Following the rollout of the Affordable Care Act (ACA), emergency department visits and hospitalizations by uninsured patients have decreased, a new study shows.
The study—published in JAMA Network Open and authored by members of the department of emergency medicine at the Renaissance School of Medicine, Stony Brook University and US Acute Care Solutions—looked at the number of uninsured patients and the number of people on Medicaid and private insurance before and after the implementation of the ACA.
The researchers found emergency department (ED) visits and hospital discharges for the uninsured declined from 16% to 8% and 6% to 4%, respectively, between 2006 and 2016. And numbers were even higher for patients between the ages of 18 and 64, where ED visits dropped from 20% to 11% and discharges dropped from 10% to 7%.
In total, there were an estimated 1.4 billion ED visits from 2006 to 2016 and 405 million hospital discharges from 2006 to 2016. Over the study period, ED visits increased by 2.3 million per year, while hospital discharges decreased from approximately 38 million per year prior to 2009 to about 36 million per year after. There was no clear decrease after 2013, according to the study.
Adam Singer, M.D., vice chairman for research in the department of emergency medicine at Stony Brook and one of the study's authors, said the data confirm “our observations that the ACA expansion did not reduce ED visits and that a significant minority of patients visiting the ED were uninsured.”
There was no significant drop in ED visits by the uninsured between 2006 (16%) and 2013 (14%). But between 2013 and 2016, the number of ED visits by uninsured individuals decreased by 2.6 million per year. However, the proportions of uninsured ED visits were largely unchanged from 2006 (16%) until 2013 (14%).
Despite these reductions, one in every 10 ED visits and one in every 20 hospital discharges were for uninsured individuals between 2014 and 2016. The study suggests that continued attention is needed to address the lack of insurance in U.S. hospital visits, particularly among people aged 18 to 64 years who have less access to government-sponsored insurance.
“Getting people insured doesn’t reduce the burden on the ED if other problems, such as access to timely primary care, is not fixed,” Singer said.
When the ACA was first passed, it instituted immediate provisions to boost healthcare coverage, such as allowing people to stay on their parents’ plan until age 26. But when the law was fully implemented in 2014, it led to an additional 20 million individuals gaining coverage and a 21% increase in Medicaid enrollment thanks to expansion.
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After 2014, there was a shift in payers for ED visits, with a proportional shift from uninsured people to those with Medicaid. And there was simultaneously a decline in private insurance.
Specifically, there was a small increase in Medicaid use from 2006 to 2013, then an increase of 3.3 percentage points per year from 2013 to 2016. In contrast, there was a corresponding small decrease in uninsured patients from 2006 (20%) to 2013 (11%), and then a decrease of 3.1 percentage points per year from 2013 to 2016. Medicaid use increased from 2006 to 2008 and then leveled off.
“There has been a shift from uninsured to Medicaid, so at least more patients have coverage and may not be bankrupted from care that they cannot afford,” Singer said.