A recent survey of 2,099 doctors conducted by the American College of Emergency Physicians showed that 28% of emergency room physicians believe that ER visits have increased greatly, 47% say they have increased slightly and 17% say they have remained the same since the requirement for health coverage under the Affordable Care Act went into effect in January of 2014. The previous year, less than half of physicians surveyed said they saw increases in ER visits.
The survey has generated some controversy because it relies on physician perception of increases, not hard data (like billing figures). As Vox's Sarah Kliff pointed out, "If you asked me whether I wrote more or fewer stories this year than last year, I'd probably say more—the recent stories I wrote were a lot of work, and I remember them better! Am I a reliable estimator? I have no idea."
Critics also point out that despite news headlines like "Contrary to goals, ER visits rise under Obamacare,", there is no way to incontrovertibly tie a rise in ED visits to the Affordable Care Act. For example, federal data shows that visits went up 4.5% between 2006 and 2011.
Still, most industry experts believe that there has been an uptick in ED visits under the healthcare law. While the ACEP survey might be squidgy statistics, it's not necessarily wrong. So what are the real numbers?
Rising volumes, key decreases
According to Modern Healthcare's most recent By the Numbers list, ER visits rose dramatically at hospitals with the highest ER use in 2013, and hospitals reported even higher volumes in 2014, despite a decrease in the number of people who are uninsured.
A Medicaid expansion study conducted in Oregon found that recent Medicaid enrollees went to the emergency room 40% more frequently than others, often for conditions that could be treated in a doctor's office or at an urgent care clinic.
Now here's the good news. Among young adults ages 19-25, there’s been a decrease in ER admissions due to an ACA provision that allows them to be covered under their parents' insurance policies. Researchers at Stanford University reviewed data from hospitals in Florida, California and New York, both before and after the law was implemented. They found that under the ACA, there was a decrease of 2.7 ER visits per 1,000 people in the 19-25 age group. "Our results suggest that the ACA's dependent coverage provision is associated with a relative decrease in the number of ED visits for young adults," the study concludes.
A study conducted in California found that although ER use among new enrollees in California's Low Income Health Program (LIHP)—California's "Medicaid-like" program—was initially higher, the increase was found to be temporary. The California study, which was conducted by UCLA's Center for Health Policy and Research, found that the new enrollees initially used the ER at a rate of 600 visits per 1,000 people. However, over the next few years, usage declined by almost 70%. The study authors attributed the decline in ER usage to preventative care and treatment for chronic illnesses, both of which are offered by the LIHP.
Why it's happening
USA TODAY says the experts are pointing to multiple causes for the increase in ER visits, including a shortage of primary care physicians, more physicians choosing to opt out of Medicaid, the inability of low-income workers to take off work during regular office hours and people having become accustomed to using the ER for primary care in the past.
Some experts believe that unfamiliarity with the process is helping to drive the trend of rising ER visits, and that it will continue until the newly insured become more comfortable with the process. "More people have insurance, but the cultural norm has been to wait until they're sick to seek care," Dr. Mitchell Morris, a provider consultant at Deloitte Consulting told Modern Healthcare. "As they get educated, ER use will go down over a period of years."