One of the hoped-for outcomes when the insurance provisions established by the Affordable Care Act (ACA)—including the expansion of state-based Medicaid programs and public health insurance exchanges—went into effect in 2014 was that the number of uninsured patients seeking care in U.S. emergency departments would decline.
Some experts predicted that the new coverage would also reduce ED visits overall, anticipating that previously uninsured individuals would be more likely to seek primary and preventive care, which would mitigate the need for emergency care. Others expected the opposite, positing that increases in insurance coverage would increase utilization of all types of care, emergency care included.
Uninsured ED visits did indeed decline in the wake of the ACA, according to a 2019 study that examined nationally representative data to describe the longitudinal associations of the ACA with ED visits and hospital discharges. After a seven-year period in which uninsured ED visits remained largely unchanged, going from 16 percent in 2006 to 14 percent in 2013, investigators from Stony Brook University and George Washington University School of Medicine found that the percentage of uninsured patients coming to the ED decreased by 2.1 percent per year beginning in 2014, dropping to eight percent in 2016 (p=.003). Annual ED visits by patients receiving Medicaid, meanwhile, increased from 26 percent in 2013 to 34 percent in 2016. (JAMA Netw Open. 2019;2:e192662; http://bit.ly/2nwCksY.)
At the same time, there was a significant change in the payer mix for ED patients beginning in 2014, with a proportional shift from uninsured individuals to those receiving Medicaid, and per capita ED visit rates increased more in states that expanded Medicaid than in those that did not. (Ann Emerg Med. 2017;70:215.) The researchers found that total ED use per 1000 population increased by 2.5 visits more in 14 Medicaid expansion states than in 11 nonexpansion states after 2014.
Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, the share of ED visits covered by Medicaid in expansion states increased by 8.8 percent, while the uninsured share decreased by 5.3 percent.
Iron Law of Economics
The lead author of the study, Sayeh Nikpay, PhD, MPH, an assistant professor of health policy at Vanderbilt University, said the ACA promised a change in payer mix for hospitals by expanding coverage to more people, and that has played out. “Hospitals only collect about 11 cents on the dollar for an uninsured patient compared with about 70 to 80 cents on the dollar for Medicaid patients,” she said. “But one of the iron laws of economics is that when the price for something goes down, people tend to use more of it. Some people assumed that patients would seek primary care instead of emergency care as a result of the ACA.
“But as wonderful as the ACA is—it has made incredible advances in improving financial security for people who were formerly uninsured and bolstered the health care safety net in states that expanded Medicaid—it focuses on financing and not on the delivery system. Because not a lot has changed in the milieu of how people access care, people still have to seek care in the ED. It's not as if the ACA radically changed the primary care environment so people could more easily access medical providers on nights and weekends.”
Primary and outpatient care are not ready to serve as alternatives to the ED, said Adam J. Singer, MD, one of the authors of the 2019 JAMA Network paper. “The idea was that if patients who had relatively minor issues had ready, insured access to outpatient services and primary care, they'd use that instead of the ED,” he said. “But outpatient services are not always readily available and particularly not available to people on Medicaid because reimbursement is terrible. If I have a cough and fever that's getting worse and I'm concerned I might have pneumonia and the next appointment I can get with a primary care doctor who takes Medicaid is not until next week, I'll go to the ED.”
Prior to the COVID-19 pandemic, efforts by the Trump administration and Republicans in Congress to erode the ACA did not, from data so far, appear to decrease use of the ED, said Jesse Pines, MD, the national director of clinical innovation at US Acute Care Solutions and a co-author of the JAMA Network study. “From the 2017 data, we know that that year at least did not show significant reductions in ED visits,” he said. “People still go to the ED when they're sick and injured and need to be there.”
Another confounding finding is that not much has changed even though the case mix coming to the ED changed, with fewer uninsured patients and more Medicaid-insured patients from the perspective of overall hospital revenue. Studies have confirmed that in states that expanded Medicaid under the ACA, Medicaid revenue rose sharply and uncompensated care costs fell sharply, relative to nonexpansion states, and new research by Dr. Pines and colleagues suggested that the relative rise in Medicaid revenue in expansion states was offset by a relative decline in other nongovernment revenue, principally from commercial insurance. (SSRN. July 11, 2019; https://bit.ly/2UMTT5d.)
Even expansion-state hospitals that in 2013 were in the top decile for Medicaid discharges and total discharges, or proportion of uninsured patients, did not gain revenue, relative to similar hospitals in nonexpansion states.
“We're not totally certain why this is occurring,” Dr. Pines said. “It could be that they are renegotiating contracts, or that there is some other relationship that's going on between private insurance companies and hospitals that could explain this, but at this point it's unclear what the balancing factor was.”
Full Medicaid expansion did increase payments for emergency physicians' professional services compared with reimbursement in nonexpansion states, Dr. Pines found in another study, which was driven “primarily by lower proportions of uninsured patients and increased reimbursement per visit for both commercially insured and self-pay patients in states with full Medicaid expansion.” (Ann Emerg Med. 2019;73:213.)
All of these findings are, of course, likely to be thrown into chaos by the system-disrupting effects of the COVID-19 pandemic. The pandemic itself produced a dramatic decline in ED visits, said Dr. Pines, and it is only starting to return as of June 2020. “There was a major reduction in the volume of ED visits like we have never seen before, primarily caused by the closing of the broader health system and fear of contagion with coming to the ED,” he said. “It's also possible that people staying home had fewer opportunities to get into accidents, producing a lower need for ED use. Whether or not people are comfortable coming back to the ED as states open back up remains an open question.”
Some 30 million Americans lost their jobs and their employer-sponsored health insurance in the first six weeks after businesses began shuttering as a result of the national health emergency. “The number of uninsured people is going to rise tremendously in the short term and for some unknown extended period,” said Dr. Singer. “We're in a very dynamic situation where we really don't know what is going to happen and how that will affect ED traffic.”
These are just the early numbers. There was a surprising upturn in hiring in a jobs report issued in early June, but those numbers were quickly revised downward. Dr. Nikpay said she also expected to see a second wave of losses. “The initial wave was service jobs and other lower-wage jobs; I'm expecting the white-collar job losses to come later,” she said. “The numbers we've had just so far translate to about 78 million people who live in a household or are otherwise dependent on someone who's experienced job losses.”
What options do those people have for health care? Approximately 12.7 million more people are expected to qualify for Medicaid, Dr. Nikpay said. “That safety net will be a workhorse here, and it will do more than it would have done otherwise because of Medicaid expansion,” she said. “Another powerful new policy lever not available in the past recession where we had unprecedented job losses is marketplace coverage. The Kaiser Family Foundation predicts that 8.4 million people will be able to pick up subsidized marketplace coverage. If those figures are correct, then about 20 million people who have lost employer-sponsored health insurance will be able to pick up coverage bolstered by the ACA, but that leaves nearly 10 million people who need coverage.”
Increased ED Visits
Emergency departments can almost certainly expect to see an increase in uninsured patients because Medicaid and marketplace coverage cannot absorb all of the lost employer-sponsored coverage, Dr. Nikpay said. “But they can also expect to find that a lot of the more ‘discretionary’ traffic might go down. People who have lost generous employer-sponsored coverage might not seek that care. But is that a good thing? Probably not. Someone with chest pain might wait longer to go to the ED, for example, and not get care for a heart attack in time.”
There may also be new restrictions on Medicaid coverage as the rolls of state-level Medicaid programs swell. “Some states have already been working on how to reduce costs as their Medicaid programs expand dramatically at the same time they will have less state revenue from taxes with people losing their jobs,” Dr. Pines said. “One obvious way would be to limit coverage in some way. Would they, perhaps, reduce the number of ED visits covered per year? That would obviously involve more hardship to the ED than to the patient since if the patient can't pay and Medicaid won't pay, it becomes a free visit under EMTALA.”
Another factor is telemedicine, which has held the potential to drive down health care costs and ED utilization and has exploded as a result of the pandemic. “The number of visits at our institution went up from just a few per day to hundreds or thousands, and that's being mirrored all over the country,” said Dr. Singer. “One of the impediments to telemedicine was figuring out reimbursement, but COVID led to emergency action and suddenly people are getting paid. Will we be able to capitalize on that going forward? In the new normal, perhaps we will continue using telemedicine in a more expanded way, and that could be used to triage ED traffic.”
Meanwhile, even as more and more people must rely on the ACA-created health insurance exchanges or ACA-expanded Medicaid programs for their health insurance coverage, efforts to dismantle the law continue. The Supreme Court will hear arguments later in 2020 on a lawsuit from GOP-led states aiming to overturn the ACA, arguing that the law was invalidated when Congress eliminated its tax penalty for not having health insurance.
“It's troubling that just at a time when the ACA is needed most, people are trying to repeal it,” said Dr. Nikpay. “I can't even think through what the impact of its loss would be on households that rely on it. And if that happens, beyond just coverage, what will it mean if the law is gutted and we lose the protections for pre-existing conditions? COVID-19 is clearly a pre-existing condition, and we are seeing that there is a long path to recovery. Repealing the ACA at this point would throw gasoline on an already terrifying fire.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.