Community Uninsurance Rates and Expenditures on Emergency Room Care: Is there Evidence of a Spillover?

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Slide 1

Community Uninsurance Rates and Expenditures on Emergency Room Care: Is there Evidence of a Spillover?

James Kirby
AHRQ

Slide 2

What is "Spillover"?

• The number of uninsured people in a community may affect medical care for everyone, even those with health insurance.

Slide 3

Why Might Spillover Occur?

• A large number of uninsured residents may:
  • Provide a less stable revenue base for providers.
  • Result in high levels of uncompensated care.

Slide 4

Literature

• Previous literature focuses on access.
• Spillover to cost is not examined.
• Spillover in the context of emergency rooms is not examined.

Slide 5

Research Questions

• Do insured individuals living in areas with many uninsured people pay more for emergency room care?
• How does this differ by insurance type?

Slide 6

Data Sources

• Individual-level data: Medical Expenditure Panel Survey, 2009:
  • Adults with at least one emergency room visit who live in a county with 65,000 residents or more (N=3,773).
• County-level data: American Community Survey, 2009.

Slide 7

Main Variables

• Main Outcome variable:
  • Average expenditure per emergency room visit.
• Main Independent variables:
  • County-level: Number of uninsured individuals per emergency room.
  • Individual-level: Insurance status.

Slide 8

Control Variables

Individual-level.

• Race/ethnicity.
• Sex.
• Age.
• Subjective health.
• Serious chronic conditions.
• Poverty status.

County-level:

• Poverty rate.
• Unemployment rate.
• Number of Federally Qualified Health Centers (FQHC) per capita.
• MSA vs non-MSA.

Slide 9

Methods

• Generalized Linear Model:
  • Family: Gamma.
  • Link: Log.
• Marginal predictions in dollars.

Slide 10

Means of Main Variables

Slide 11

Marginal Predictions for Per-Visit Emergency Room Expenditure, All Adults

Image: A bar graph compares expenditure for the Uninsured All Year and the Insured Anytime:

Uninsured All Year:

• 10,000 uninsured per ED: $1,004.
• 20,000 uninsured per ED: $1,009.
• 30,000 uninsured per ED: $1,013.

Insured Anytime:

• 10,000 uninsured per ED: $950.
• 20,000 uninsured per ED: $1,006.
• 30,000 uninsured per ED: $1,065.

Slide 12

Marginal Predictions for Per-Visit Emergency Room Expenditure, All Adults

Image: A bar graph compares expenditure for the Uninsured All Year and those with private and public insurance:

Uninsured All Year:

• 10,000 uninsured per ED: $1,004.
• 20,000 uninsured per ED: $1,009.
• 30,000 uninsured per ED: $1,013.

Private:

• 10,000 uninsured per ED: $1,116.
• 20,000 uninsured per ED: $1,177.
• 30,000 uninsured per ED: $1,241.

Public:

• 10,000 uninsured per ED: $579.
• 20,000 uninsured per ED: $662.
• 30,000 uninsured per ED: $757.

Slide 13

Marginal Predictions for Per-visit Emergency Room Expenditure

Image: A line graph compares mean-per-visit expenditures for the uninsured and those with private and public insurance. Mean-per-visit expenditures for the uninsured remains at about $1,000 for number of uninsured per emergency room in a county from 2,000 to 82,000. Mean-per-visit expenditures for those with public insurance rises from $500 at 2,000 uninsured per emergency room in a county to $1,700 at 82,000. Mean-per-visit expenditures for those with private insurance rises from just above $1000 at 2,000 uninsured per emergency room in a county to $1,700 at 82,000.

Slide 14

Summary & Conclusion

• The number of uninsured people per ED in a county is positively associated with average expenditures per ED visit:
  • This association exists only among insured individuals.
  • The association is strongest among those with public insurance.
• Reducing the number of uninsured people in communities may lower ED expenditures for the insured, but especially for those with public insurance.

Slide 15

Limitations

• Unobserved differences in intensity of use?
• Unobserved differences in county characteristics?