COMMENTARY

Emergency Care and the Affordable Care Act:How Can We Learn From the Past to Predictthe Future?

I n this issue of Academic Emergency Medicine, Heav-rin and colleagues1 report data from the HealthcareCost and Utilization Project on how the demand for

emergency department (ED) and hospital services chan-ged after TennCare, which administers Medicaid insur-ance in the state of Tennessee, disenrolled 171,000 adultsin 2005.1 After disenrollment, the ED case mix shiftedtoward lower rates of TennCare beneficiaries being seenand higher rates of the uninsured, but the net result wasa reduction in the rate of ED visits: visits by TennCarebeneficiaries fell more than the increase in visits by theuninsured. Despite a decrease in overall visits, the admis-sion rate for the uninsured increased slightly (by 2%),suggesting that disenrollment may make the uninsuredED population sicker.

Studies that test how changes in insurance coverageaffect the demand for ED services have become increas-ingly popular in recent years. State-level changes, suchas the one that occurred in Tennessee, are ‘‘naturalexperiments’’ in how people use health care servicesbefore and after a policy implementation and can beassessed after the fact.

The reason for increased interest in these questionsis the major looming change in U.S. insurance cover-age: the Affordable Care Act (ACA). As the ACA isimplemented, we are headed for the greatest change ininsurance coverage since the passage of Medicare in1965. Understanding how Medicaid beneficiarieschange their behavior as they move in and out of cov-erage is an important question, since more than 30 mil-lion Americans will gain health insurance coverageunder ACA, most commonly through the Medicaidprogram.2

The promise of improvement in insurance coverageis that people, through increased access to health careservices, will have improved health and better qualityof life. Presumably, increased access to outpatient pro-viders for needed preventive services should reduce EDvisits and hospitalizations by preventing people fromgetting sick. In addition, people who have a ‘‘minor’’illness that can be cared for in the outpatient systemwould go to a clinic and not a hospital.

In reality, data tell a very different story. In Tennes-see, ED visits decreased after more patients becameuninsured—the opposite of what would be expected,but the severity of those visits was higher, which wasexpected as presumably less prevention leads to higherburden of illness when people finally end up in the EDor, alternatively, perhaps some uninsured patients withminor illnesses just stayed home.

Examining data on the effects of health care reformin other states tells us a similar, but slightly differenttale. In 2008, Oregon conducted a lottery where low-income adults could apply for slots in the Medicaid pro-gram and were chosen at random.3 Data from the firstyear of the program were published this summer andshowed that those assigned to the Medicaid programwere 35% more likely to use outpatient care and 30%more likely to be admitted to the hospital and had a15% higher rate of prescription drug use.4

Surprisingly, the higher admission rates in Oregonwere not through the ED, but through other sources. Inaddition, there was no significant rise in the number ofED visits overall, although the authors warned thattheir estimates of ED use were not precise.3 Theincrease in utilization was also associated with gener-ally improved perceptions of health-related quality oflife and also better financial health, given that patientsspent less money out of pocket for health care.

After health reform increased access to insurance inMassachusetts in 2009, total ED visits increased whileat the same time, the low-severity visits decreased in asample of 11 EDs.5 Coverage expansion in Massachu-setts was associated with increased ED utilization, andthe severity of those visits was higher on average, atleast in the EDs that contributed data to the study.

Exploring data from these myriad experiments raisestwo important questions: 1) how can we use these stud-ies to project the future demand for emergency carewith ACA? 2) If increased coverage does lead to morevisits to our nation’s EDs, how should the emergencycare system respond? Before answering these questionswe need to first describe the baseline, because in com-parison to the last large national expansion in healthcoverage in 1965, the state of our emergency caresystem today is very different.

As many of us know, many EDs, particularly those inurban public hospitals, are overwhelmed, underfunded,

ª 2011 by the Society for Academic Emergency Medicine ISSN 1069–6563doi: 10.1111/j.1553-2712.2011.01212.x PII ISSN 1069–6563583 1189

A related article appears on page 1121.

and experiencing yearly increases in visits that outpacepopulation growth.6 The number of EDs has shrunk bya quarter over the past two decades, and the popula-tions treated are sicker, older, and tend to remain inthe ED for longer periods of time receiving more inten-sive services.7 Compounding this is the practice of‘‘boarding’’ admitted patients in the ED for hoursor days as they wait for scarce inpatient beds. In bil-liards terms, the emergency care system can best bedescribed as ‘‘behind the eight ball,’’ making additionalsystem strains potentially devastating.

One of the commonalities among the natural experi-ments is that as people become insured, they tend touse more health care services in general; they reduceuse when they become uninsured. This makes sensewith what we know about moral hazards: as partiesbecome more insulated from risks (i.e., payment forservices), they are likely to behave differently (i.e., usemore services), as was originally demonstrated in theRAND Health Insurance Experiment of the 1970s.8 Fur-ther, when patients have coverage, they assume theyshould have access. However many primary care physi-cians do not accept patients with Medicaid or evenMedicare, and many already have as many patients asthey can manage. So for these newly insured, coveragedoes not mean access, except through the ED.

Therefore, the likely result of the ACA will be anincrease in demand for emergency services; however,the increases may vary dramatically based on the localhealth care environment, as different magnitudes ofeffects were seen in Tennessee, Oregon, and Massachu-setts after the introduction and removal of coverage.Specifically, the local effects will probably vary basedon the availability of EDs, outpatient providers, and thenumbers of uninsured who get insurance.

Different communities have very different health careresources. Communities with fewer outpatient providerswill likely see a higher surge in ED visits. Similarly, inareas where there are higher numbers of uninsured whogain health insurance, there will likely also be more EDvisits. There may even be an interaction where communi-ties with both low numbers of outpatient providers andhigh rates of uninsurance (which describes a not insignif-icant portion of the United States) may experience aneven more dramatic surge in ED visits.

The second question is whether the emergency caresystem can absorb this increase in volume and orillness. The answer is: only if EDs function at peakefficiency. Most importantly, that means ending thepractice of boarding patients in the ED.

It is also important to recognize that the promise ofbroadening health insurance in improving long-termhealth really has more to do with enhancing primarycare: not EDs, not hospitals, and not specialists. Paymentreform through accountable care organizations, effortsto enhance the medical home, and increases in the num-ber of medical schools are all intended to improve pri-mary care capacity and make this value proposition areality. The problem is that these reforms may take yearsif not decades to realize any meaningful change. EDstoday already provide a disproportionate share of carefor patients with acute medical problems, compared toprimary care providers.9 That seems unlikely to change.

As we look to the future of ED care and rollout ofthe ACA in coming years, it is important to recognizethat natural experiments like the ones in Tennessee,Oregon, and Massachusetts all provide important cluesto the changing tides of health care services demands.More importantly, as we prepare for the eventual rushof patients, we need to look to our communities toensure that services are available both within and out-side of hospitals to meet the health care needs of ourlocal populations.

Jesse M. Pines, MD, MBA, MSCE(jesse.pines@gwumc.edu)Departments of Emergency Medicine and Health PolicyGeorge Washington UniversityWashington, DC

Sandra M. Schneider, MDDepartment of Emergency MedicineUniversity of RochesterRochester, NY

Steven L. Bernstein, MDAssociate EditorAcademic Emergency MedicineDepartment of Emergency MedicineYale University School of MedicineNew Haven, CT

References

1. Heavrin BS, Fu R, Han JH, et al. An evaluation ofstatewide emergency department utilization follow-ing Tennessee Medicaid disenrollment. Acad EmergMed. 2011; 18:1121–1128.

2. Sommers BD, Epstein AM. Medicaid expansion–thesoft underbelly of health care reform? N Engl J Med.2010; 363:2085–7.

3. Baicker K, Finkelstein A. The effects of Medicaidcoverage–learning from the Oregon experiment. NEngl J Med. 2011; 365:683–5.

4. Finkelstein A, Taubman S, Wright B, et al. The Ore-gon Health Insurance Experiment: Evidence Fromthe First Year. NBER working paper no. 17190. Cam-bridge, MA: National Bureau of Economic Research,July 2011.

5. Smulowitz PB, Lipton R, Wharam JF, et al. Emer-gency department utilization after the implementa-tion of Massachusetts health reform. Ann EmergMed. 2011; 58:225–34.

6. Tang N, Stein J, Hsia RY, et al. Trends and character-istics of US emergency department visits, 1997-2007.JAMA. 2010; 304:664–70.

7. Hsia RY, Kellermann AL, Shen YC. Factors associ-ated with closures of emergency departments in theUnited States. JAMA. 2011; 305:1978–85.

8. Brook RH, Ware JE Jr, Rogers WH, et al. The Effect ofCoinsurance on the Health of Adults: Results Fromthe Rand Health Insurance Experiment. Availableat: http: ⁄ ⁄ www.rand.org ⁄ pubs ⁄ reports ⁄ 2006 ⁄ R3055.pdf. Accessed Sep 6, 2011.

9. Pitts SR, Carrier ER, Rich EC, Kellermann AL. WhereAmericans get acute care: increasingly, it’s not at theirdoctor’s office. Health Aff. 2011; 29:1620–9.

1190 Pines et al. • EMERGENCY CARE AND THE ACA