Affordable Care Act: Fewer ED Visits? Not Yet

JULY 01, 2015
Sanjey Gupta, MD
One of the goals of  the Affordable Care Act was to decrease non-emergency visits to hospital emergency rooms.

On June 25th, in the King vs. Burwell case, the Supreme Court upheld a key portion of the Affordable Care Act that permits health insurance subsidies for all qualifying Americans regardless of whether their home states had established insurance marketplaces. This ruling insures that the millions of individuals who depend on the Affordable Care Act for insurance coverage through the purchase of individuals plans or through the expansion of Medicaid programs will maintain their health care plans. 

Despite the success of this ruling, a reality that is often faced is that health insurance coverage does not guarantee access to medical care. Emergency physicians and other emergency department staff are already seeing this phenomenon firsthand. Patients are apparently visiting the ED more than ever. 

In May, 2015, a poll commissioned by the Emergency Medicine Action Fund reported that three-quarters of emergency physicians felt emergency visits were going up. 

Of the almost 2100 emergency medicine physician respondents, about 90% stated that the severity of illness or injury among emergency patients has increased or stayed the same. 

Additionally, 28% of the respondents reported significant increases in emergency patient visits since the implementation of the individual insurance mandate of the ACA, which began in January, 2014. 

Further, 56% of respondents reported an increase in the number of patients with Medicaid insurance.  This trend runs contrary to one of the primary goals of health care reform, i.e. to improve access to primary care by increasing the number of patients with insurance and subsequently reducing the number of patient visits in the nation’s emergency departments.

The cause of this increase in emergency department visits is multifold and follows many recent observations of trends in medicine. 

The nation is struggling with a shortage of primary care physicians and many primary care doctors do not accept Medicaid insurance due to its generally low reimbursement rate.  Second, many recently insured and low-income patients have personal barriers to attending primary care visits, like the inability to take off of work to go for a doctor’s visit or problems arranging transportation to physically get to a visit. 

Further, the convenience of the emergency department being available to provide care by a physician 24 hours a day makes it an attractive alternative to waiting for a primary care visit, which may take weeks to schedule.    
  
These increases in emergency visits after the implementation of the Affordable Care Act are not likely to abate any time soon. 

Until access to primary care services is improved, the emergency department will hold an important, yet not 100% suitably utilized, site for care. What has been truly reinforced with the enactment of the Affordable Care Act is that the emergency department is the last safety net for care in the United States for all people regardless of their ability to pay. 


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