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Health Policy Journal Club, Health Policy

Health Policy Journal Club: ACA Expanded Coverage for Emergencies

The ACA expansion led to more emergency visits without an increase in admissions

The Patient Protection and Affordable Care Act (ACA) sought to reduce the number of uninsured Americans. Advocates hoped that this would increase access to outpatient resources and potentially decrease ED utilization and inpatient admissions.

The authors of this study sought to determine if the ACA impacted the number of uninsured patients visiting emergency departments and whether rates of inpatient admission fluctuated. They examined data from the National Hospital Ambulatory Care Survey and the Healthcare Cost and Utilization Project from the years 2006-2016. These dates allowed the authors to see trends both before and after the ACA was implemented.

This study found that while overall emergency department visits increased during the study period, the rates of uninsured patients visiting emergency departments decreased. During this time, the proportion of Medicaid patients visiting emergency departments increased. These trends were most pronounced after 2013, when many states expanded Medicaid. This effect was most pronounced among patients age 18-64, who typically have the highest risk for being uninsured.

The data also showed that rates of admissions from the emergency department actually decreased after ACA implementation. Interestingly, this was not due to decreased emergency department utilization. In fact, the number of emergency department visits consistently increased during the study period.

This study shows that more patients who visited the emergency department after ACA implementation were insured and that more of these patients were ultimately discharged home. The ACA has provided health coverage to over 20 million Americans and has translated to higher rates of insured patients visiting emergency departments. This was also associated with lower inpatient admissions. Decreased admission rates could be due to expanded insurance leading to greater access to outpatient resources, obviating the need to inpatient admission. Yet the authors note that other factors, such as increasing use of observation services, may have also impacted this trend.

The ACA has greatly expanded health insurance coverage in this nation, changing the insurance status of our patients and maybe even be affecting our willingness to discharge them. As the future of the ACA and other health policy debates continue, emergency physicians should remain engaged. As this study shows, the outcome of these debates will impact the patients we treat.

Abstract: Singer AJ, Thode HC Jr, Pines JM. US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation fo the Affordable Care ActJAMA Netw Open. 2019;2(4):e1926626.

IMPORTANCE: The US Patient Protection and Affordable Care Act of 2010 (ACA) was enacted in 2010 with several provisions that targeted reducing numbers of uninsured Americans.
OBJECTIVE: To assess the numbers and proportion of emergency department (ED) visits (2006-2016) and hospital discharges (2006-2016) by uninsured patients, focusing on the 2014 ACA insurance reforms (Medicaid expansion, individual mandate, and private insurance exchanges).
DESIGN, SETTING, and PARTICIPANTS: Cross-sectional study of visitors to US EDs and patients discharged from US hospitals using National Hospital Ambulatory Care Survey data and Healthcare Cost and Utilization Project data, respectively, from 2006 to 2016. Data analysis took place in February 2019.
MAIN OUTCOMES AND MEASURES: Numbers and proportions of total and uninsured ED visits and hospital discharges. Simple descriptive statistics and interrupted time-series analysis were used to assess changes in uninsured visits over time and after the implementation of insurance provisions in 2014.
RESULTS: There were an estimated 1.4 billion US ED visits from 2006 to 2016 and 405 million hospital discharges from 2006 to 2016. Over the study period, ED visits increased by 2.3 million per year, while hospital discharges decreased from approximately 38 million per year prior to 2009 to approximately 36 million per year after, with no clear decrease after 2013. Proportions of uninsured ED visits were largely unchanged from 2006 (16%) until 2013 (14%) (-0.2 percentage point per year; 95% CI, -0.46 to -0.01 percentage point; P = .11) but then decreased by 2.1 percentage points per year from 2014 to 2016 (95% CI, -4.3 to -1.8 percentage points; P = .003), with uninsured visits composing 8% of the total in 2016. For patients aged 18 to 64 years, uninsured ED visits declined from approximately 20% from 2006 through 2013 to 11% in 2016 (3.1% decrease per year after 2013; 95% CI, -4.3 to -1.8 percentage points; P = .003). The proportion of hospital discharges by uninsured patients remained steady at approximately 6% from 2006 to 2013, then declined to 5% in 2014 and 4% in 2016. Similar changes were seen for patients aged 18 to 64 years, with a decrease in hospital discharges from 10% to 7% over the study period.
CONCLUSIONS AND RELEVANCE: Proportions of ED visits and hospital discharges by uninsured patients decreased considerably after the implementation of the 2014 ACA insurance provisions. Despite these changes, approximately 1 in 10 ED visits and 1 in 20 hospital discharges were made by uninsured individuals in 2014 to 2016. This suggests that continued attention is needed to address the lack of insurance in US hospital visits, particularly among people aged 18 to 64 years who have less access to governmentsponsored insurance.

PMID: 31002327

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.