A visit to the emergency room is never cheap — it’s often an apparent contest to see how many different medical practitioners can bill you all at once. But a new study shows the sticker shock is especially acute in Nevada.

The Health Care Cost Institute revealed last week that the cost of an emergency room visit in Nevada — excluding services actually performed — is rising at the fastest rate in the country, increasing 147 percent between 2009 and 2016. In addition, the average price per visit was $1,281, just barely behind California, the most expensive state.

The Review-Journal’s Jessie Bekker reported that experts have a number of theories for the soaring prices, including a sicker population and efforts by hospitals to maximize insurance reimbursements. While those factors may certainly play a role, they likely pale in comparison to the elephants in the room: illegal immigrants and Medicaid expansion.

A January report on money.cnn.com found that as many as 71 percent of undocumented workers lack health insurance. For many, their health care facility of choice is the emergency room. In addition, “many forgo preventive care, making chronic conditions worse — and more expensive to treat,” the report noted. That forces hospitals to cost-shift by raising prices on insured patients.

Then there’s Medicaid. In 2014, Gov. Brian Sandoval grabbed the federal money dangled as part of Obamacare and agreed to relax eligibility requirements for the program, originally created as a safety net for the poor. As a result, enrollment exploded to include many able-bodied, middle-income adults. In 2010, about 232,000 Nevadans participated; that number was more than 637,000 in 2017.

But Medicaid reimbursement rates are set by Washington and typically lag behind the rates private insurance carriers pay. If more Medicaid patients are visiting Nevada emergency rooms, it would make financial sense for hospitals to make up the difference by again shifting costs onto those with private insurance.

Medicaid expansion was sold to the states as a way to reduce their uninsured populations while the federal government picked up the tab for the first three years. What’s that old saying about a “free lunch”? In fact, these policy decisions have significant costs, and taxpayers must ultimately foot the bill. Nevada’s emergency rooms aren’t immune from economic reality.