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Cosmos Study

Uninsured Emergency Visits on the Rise Since the End of Medicaid Continuous Enrollment

October 10, 2024
Dual-Team Study
Team A:Christopher Alban, MDBrendan Joyce
Team B:Kersten Bartelt, RNNeil Sandberg

Key Findings

  • Self-pay emergency visits are on the rise in all age groups since the end of Medicaid continuous enrollment. 
  • The greatest increase was in children under 18 years old, who had a 60% increase in the number of emergency visits that were self-pay.  

In April 2023, some states started terminating Medicaid coverage for people who no longer qualified but had continued to receive coverage under a pandemic-era program.1 States now have until June 2025 to resume standard eligibility requirements.2 Theoretically, patients who have their Medicaid coverage terminated should get commercial healthcare coverage through an employer or the Affordable Care Act Marketplace, but there are concerns that many patients will remain uninsured.3,4 

To understand whether this termination of coverage varied across different age groups, we studied 196 million emergency encounters between January 2017 and June 2024 to assess the proportions of encounters with a coverage type of self-pay by age group. Because 47.1% of Medicaid and Children’s Health Insurance Programs (CHIP) enrollees are under the age of 18,5 we were particularly interested in how the rate of self-pay encounters changed for pediatric patients.  

We found that the self-pay rate for all age groups decreased throughout the period of continuous coverage during the COVID-19 pandemic and began to increase again when coverage terminations began in April 2023, as shown in Figure 1. While most age groups returned to their pre-pandemic baselines by June 2024, patients under age 18 exceeded the pre-pandemic average self-pay rate of 3.4%, reaching a rate of 5.4% of emergency encounters in June 2024, an increase of nearly 60%. 

Figure 1
Proportion of Emergency Encounters with Self-Pay Coverage by Age Group
Proportion of Emergency Encounters with Self-Pay Coverage by Age Group
Figure 1. The proportion of emergency encounters with a coverage type of self-pay by month from January 2017 to June 2024 stratified by patient age at the time of the encounter.

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,557 hospitals and more than 35,000 clinics from all 50 states and Lebanon. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

References

  1. Unwinding and returning to regular operations after COVID-19. (n.d.). Medicaid.gov. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html. Accessed September 5, 2024.  
  2. Tsai, D. Extension of Temporary Unwinding-Related Flexibilities. Centers for Medicaid & CHIP Services. https://www.medicaid.gov/federal-policy-guidance/downloads/cib050924-e14.pdf. Published May 9, 2024. Accessed September 5, 2024. 
  3. Lopes L, Sparks G, Presiado M, et al. KFF Survey of Medicaid Unwinding. KFF. https://www.kff.org/medicaid/poll-finding/kff-survey-of-medicaid-unwinding/. Accessed September 12, 2024.  
  4. Galewitz P, Houghton K, Kelman B, Liss S. ‘Worse than People Can Imagine’: Medicaid ‘Unwinding’ Breeds Chaos in States. KFF Health News. https://kffhealthnews.org/news/article/medicaid-unwinding-disenrollment-redetermination-state-delays/. Accessed September 12, 2024.  
  5. April 2024 Medicaid & CHIP Enrollment Data Highlights. Medicaid. April 2024 Medicaid & CHIP Enrollment Data Highlights | Medicaid. Accessed September 5, 2024.