Medicaid Reform Proposals and their Impact on Emergency Medicine

Two major concerns have come to light in regards to Medicaid reforms currently being discussed on the National level that could have a profound impact on emergency department care.  Emergency Departments serve as the nation's health care safety net and play a critical role as first responders in homeland security, but this safety net is under considerable strain.

Co-pay for non-emergency care provided at emergency departments:

This idea was included in the National Governors Association's draft Medicaid reform proposal. A co-pay would be charged to Medicaid recipients who receive care in the emergency department that is determined to be non-emergent. While we recognize efforts to reduce unnecessary care, co-pays for emergency care cannot be implemented in practice because

1. Payment of a co-pay CANNOT be requested prior to providing emergency care required by the Federal Emergency Medical Treatment and Active Labor Act (EMTALA).
2. All Medicaid managed care programs already require payment for care that meets the prudent layperson standard definition of an emergency.
3. There is no simple way to determine whether the care provided is a non-emergency and there are substantial administrative costs in trying to do so.
4. The cost of collecting co-pays from Medicaid patients after care is provided is far greater than the amount recovered, leading most institutions to abandon the effort and absorb the loss.
5. Absorption of losses associated with collection of co-pays will just exacerbate the uncompensated/ under-compensated care crisis facing emergency care providers and lead to more overcrowding.
6. Requiring a co-pay will mean some patients that need emergency care will not seek it, leading them to wait until the problem is more severe and thereby increasing overall costs to the Medicaid program.

Unintended consequences of other Medicaid reform efforts:

1. Co-pays and deductibles for primary care could lead some patients to bypass primary care providers and seek out emergency care, where they know they will be seen even if they don't pay (c.f. EMTALA). 
2. Reductions in physician reimbursement result in fewer physicians seeing Medicaid patients, forcing more to seek care in the emergency department. 
3. Similarly, those reductions contribute to the problem of on-call specialists being unavailable in the emergency department.

The Maryland Experience:

During the 2004 Legislative Session language was included in the FY2005 budget that a $10 co-pay be collected from "Medicaid recipients 21 years old or older who present to the hospital emergency room for non-emergency services".  The co-pay amount was later reduced to $6 when the state found out that was the maximum that could be collected. 

Ultimately the effort in Maryland to collect a co-pay failed.  During the course of discussions it became readily apparent that the burden of administering and collecting the co-pay was going to far outweigh any potential benefits.  The co-pay has since been taken off the table as the issues began to emerge such as:  how will it be collected?, who will make the determination as to what an emergency is?, and the fact that requesting a co-pay prior to providing care violates federal EMTALA standards.

Information provided by the American College of Emergency Physicians (ACEP) and the Maryland Chapter, American College of Emergency Physicians (MD ACEP).