Oregon health plan cutbacks and access to care: A survey of emergency department patients

Study objectives: In February 2003, the Oregon Health Plan (OHP) altered coverage, enforcing premiums and copayments and reducing the scope of benefits for many members. Oregonʹs Medicaid expansion population, OHP Standard, was most seriously affected, with 49% of members leaving OHP so far and further reductions likely. Emergency departments (EDs) reported substantial increases in uninsured visits after these changes. The objective of this study was to survey ED patients several months after the changes to understand factors that affected their decision to seek care in the ED. Methods: This was a survey of patients treated in an Oregon university hospital ED (annual volume 45,000 visits) from October 12, 2003, to November 3, 2003. Interviewers were available 8 AM to midnight, 7 days a week; study subjects were selected randomly (coin toss) from ED patients treated during these periods. Patients were excluded from the study if they were on psychiatric holds, trauma or sexual assault victims, in police custody, transferred from a skilled nursing facility, or unable to answer the survey in either English or Spanish or had been interviewed before. Surveys were administered in person to patients (or, for children, to their parents). Questions addressed the domains of demographics, medical-care-seeking behavior, outpatient resources, insurance status, and frequency of medical care use. Frequencies were compared with χ2 analysis and counts with analysis of variance (with Bonferroni correction for multiple comparisons). Multivariable analysis was performed using a logistic regression model. Results: There were 647 surveys completed, with a cooperation rate of 73%. Respondents were similar to the overall ED patient population in age, sex, and insurance status. Respondentsʹ ages ranged from 5 days to 87 years, with a median age of 34 years. There were 353 (55%) female respondents. Two hundred twenty-three (35%) respondents reported their insurance status to be OHP, with 164 (26%) uninsured, 161 (25%) commercial or employer-sponsored insurance (ESI), 66 (10%) Medicare, and 27 (4%) other insurers. Of the uninsured patients, 48% reported their previous insurance as ESI, 44% as OHP, and 8% as other. Also, of the uninsured patients, 27% had been uninsured for less than 6 months (“newly uninsured”); 64% of these newly uninsured patients reported that their most recent insurance was OHP. Seventy-four percent of patients reported that their usual source of medical care was a traditional primary care provider such as a physicianʹs office or outpatient clinic, 12% utilized the ED or an urgent care center as their usual source of care, and 15% reported that they did not have access to a regular source of care. Although only 45% of uninsured patients reported having a traditional continuity provider, such providers were reported much more frequently by patients with commercial insurance (87%), Medicare (85%), or OHP (81%; P<.001). Two hundred sixty (40%) respondents reported seeking medical advice elsewhere before coming to the ED. Only 26% of uninsured patients sought medical advice before coming to the ED compared with 47% of commercially insured patients, 38% of Medicare patients, and 47% of OHP enrollees (P<.001). Of patients with traditional continuity providers, 45% sought medical advice before coming to the ED compared with 26% of patients who identified the ED or an urgent care center as their usual source of care and 23% of patients with no regular source of care (P<.001). In a multivariable logistic model, insured patients were more likely to seek medical care before coming to the ED (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.2 to 2.9), as were patients with a primary care provider (OR 2.1; 95% CI 1.4 to 3.3). Respondents reported an average of 2.1 ED visits in the 12 months preceding their current ED visit. OHP beneficiaries reported substantially more ED visits (mean 3.1) compared with uninsured patients (1.4) and commercially insured (1.2) patients (P<.001). Conclusion: This study confirms previous research demonstrating the importance of the ED as a safety net for patients without insurance, with limited insurance, and without primary care providers. Although affiliation with a traditional primary care provider was reported about as often for OHP beneficiaries as for the commercially insured, the lack of such access by the uninsured raises concerns about worsening access to care as more Oregonians lose OHP coverage because of the current cutbacks. The higher ED use by OHP beneficiaries may reflect greater burden of illness, limited accessibility of the medical care delivery system that serves them, or individualsʹ selection of sites of medical care. Most of the newly uninsured had been covered by OHP. Future research will assess whether ED use will increase with the deteriorating access to primary care that is anticipated with further OHP cuts or decrease because of financial barriers among patients who lose OHP.