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


Recent studies have reported an increase in uninsured patients being transferred from emergency departments (EDs) to other hospitals, which may result from financial incentives. In this study, the researchers wanted to understand differences in transfer and discharge rates by patient insurance status. To do so, they analyzed ED visits for pulmonary disease between January and December 2015. These visits were at hospitals that could provide care necessary for the treatment of pulmonary disease. The primary outcomes were ED discharges, transfers, and hospital admissions. The researchers calculated the rates at which uninsured patients were discharged or transferred compared to patients with Medicaid/Medicare or private insurance. They also examined whether the hospital being nonprofit or for-profit had an effect on these rates.

The researchers analyzed 215,028 ED visits at 160 hospitals. The average age of patients was 55 years old, and they were mostly female. The researchers found significant differences in ED discharge and transfer, and hospital admission across different EDs. They also found that compared to patients with private insurance, uninsured patients were more likely to be discharged and transferred. Patients on Medicaid had similar rates of discharge but higher rates of transfer compared to patients with private insurance. For-profit hospitals had higher rates of ED transfer than non-profit hospitals.

In conclusion, the study found that uninsured patients and patients on Medicaid were subjected to higher rates of hospital transfer, even when they had the same medical conditions as patients with private insurance.


The researchers wanted to identify and understand differences in transfer and discharge rates between patients with different insurance statuses. They also wanted to understand if hospital ownership status (nonprofit or for-profit) had an effect on these differences.


The United States passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, which works to ensure equitable access to emergency care. The act was passed because at the time, many hospitals refused to provide care to patients who went to emergency departments (EDs) and were uninsured or underinsured. This resulted in these patients being transferred to other hospitals, which compromised their care. Although blatant violations of EMTALA are rare, more subtle violations that occur after admission into the ED have not been examined.

Previous studies show that uninsured/underinsured patients are more likely to be transferred than admitted, especially for conditions requiring specialized (and usually expensive) care. However, these studies did not account for differences in whether hospitals could provide this specialized care at all. So, these results may reflect actual patient needs for specialty care. Previous studies also did not include discharge, in addition to transfer and refusal of hospital admission, as a potential way to limit access to care.

In this study, the researchers tested the hypothesis that uninsured/underinsured patients with pulmonary conditions are more likely to be transferred or discharged from the ED even though the hospital could provide the necessary specialized care. They also sought to understand whether hospital ownership status had an effect on whether uninsured/underinsured patients were transferred or discharged.


Characteristics of Study Sample

215,028 studies were identified at 160 intensive-care capable hospitals. Of these visits for pulmonary diseases, 66.5% resulted in ED discharge, 1.5% resulted in ED transfer, and 32.1% resulted in hospital admission. Patients had a median age of 55 and were mostly female. 9.4% of visits were uninsured, 25.5% insured by Medicaid, 65.1% insured by Medicare or private insurance.

The hospitals included in the study were mostly non-teaching hospitals in urban areas. The median number of ED visits for pulmonary conditions was 1175.

Main Findings

Hospital-Level Variation in ED Disposition

At the hospital level, the researchers found a lot of variation in ED discharge, ED transfer, and hospital admission rates. Variation was particularly high for ED transfers.

ED Disposition and Insurance Status

Uninsured/Medicaid patients were transferred more often than privately insured/Medicare patients, even after adjusting for other variables. In addition, uninsured patients were more likely to be discharged, but Medicaid patients had similar rates of discharge to privately insured/Medicare patients.

Hospital Ownership Status

Among the 71 hospitals included in the secondary analysis, 23 were for-profit and 48 were nonprofit. The probability of ED transfer for uninsured patients was lower than that of privately insured patients in nonprofit hospitals, but higher in for-profit hospitals. Uninsured patients also had higher probability of ED discharge both non-profit and for-profit hospitals. Medicaid patients had lower probabilities of ED transfer in both non-profit and for-profit hospitals.


In this study, the researchers found that uninsured/Medicaid patients were more likely to be transferred to another hospital than patients with private insurance, even if they have the same medical conditions and hospitals have the capability to care for them. This is consistent with previous studies and confirm that a patient’s ability to pay may influence decisions about hospitalization.

Uninsured patients were also more likely to be discharged from EDs. Uninsured patients had nearly half the hospital admission rate of privately insured patients even though guidelines for diagnosis and hospitalizations for pulmonary conditions are standardized across hospitals. These findings suggest that there may be a higher threshold for admitting uninsured patients than for insured patients, which has also been confirmed in previous studies about trauma, cardiovascular, and pulmonary diseases. Lack of admission for these diseases has been associated with increases in deaths.

Traditional violations of EMTALA through complete refusal of ED care are rare. However, the results of this study suggest that there may be more subtle violations of EMTALA after patients enter the ED, and that there may be financial incentives associated with hospital admission from the ED. Policymakers should seek to address this loophole to develop policies that fully support the hospitalization of uninsured patients.

The researchers restricted analysis to hospitals that were able to provide critical care for patients with pulmonary conditions. This enabled them to more accurately say that ED transfers/discharges are financially motivated. By accounting for discharges, transfers, and admissions, the researchers were also able to consider all kinds of ED disposition.

An encouraging finding is that patients with Medicaid/Medicare had similar rates for hospital admission with privately insured patients. This aligns with previous studies that found that access to care for people with public insurance has improved.

In contrast to previous studies, this study found that for-profit hospitals were more likely to transfer uninsured patients compared to non-profit hospitals. Although the financial incentive behind these findings are clear, more studies should be done to make conclusions.


Study Design and Setting

The researchers analyzed ED visits from the 2015 National Emergency Department Sample (NEDS) between January and December.

Selection of Participants and Measurements

The researchers included all ED visits of patients over 18 years old that resulted in transfer, discharge, or hospital admission. Demographic data of these visits included age, sex, insurance status, median income of the area where they lived, and diagnoses. The researchers accounted for comorbidities and identified insurance statuses as uninsured , Medicaid, Medicare, or private.

For the primary analysis, the researchers examined ED visits for uninsured patients and Medicaid patients, since previous research suggested higher transfer rates for these groups.

The researchers limited ED visits to common medical conditions not requiring specialized care. Specifically, they included visits for pneumonia, asthma, and chronic obstructive pulmonary disease (COPD). The researchers also limited the visits to those that had critical care capabilities for these conditions.

For secondary analysis, the researchers collected data about hospital ownership from NEDS, and categorized hospitals as nonprofit or for-profit.


The hospital-level primary outcome was ED discharge, ED transfer, and hospital admission rates. The patient-level primary outcome was ED discharge, Ed transfer, or hospital admission status. These outcomes were reported based on patient insurance status. 

ED discharge was defined as discharge to the patient’s home, transfer to a care facility, or home health care. ED transfer was defined as a transfer from the ED to another hospital. Hospital admission was defined as admission from the ED to its respective hospital.

Statistical Analysis

Primary analysis was conducted at the patient- and hospital-level. At the hospital level, the researchers calculated the rates of ED discharge and transfer, and hospital admission rates. At the patient level, the researchers calculated the probability of ED transfer or discharge compared to hospital admission based on patient insurance status.

For the secondary analysis, the researchers used data from 71 hospitals that provided information about hospital ownership. They calculated the probability of ED discharge or transfer compared with hospital admission for uninsured/Medicaid patients and Medicare/privately insured patients in nonprofit and for-profit hospitals.

All analyses were performed using SAS. 


3 decades after EMTALA, there are still differences in access to hospital care based on insurance status. Policymakers should improve access to hospital care by more broadly addressing hospital quality, payment, and certification initiatives.