Proponents of the Affordable Care Act have argued that expanding health insurance coverage will increase the use of outpatient care services and, in turn, reduce the use of costly and crowded emergency departments (EDs).
But only part of that claim may come true as the law takes effect, according to a new study by Robert Wood Johnson Foundation (RWJF) Clinical Scholar Adrianne Haggins, MD, MS (2010-2012), a clinical lecturer in the Department of Emergency Medicine at the University of Michigan. She found that primary care and specialty care use increased for adolescents, but ED use did not decline in the wake of the last major health insurance coverage expansion: the Children’s Health Insurance Program (CHIP) of 1997.
“The assumption of an automatic decrease in emergency department use simply by expanding insurance coverage may not be realized,” Haggins said.
The findings suggest that expanding insurance coverage may not reduce reliance on the nation’s EDs, which have become more crowded in recent decades. Nationwide, the number of EDs has decreased while the number of visits has increased, contributing to overcrowding and longer waits, according to a statement by the Centers for Disease Control and Prevention.
No Change After CHIP
CHIP proponents hoped to alleviate the unmet need for health care among children from near-poor families, and avoid foregone care and likely reliance on EDs for sporadic care, Haggins said. Expanded insurance, proponents argued, would enable more children to gain access to primary care providers and preventive care.
But Haggins found no statistically significant change in ED use among adolescents after the 1997 CHIP expansion. One reason could be related to the setting’s greater accessibility, she said.
Also, EDs are required by law to treat all patients regardless of insurance-type, unlike other outpatient settings. EDs also are open around the clock—a key advantage for job-holders who may find it challenging to keep medical appointments during the workday. Shortages of primary care providers or difficulties finding providers to accept CHIP/Medicaid coverage have been shown to lead to additional delays or barriers to obtaining care in outpatient settings, Haggins added.
“Future studies examining changes in admission rates, diagnoses, and acuity over time would provide richer detail on how patterns of health-seeking have evolved since implementation of CHIP, and better inform interventions to meaningfully shift patients to non-ED settings,” Haggins said.
“Our findings have particular relevance as our country prepares for a large-scale expansion of health care coverage,” Haggins and her co-authors wrote in the study published October 17, 2013 in Academic Emergency Medicine. “As the implementation of the Affordable Care Act moves forward, it will be vital to develop a comprehensive understanding of how these policies affect use of health care services in ED and non-ED outpatient settings.”
Earlier studies of the effects of insurance coverage on ED use varied widely, with some showing an increase, others showing a decrease, and still others showing no change at all. Haggins’ study builds on these prior studies by examining nationally representative data sources over longer periods of time, and exploring the relationship between both outpatient and emergency care.
RWJF Clinical Scholar Stephen Patrick, MD, MPH, MS, (2010-2012) and Matthew Davis, MD, MAPP, co-director of the Michigan RWJF Clinical Scholars program, contributed to the study.
Haggins became interested in ED use as a resident at the University of Chicago from 2007-2010. “When I was a resident, we had a lot of patients …who were coming to the ED to get their diabetes managed…I thought, ‘When we have expansion of coverage, will it really change these patterns of care that we see in the ED?’”
She plans to further study that question to figure out more efficient ways to allocate scarce health care resources. “We still don’t understand why one patient goes to primary care for everything, or why others go to the ED,” she says. “We also need increased transparency of alternative options” and strategies to “optimize resources in a way that aligns with how patients want to be seen and in a way that is realistic with how providers can provide care.”