Roberta Capp is a Robert Wood Johnson clinical scholar fellow at Yale University, where she practices emergency medicine and is researching health care delivery for patients with Medicaid and Medicare insurance.
The debate over “Obamacare” has focused largely on the number of uninsured Americans and how the regulations will be implemented. Not enough attention is being paid to the difficulties our health-care system imposes on those with Medicaid insurance, which is being extended to millions who lack coverage.
Frequently, people blame patients for using emergency departments “inappropriately.” But some Medicaid patients do everything they can to see a doctor, to no avail, and must resort to emergency department visits. My own experience has been instructive.
One Monday a few months ago, the waiting room of the emergency department (ED) where I work had 30 patients, some of whom had waited 12 hours to be seen. My first patient was a woman with chest pain. She has Medicaid insurance. Her medical problems include diabetes, previous heart attacks, asthma and acid reflux. I ordered an electrocardiogram and saw from her file that she had been evaluated in the ED for chest pain 14 times in the past year and hospitalized on seven of those occasions. After reading her previous diagnostic tests and treatments, I was confident that her chest pain was not caused by a heart or lung problem. I was also curious about how her care was being coordinated.
The first time this woman had chest pain, she said, she called our hospital’s primary-care clinic, where she had seen a different doctor at each previous appointment. After holding for more than 30 minutes, she hung up and went to the emergency department. That visit resulted in a hospital admission for a heart stress test, the results of which were normal. But this woman continued to experience pain. She later saw a doctor at our primary-care clinic who prescribed an acid-reflux medication and told her to return to the ED if she had more pain.
This woman prefers to see a primary-care doctor, she told me, which is why she would call the clinic when she had pain. But often she was either unable to get an appointment right away or couldn’t get a person on the phone. When she did reach someone, once she said “chest pain,” she was almost always told to call 911 immediately and go to the ED.
The patient’s records showed that in the past year she had had two cardiac stress tests, one coronary catheterization procedure and two CT scans of her chest, all of which were normal. Simply put, she received the best care possible — and doctors assessing her were reassured that she did not have heart disease or a clot in her lungs. But she also underwent duplicate testing, which increased her costs without providing additional benefits, exposed her to more radiation and raised the potential for false-positive test results.
When this patient was able to get an appointment quickly, she then had to arrange transportation. Medicaid will pay for taxi service, she told me, but she has to call at least three days ahead to schedule the ride. Ultimately, she told me, she has concluded that “the only way to see a doctor soon enough is to call an ambulance” and go to the ED.
She cried as she told me her story. A primary-care doctor had recommended that she see a gastroenterologist for her chest pain, as it might be coming from her stomach, but the next available appointment was two months later. She hoped to see one in the emergency department, she told me, because she could no longer deal with her pain.
In our hospital, about one in 10 patients with Medicaid is a frequent visitor to the emergency department because many physicians don’t accept that insurance. Trying to understand the inability of patients with insurance to see primary-care providers, I called three local clinics, pretending to be a patient with Medicaid, and tried to make an appointment. The soonest I could see a primary-care doctor was two months. Primary-care physicians who accept Medicaid insurance are overwhelmed with patients, many of whom have social challenges in addition to health issues. Some are their family’s sole caretaker; many are dealing with housing or transportation issues or food insecurity. These complexities often go unaddressed by health-care providers.
The experience of many such Medicaid patients who struggle to see primary-care doctors inspired me to partner this spring with Project Access New Haven, a nonprofit in Connecticut that provides services to frequent ED users who have Medicaid. Patients work with a “navigator” dedicated to helping them maneuver through our complex health system. The patient and navigator work as a team to figure out transportation and housing problems, get food vouchers, make immediate appointments with primary-care doctors or address other issues that can improve patients’ health.
If all states implement the Affordable Care Act, 18 million more people will be enrolled in Medicaid by the end of 2016. Even if some states opt out, the program is poised for a huge expansion. But having insurance does not guarantee access to health care. Policymakers need to explore and reduce the barriers Medicaid patients face as millions join an already overburdened system.