Science2014-06-13 2:30 PM

全民医保意味着到急诊就诊的次数增多 Medicaid Increases Emergency-Department Use: Evidence from Oregon's Health Insurance Experiment

论文摘要 

它被称作俄勒冈健康保险实验,其目的是为了阐明得到保证的医疗补助保险覆盖对低收入、无保险成年人的影响,在美国这尤其是一个重要的话题,因为向穷人提供医疗保险是《可支付得起医疗法》的一个很大的组成部分。

尽管先前来自该团体的2项研究应用调查及亲自面谈来评估俄勒冈健康保险实验的影响,但这一最新的研究所用的是急诊室的行政记录以进行更详细的观察。支持扩大穷人对医疗补助保险获取的人包括联邦及州政府中的决策者,他们认为,能够获取健康保险的低收入者会充分利用初级诊疗,会有更好的身体健康,因此会较少使用急诊室。但没有多少过硬的数据来支持这一说法。通过比较来自急诊室的有或没有医疗补助保险的低收入者的行政记录,Taubman及其同事发现,那些有该保险的人前往急诊室的次数会增加约40%,而这些就诊中的大多数属于被分类为“非急诊性”或“初级诊疗可以治疗的”情形。他们不但更多地使用急诊室,而且他们在可用恰当的治疗进行管理的医疗情况的测试中没有显示出健康情况的改善,这些疾病被人们预计会在此分析的时间间隔内显示出变化,如果病情确实已经得到改善的话。因此,来自俄勒冈健康保险实验的总体情况是拥有保险并不一定会导致健康结果的改善。

这份报告的发现可能有益于目前正在进行的关于健康保险政策的辩论,尤其是当决策者们在权衡扩大医疗补助保险与其成本的增加进行比较时。在一个相关的政策论坛中,Ray Fisman重点介绍了“发生在ER的引人注目的医疗部分”。而且由于大部分的美国人不久就会因为《可支付得起的医疗法》而得到保险,Fisman提出,在俄勒冈出现的急诊室负担过重的情形将只会继续存在,而决策者及医院必须开始作出规划。

Abstract 

In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage by using a randomized controlled design. By using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we studied the emergency department use of about 25,000 lottery participants over about 18 months after the lottery. We found that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40% relative to an average of 1.02 visits per person in the control group. We found increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.

Editor's Summary

Health Economy?

The intensity of arguments over social science issues often seems inversely correlated with the quantity of experimental evidence. Taubman et al. (p. 263, published online 2 January; see the Policy Forum by Fisman) report on the latest analysis of an ongoing controlled experiment—the Oregon Health Insurance Experiment—that seeks to identify and quantify the effects of extending health insurance coverage to a low-income adult population. A substantial increase was observed in visits to the emergency departments of hospitals, corresponding to approximately 120 U.S. dollars per year more in hospital costs.

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