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JAMA Intern Med. 2019 Apr 1. doi: 10.1001/jamainternmed.2019.0037. [Epub ahead of print]

Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition.

Author information

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut.
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Yale University School of Medicine, New Haven, Connecticut.
Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.
Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Clover Health, Jersey City, New Jersey.



Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives.


To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care.

Design, Setting, and Participants:

A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included.

Main Outcomes and Measures:

The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis.


Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33).

Conclusions and Relevance:

After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.

[Available on 2020-04-01]

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