ED visits increased nearly 10% in California after ACA
A new Health Affairs study found that after the Affordable Care Act the “likelihood of being a frequent” emergency department user dropped compared to numbers before the ACA for uninsured patients.
Overall, the researchers found that ED users increased by 7.7% in the two years after the ACA coverage expansions compared to the two previous years. The number of total ED visits increased by 9.9%. Frequent users, those who visited the ED four or more times in a year, increased 7.6% after the ACA was signed into law.
The report also found that Medicaid expansion in California increased the share of Medicaid patients in EDs, as well as the number of frequent ED users. However, when using patient-level characteristics, the researchers found that there was a lower chance of a Medicaid enrollee being a frequent ED user after the ACA.
Policymakers hoped that ACA provisions to increase the rate of insured Americans would result in more patients getting care at lower-cost physician offices instead of going to EDs for non-urgent care. The ACA provided 20 million more adults with health insurance, most of which came via Medicaid expansion.
The report comes as insurers increasingly look to reduce ED care. Payers like Anthem and Blue Cross Blue Shield of Texas have created policies to deny coverage for emergency care that is deemed unnecessary. UnitedHealthcare created its own ED policy to reduce incorrect claims with the most serious conditions evaluation and management codes in commercial and Medicare Advantage plans.
There is also the ongoing debate about Medicaid expansion. More than a dozen states have not expanded Medicaid under the ACA, but states like Utah and Idaho may have expansion on the ballot in the fall. Some states that already expanded Medicaid, like Kentucky, are also looking for ways to slow or stop the growth rate of the program, including a work requirement and charging enrollees who misuse the ED.
These kinds of policies and restrictions may become more common in the coming years as Medicaid expansion states seek to bend the cost curve. The Health Affairs study said more Medicaid enrollees present challenges for Medicaid managed care plans and state budgets. They added that Medicaid managed care plans must address frequent ED use since more than two-thirds of frequent users after the ACA had primary Medicaid coverage.
The study analyzed 2012-2015 data from California’s Office of Statewide Health Planning and Development to compare “the characteristics of frequent ED users” before and the ACA. They reviewed data from 13.7 million patients who made at least one ED visit in California.
Researchers found that the share of Medicaid patients increased from 21.5% to 37.6% of the total ED patient population, while the percentage of uninsured patients declined from 26.9% to 13.2.%. For frequent ED users, the share of Medicaid-enrolled increased from 44.6% to 67.6%, while uninsured patients declined from 29% to 8.3%.
However, when the researchers used patient-level characteristics, such as health conditions, primary coverage and county of residence, they found Medicaid enrollees and uninsured patients were less likely to be frequent ED users after the ACA was implemented.