The Affordable Care Act and Emergency Care

Mark McClelland, DNP, Brent Asplin, MD, MPH; Stephen K. Epstein, MD, MPP; Keith Eric Kocher, MD, MPH; Randy Pilgrim, MD; Jesse Pines, MD, MBA, MSCE; Elaine Judith Rabin, MD; Niels Kumar Rathlev, MD


Am J Public Health. 2014;104(10):e8-e10. 

In This Article

Abstract and Introduction


The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.


The Affordable Care Act (ACA) focuses on improving access and quality by expanding insurance coverage, using payment reform strategies, and increasing quality reporting.[1] In the ACA, hospital-based emergency departments (EDs) are referenced as places to be avoided and reduced; no new payment models focus on ED care, and there are no plans to broadly address ED-specific quality through new measurement programs.

Promoting value in ED care needs to be a greater focus for policymakers as the ACA is implemented. Emergency departments play a central role in health care delivery as the staging area for the ill and injured, and as an always-available resource for unscheduled care. Emergency department physicians constitute less than 5% of the US physician workforce, yet manage 28% of acute care encounters.[2] Historically, the need for EDs arose from increases in vehicular trauma that accompanied the expansion of the Interstate Highway System in the 1960s.[3] However, EDs also quickly became providers of low acuity unscheduled care as well.[4] The Emergency Medical Treatment and Active Labor Act legislation passed in 1986 institutionalized EDs as provider of last resort for all, regardless of their ability to pay. Emergency departments have replaced the community physician's office as the primary source for hospital admissions and provide a safety net for the uninsured, underinsured, and medically disenfranchised.[5,6]

Several elements of the ACA—the insurance expansion, patient-centered medical homes, accountable care organizations, and bundled payments—will directly affect both demand for ED care and expectations for its role in providing coordinated care. We explore these effects and suggest some practical ways that EDs can be better integrated into these efforts.