By Aabha Sharma, Driskill Graduate Program in the Life Sciences at Northwestern University Feinberg School of Medicine
One of the reasons why the Affordable Care Act (ACA), also referred to as “Obamacare,” was passed in 2010 was to drive better health outcomes through affordable access to healthcare, especially preventive care, without prejudice due to pre-existing conditions or ceilings on coverage. Better preventive care would mean better health outcomes and fewer Emergency room visits. Sounds straightforward? Not really.
What are the first things that come to mind when picturing an Emergency Room? Chaos, long waiting times and a fat bill. Trends in Emergency Department (ED) usage corroborate this description. Use of hospital EDs by patients with all types of insurance has been increasing for many years despite the growth of urgent care centers and more comprehensive primary care medical homes. With the passage of Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, all hospitals eligible for Medicare reimbursement must provide appropriate medical screening to anyone visiting the Emergency Department (ED) regardless of their citizenship, legal status or ability to pay. Thus EDs, especially in safety-net hospitals, have been disproportionately providing healthcare to the most vulnerable and uninsured.
Oregon’s Health Insurance Experiment from 2008 is one of the most popular health insurance expansion studies. Low income adults from a Medicaid waiting list were enrolled into Medicaid randomly via a state-wide lottery. The study found an increase in ED usage by patients newly enrolled into Medicaid compared to their counterparts who didn’t win the lottery. It is too early to comment on the long term impact of the ACA. However, the pattern we are seeing post-ACA in Illinois is similar to the Oregon study. A study published by Dresden et al. at Feinberg School of Medicine found that uninsurance in Illinois has decreased, but ED usage by Medicaid patients has increased post-ACA implementation. However, proportional visits by the uninsured compared to insured individuals decreased significantly in Illinois after the ACA.
Why would a policy change aimed at decreasing ED usage increase it for the newly insured? This is a multi-tiered issue that has its root in the lack of primary care. When working at Health and Medicine Policy Research Group, where I had interacted with several federally qualified health centers, the most common theme was that several uninsured patients had medical conditions that had needed attention for years but had been ignored because of the lack of insurance. When their patients, who were few of the 20 million Americans who got insurance coverage as a result of the ACA expansion, gained health insurance, they finally had the ability to attend to their medical needs that had been ignored for years. Moreover, studies show that people who usually enroll in a health insurance plan once they become eligible are also the people who need health care the most. Therefore, until the unattended healthcare gets to an equilibrium level, we will continue to see an increase in healthcare usage for the newly insured. This trend is a manifestation of years of ignored healthcare especially for the vulnerable population and not necessarily an overuse of the healthcare system.
Health education is another factor that has affected the ED usage especially in safety-net hospitals. The most vulnerable are used to getting healthcare from ED as it is the only place which will receive them without insurance. Accessing preventive primary care, unfortunately, is a new realm. Therefore, health literacy needs to go in hand with insurance expansion.
The most important factor in addressing the rise in ED usage post insurance expansion is care coordination focused on improved access to home and ambulatory care. There is an association between good primary care and improved health outcomes. Coordinated primary care that focuses on “frequent ED users” who account for majority of the ED visits, would not only reduce expensive ED visit and hospitalizations but also improve overall patient health quality. The good news is that a few hospitals have already pioneered programs where they partner with community health workers to reach out to the frequent ED users and help them coordinate preventive care. Insurance expansion was the start. There are several milestones to be attained before health as a basic human right becomes a reality with a focus on preventive care rather than sick care.
Aabha Sharma is PhD and MPH Candidate within the Driskill Graduate Program in the Life Sciences at Northwestern University Feinberg School of Medicine. Her main interests include infectious disease research, global health epidemiology and public health policy. This article highlights major findings from her MPH Culminating Experience research with advisor Dr. Joseph Feinglass titled “Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion” PMID: 27837359.
Cover Photo: http://www.cnn.com/2013/10/02/health/obamacare-doctor-shortage/
Other images courtesy of Aabha Sharma
These are the personal opinions of the author and do not represent the views of any organization or other individuals