When PR meets the ER: Behavior Change and the Medicaid Debate

April 27, 2015

We all know healthcare costs have gotten astronomical of late, and it’s a hot-button issue for Texas — one of the states currently at the epicenter of the Medicaid debate. The big question at the forefront of media coverage is: (1) should Texas expand Medicaid and in the process, receive additional federal funding or (2) reject federal funding and risk having taxpayers subsidize the cost of uncompensated care?

People on both sides of the debate have their own arguments, but what if the issue centers on the completely wrong question?

One of the driving messages behind the issue is that covering more people with Medicaid equals less out-of-pocket ER visits that translate into uncompensated care costs for taxpayers. However, a study out of Oregon shows that’s not necessarily the case.

In 2008, the state of Oregon realized it had enough surplus budget to cover an additional 10,000 individuals. Because the number of individuals who would qualify far exceeded 10,000, Oregon decided to use a lottery-based system to determine who would get coverage. The results were a natural experiment — a treasure trove of data to help boil things down to numbers and take the partisan debate out of the equation.

Contrary to what is a popular argument in favor of Medicaid expansion, the study found that covering the uninsured in Oregon actually increased emergency room use by 40 percent.

This is because people covered by Medicaid simply let Medicaid cover the cost of their emergency room visits, but didn’t actually change their behavior by taking advantage of preventative care. Amy Finkelstein with J-PAL out of MIT explains this lack of behavior change further (as told to Freakonomics):

“The premise for why covering the uninsured with Medicaid would get them out of the emergency room is that Medicaid makes the doctor’s office free and so now people would go to the doctor, instead of going to the emergency room. But what you forget is that Medicaid also makes the emergency room free. And so…while you’re allowed to go to the emergency room and you have to be treated even if you don’t have insurance, you can be charged for it after the fact, which means you either have to pay it out of pocket or you may have collection agencies harassing you and that can affect your credit rating or just be unpleasant.”

Thus, the study showed emergency visits increased after expanding Medicaid since the state now covered those out-of-pocket expenses.

On the flip side, the study also found that people covered by Medicaid were both less depressed and more financially secure — so, as you can imagine pundits on both sides latched onto these distinct different pieces of the research to further their arguments.

However, to get out of the political weeds, the larger message here is that there’s a lot more to the story than a partisan debate on the expansion of Medicaid. Instead, what we have is a problem of behavior change — which is exactly the type of situation Hahn Public likes to help our clients navigate.

According to Cialdini’s “Influence,” a book on the science of persuasion, there are several tactics public relations practitioners can use to help enact a behavior change, and in this case, reduce emergency room visits.

To solve the problem, research is needed to determine what motivates Texans to utilize the emergency room over primary care doctors. What percent of emergencies are warranted emergency room visits? What is the breakdown in types of visits? Is it the common cold? Is it acute problems that could be prevented by managing long-term problems like diabetes and hypertension? Once armed with data, we can then figure out which “weapon” of influence should be implemented.

Cialdini provides a guidebook with several techniques, but the following stand out to me as potential fits for this particular issue:

Authority We could appeal to the Authority principle and provide statistically cited evidence about time and money wasted in the ER.

Consistency We could use the Consistency principle and set up a program asking patients to make a public commitment to their health — pledging to make regular visits to their primary care doctor. We could take it one step further by adding a social media component, asking patients to post to social media by providing a relevant hook — further solidifying the commitment.

Loss Framing We could use Loss Framing to point out potential quality of life that could be lost by not going to the doctor regularly and the dangers in not detecting high-risk diseases in the early stages.

Loss Framing seems to me to likely be the most effective in this type of scenario, and the thought of saving all Texans on uncompensated healthcare costs is certainly an encouraging thought. In the meantime, we’ll stay tuned and see where Texas lands in the Medicaid debate.

Originally published at www.hahnpublic.com on April 27, 2015.

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