Changes in Emergency Department Payer Mix Among Children Following Medicaid Unwinding in Texas

Objective: To examine trends in children's emergency department (ED) visits' payer mix before and after Texas initiated Medicaid unwinding. Study Setting and Design: We conducted a retrospective, secondary data analysis of children's ED visits in Texas, aggregated at the facility level. We analyzed trends in ED visit payer mix before and after Texas initiated unwinding and employed an interrupted time series design to examine the association between unwinding and ED visit payer mix. Data Sources and Analytic Sample: We used data from the Texas Emergency Department Public Use Data Files encompassing all children's ED visits between 2021 Q2 and 2024 Q2 and included 7.6 million visits from 472 facilities. Principal Findings: Average quarterly visits per facility increased from 1225.2 at baseline to 1254.8 visits during the post-unwinding period (p < 0.001). The average share of quarterly Medicaid visits declined by 11.7% (−7.2 pp.; from 64.3% to 57.1%, p < 0.001) in the post- relative to the pre-unwinding period. This decline was split between a 12.5% increase in the average share of quarterly ED visits attributed to commercial plans (3.4 pp.; from 26.0% to 29.4%, p < 0.001) and a 45.2% increase in the share attributed to uninsured children (3.8 pp.; from 6.9% to 10.7%, p < 0.001). Conclusions: Unwinding was associated with decreased ED visit share for Medicaid among children, while commercial and uninsured ED visit shares increased.