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ED visits likely to increase under ACA


Massachusetts and Oregon studies show emergency department increases once patients have health insurance coverage

Health plans that expect emergency department utilization to drop under the Affordable Care Act (ACA) could be in for an expensive surprise. Two studies looking at expanded access to healthcare both found that ED usage increased by about 2% as access to care improved.

 “It is impossible to fully know the impact of expanded access to care under ACA,” says Peter Smulowitz, MD, MPH, Beth Israel Deaconess Medical Center, Boston. “But based on what we found in Massachusetts, I would say that health plans in the rest of the country should be prepared for an increase in ED use.”

 Dr. Smulowitz is lead author of a study of ED utilization that followed Massachusetts expansion of health coverage that began in 2006 and served as a model for ACA. Researchers compared ED utilization based on more than 13 million visits from 2004 through 2009. Implementation of state-level health reform resulted in as much as a 1.2% increase in utilization  during the first year of Massachusetts’ improved access to care. ED utilization increased up to 2.2% during the second year of reform.

Many in the industry have used Massachusetts’ experience as a benchmark for national reform.

The study, “Increased Use of Emergency Department After Health Care Reform in Massachusetts,” was published in The Annals of Emergency Medicine on March 24, 2014.

 A study in the metropolitan Portland, Ore., area following expanded Medicaid access in 2008 found that improved access boosted ED utilization by 40%. But study authors are in no rush to generalize their results across a national population of ACA enrollees.

 “Our ED findings are very specific to the Portland area,” says lead author Sarah Taubman, ScD, National Bureau of Economic Research, Cambridge, Mass. “We had a very small population, about 10,000 individuals, who were self-selected and enrolled under a voluntary program. In a population where millions are gaining coverage under a mandatory program, you may see very different effects.”

Why ED utilization increased as access to care became easier is not clear. Oregon saw a general increase in demand for health services in all settings when the state Medicaid program expanded coverage on an experimental basis. Primary care visits, overall physician visits, hospital admissions, pharmaceutical claims and ED use all increased, Dr. Taubman says. 

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 “As care becomes more accessible, people will use more as a general observation,” she says. “It’s not a simple story with this Medicaid population. People are seeing primary care providers more and using the ED more. Our study suggests that just providing coverage does not change the broad patterns of utilization of healthcare. If you want to shift utilization from one setting to another, you will have to take more specific steps to influence patient decision making.”

 Statewide trends from Massachusetts are no more clear-cut. Dr. Smulowitz says the observed increase in ED utilization could be the result of difficulties in accessing primary care. It could be pent-up demand. It could be individuals selecting the ED as the most appropriate setting for care when the need arose. It could be some combination of factors.

 “Whatever the reason or reasons behind individual decisions to see care in the ER, increased utilization was what we saw,” he says. “States and health plans can’t assume that giving people better access to health coverage will reduce the demand for ED utilization. When people have health coverage, it appears that they will go to the setting they feel is right for them at the time, which is sometimes the ER.”

 Managed care plans that operate in Massachusetts, Oregon and other states declined to comment on the studies or their expectations for ED utilization under ACA.

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