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

The Wave of Newly Insured

As broad populations within the United States gain health insurance through the ACA, emergency department volumes will be affected. Forecasting future demands is challenging; however, data from similar insurance expansions provide some clues. Studies after Massachusetts' expansion showed ED visits increased at similar rates as neighboring states.[7–9] However, a National Health Interview Study report found ED use was higher among the newly insured compared with the continuously insured.[10] One of the largest groups gaining insurance status after ACA is newly eligible Medicaid beneficiaries. In an analysis of Oregon's Medicaid expansion lottery, there was a 40% increase in ED use in this population relative to those who remained uninsured.[11] However, the effect of insurance expansion will vary state-to-state depending upon whether the Medicaid expansion occurs and how local insurance markets handle the existing and newly insured. In states where large numbers move into high-deductible "bronze" plans, it is likely that ED visits will be less affected, while those with large increases in Medicaid patients will experience larger increases.

Looking backward, prereform national ED visit growth outpaced population growth. In 1995 there were 37 visits per 100 persons; by 2010, this number grew to 43 per 100.[2] Growth was fueled by a fee-for-service payment system that underpaid primary care physicians in favor of EDs, hospitals, and specialists. Over the same period, the intensity of ED care grew, as did expectations for diagnostic perfection.[12] The result is an ED system that in many parts of the nation cannot handle demands, resulting in congested waiting rooms and long delays for admitted patients.[12,13] However, a growing number of hospitals have mitigated crowding and improved flow by redesigning ED intake processes and increasing hospital efficiency.[14–18] As the ACA drives additional patients into EDs in many communities through insurance expansion, hospitals will need to employ the strategies proven to reduce crowding. In addition, further scrutiny may be placed on hospitals to reduce crowding through public reporting of ED throughput measures and inclusion of ED metrics, such as patient experience survey data, in hospital reimbursement calculations.