Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

The Patient Protection and Affordable Care Act (ACA) sought to reduce the number of uninsured Americans. Advocates hoped that this would increase access to outpatient resources and potentially decrease ED utilization and inpatient admissions.

Researchers sought to determine if the ACA changed the number of uninsured patients visiting emergency departments and whether rates of inpatient admission fluctuated.¹ They examined data from the National Hospital Ambulatory Care Survey and the Healthcare Cost and Utilization Project from the years 2006–2016. These dates allowed the authors to see trends both before and after the ACA was implemented.

The study found that while overall emergency department visits increased during the study period, the rates of uninsured patients visiting emergency departments decreased. During this time, the proportion of Medicaid patients visiting emergency departments increased. These trends were most pronounced after 2013, when many states expanded Medicaid. This effect was most pronounced among patients ages 18–64, who typically have the highest risk for being uninsured.

The data also showed that rates of admissions from the emergency department actually decreased after ACA implementation. Interestingly, this was not due to decreased emergency department utilization. In fact, the number of ED visits consistently increased during the study period.

This study shows that more patients who visited the emergency department after ACA implementation were insured and that more of these patients were ultimately discharged home. The ACA has provided health coverage to more than 20 million Americans and has translated to higher rates of insured patients visiting emergency departments. This was also associated with lower inpatient admissions. Decreased admission rates could be due to expanded insurance leading to greater access to outpatient resources, obviating the need for inpatient admission. Yet the authors note that other factors, such as increasing use of observation services, may have also had an effect on this trend. 

The ACA has greatly expanded health insurance coverage in the United States, changing the insurance status of our patients and possibly even increasing our willingness to discharge patients. As debates about the future of the ACA and other health policy issues continue, emergency physicians should remain engaged. This study shows that the outcome of these debates will influence the health and longevity of the patients we treat.

Dr. Jasani is an emergency medicine resident at the University of Maryland in Baltimore.

Reference

1. Singer AJ, Thode HC Jr, Pines JM. US emergency department visits and hospital discharges among uninsured patients before and after implementation of the Affordable Care Act. JAMA Netw Open. 2019;2(4):e192662.