Affordable Care Act, Health Policy, Advocacy, Health Policy Journal Club

ACA Increased Emergency Department Use


Increasing access to insurance alone does not lead to a decrease in ED visits

As the Affordable Care Act was being implemented, many politicians and health policy experts predicted a decline in ED use, as newly-insured patients would receive care from primary care providers instead of the ED, leading to more efficient and less costly health care. This study, an analysis of ED use before and after ACA implementation in Illinois, provides evidence against that conclusion.

The authors analyzed ED visits across Illinois from 2011 to 2015, comprising 36 months prior to and 24 months following ACA implementation. Although the number of ED visits by uninsured patients dropped, visits by Medicaid and private insurance patients increased more substantially, leading overall to a 5.7% increase in ED usage. Meanwhile, visit acuity appeared to remain constant, as the number of hospitalizations through the ED was essentially unchanged throughout the study period.

This study indicates that increasing access to insurance alone does not lead to a decrease in ED visits, and similar results have been found in Massachusetts, Oregon, Kentucky, and Colorado . A program in Virginia offers an interesting alternative where, in addition to receiving health care, patients were assigned to primary care providers. Although these PCPs were paid at rates higher than those offered by Medicaid, cost per patient had decreased significantly after 3 years of the program.

These potentially counterintuitive results highlight the complexity of health care reform. While providing health insurance may lead to fewer ED visits for some patients (like young adults), that effect does not hold universally. Of course, this immediate increase in ED use may be an anomaly in a long-term trend toward less ED use, though studies from Oregon have shown this effect to be fairly long-lasting. Additionally, there may be benefits to health insurance (financial security, increased PCP visits, or potentially improved overall health) that are not captured in this study. However, while removing financial barriers to receiving care is likely an important part of reforming our healthcare system, this study indicates that health insurance expansion alone is unlikely to lead to more efficient healthcare delivery through reduced ED usage.

Abstract: Dresden SM, Powell ES, Kang R, McHugh M, Cooper AJ, Feinglass J. Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act. Ann Emerg Med. 2017;69(2):172-180.

OBJECTIVE: We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state.

METHODS: Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation.

RESULTS: Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI 27,037 to 21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI 11.1 to 6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged.


CONCLUSION: ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation. PMID: 27569108

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.