Health Policy, Health Policy Journal Club

Health Policy Journal Club: ACA Impact On Frequent Flyers in California

The odds of ED visits by frequent users declined after the Affordable Care Act. 

Frequent users of the Emergency Department (ED) often disproportionately consume a high amount of health care. However, much of the data describing this patient population is outdated as it does not account for potential changes since implementation of the Affordable Care Act (ACA).

This study aimed to help further our understanding of the characteristics of frequent ED users before and after coverage expansions achieved through the ACA in California. The study explored a statewide database of patient-level information collected from 2012-2015. Years 2012 and 2013 were considered pre-ACA and years 2014 and 2015 were post-ACA.

The authors found that the overall proportion of ED patients that were frequent users increased from 7.9% to 8.5%. The share of visits that were from frequent ED users likewise increased from 30.7% to 31.6%. However, this was likely confounded by a disproportionately higher percentage of patients with mental health conditions and substance abuse disorders. These patient level factors, as they have in the past, were shown to increase the odds of being a frequent ED user in this study. Once controlling for these patient level factors, the odds of being a frequent ED user were significantly lower post-ACA. When separating patients by insurance coverage, the odds of being a frequent user were lower for the uninsured and those with Medicaid, and only slightly higher for those with private insurance. 

There has been much uncertainty about how those with new insurance coverage under the ACA will choose to access care. There is some worry that due to previous inability to access ED care due to cost, newly insured patients would increase the number of frequent ED users if they could not access non-ED care. This study suggests that the opposite occurred, and the odds of being a frequent ED user decreased in the post-ACA period. This could be due to a number of factors, including an overall healthier population becoming newly insured or better access to preventative care. While these study results are limited to the state of California we should hope to see if these results can be replicated in other states or nation-wide.

PMID: 29851439

ARTICLE: Patel PB, Vinson DR, Gardner MN, Wulf DA, Kipnis P, Liu V, Escobar GJ. Impact of emergency physician-provided patient education about alternative care venues. Am J Manag Care. 2018;24(5):225-231.


Frequent emergency department (ED) use often serves as a marker for poor access to non-ED ambulatory care. Policy makers and providers hoped that by expanding coverage, the Affordable Care Act (ACA) would curtail frequent ED use. We used data from California's Office of Statewide Health Planning and Development to compare the characteristics of frequent ED users among nonelderly adults in California before and after implementation of several major coverage expansion provisions in the ACA. Frequent users-patients with four or more annual ED visits-accounted for 7.9 percent of ED patients before and
8.5 percent after those provisions were implemented, and they were responsible for 30.7 percent of all visits before and 31.6 percent after. However, after controlling for patient-level characteristics, we found that the odds of being a frequent ED user were significantly lower post ACA for Medicaid-insured patients. Uninsured patients were also less likely to be frequent users post ACA, while privately insured patients experienced little change. The largest predictors of frequent ED use included having a diagnosis of a mental health condition or a substance use disorder. Interventions to address frequent ED use must involve Medicaid managed care plans, given that more than two-thirds of frequent ED users post ACA have Medicaid as their primary coverage source.

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.

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