a guarantee to emergency care, but that really only guarantees a medical screening exam. What our paper suggests is that there may be an access barrier to acute hospital care,” he said.

The study authors urge policymakers to recognize this access gap through research and strategies to support coverage for the uninsured and Medicaid recipients.

Other study authors are Shih-Chuan Chou, Shu-Xia Li, Jennie Choi, Joseph S. Ross, Gail D’Onofrio, Harlan M. Krumholz, and Kumar Dharmarajan.

This study was supported in part by an Emergency Medicine Foundation Health Policy Scholar Award and a Yale Center for Clinical Investigation grant from the National Center for Advancing Translational Science of the National Institutes of Health. A full list of funders and disclosures are detailed in JAMA Internal Medicine.


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