Medicaid Enrollment After Hospital Presumptive Eligibility in the Emergency Department.

Importance: Hospital presumptive eligibility (HPE) is an emergency Medicaid program enabling eligible uninsured patients to temporarily access Medicaid benefits during hospital encounters. It provides a pathway to long-term Medicaid coverage, but this feature may be underutilized among patients who received HPE in the emergency department (ED) and were discharged immediately thereafter.

Objective: To characterize if 6-month Medicaid enrollment rates varied by patient demographics and ED encounter characteristics and identify factors that potentially impact enrollment.

Design, setting, and participants: A retrospective cohort study analyzing data from HPE-participating EDs in California between January 1, 2016, and December 31, 2021, was carried out from January 2024 to November 2024. Unadjusted differences in 6-month Medicaid enrollment rates among patient groups were analyzed with χ2 tests. Multivariable logistic regression was used to evaluate the adjusted odds of enrollment by different demographic and encounter characteristics. Patients aged 19 to 64 years who were uninsured, were treated and released from ED, and received HPE during the encounter were included.

Exposures: Receiving HPE during ED encounters.

Main outcomes: The primary outcome was Medicaid enrollment within 6 months after receiving HPE in ED.

Results: Of the 585 693 patients who received HPE during ED treat-and-release encounters, 175 495 were of Hispanic ethnicity (30.0%), 73 518 were White (12.6%), 33 829 were Black (5.8%), 12 824 were Asian or Pacific Islanders (2.2%), 1685 were Alaskan Native or American Indian (0.003%), 27 610 were of other race and ethnicity (0.05%), and 260 732 did not report race and ethnicity (44.5%). A total of 217 430 (37.1%) of 585 693 patientsof the total study population who received HPE during ED treat-and-release encounters enrolled in Medicaid by 6 months. In the regression model, male (adjusted odds ratio [aOR] 0.74; 95% CI, 0.72-0.76; P < .001), Hispanic (vs White: aOR, 0.94; 95% CI, 0.90-0.98; P = .007), and Spanish speaking (vs English speaking: aOR, 0.72; 95% CI, 0.68-0.77; P < .001) patients were less likely to enroll in Medicaid coverage. Annual enrollment rates declined notably following the onset of the COVID-19 pandemic (40.6% to 29.8%). Weekend encounters were more likely to have lower enrollment (vs weekday: aOR, 0.95; 95% CI, 0.93-0.97; P < .001). EDs in public hospitals (vs nonprofit: aOR, 1.27; 95% CI, 1.04-1.55; P = .02) or large hospitals (vs small: aOR, 1.13; 95% CI, 1.00-1.27; P = .04) were more likely to have higher enrollment. There was variable enrollment across different regions of California (27.3%-47.2%).

Conclusions and relevance: In this cohort study, Medicaid enrollment rates after receiving HPE in ED varied across different patient, facility, and geographic characteristics, highlighting the need for additional resources to ensure Medicaid coverage among this high-risk uninsured population.