ACA Has Little Impact on Reducing ER Visits

Emergency department visits in Maryland fell by 1% statewide in the months after Medicaid expanded. The number of Medicaid ED visits increased 6%, with a corresponding 6% drop in the number of uninsured emergency department visits.

Emergency department visits across Maryland declined slightly in the months after the state expanded its Medicaid population under the Affordable Care Act, Johns Hopkins researchers say.

In a paper published in the Annals of Emergency Medicine, the Johns Hopkins researchers said that the number of people covered by Medicaid in Maryland increased more than 20% percent, or 160,000, with the ACA, and the total number of ED visits in state fell by more than 36,000 during the study period.

“Thirty-six thousand may seem like a lot of visits, but, in Maryland, that only equates to about a 1% change,” said researcher Eili Klein, PhD, assistant professor of Emergency Medicine in the Johns Hopkins University School of Medicine. “So, the effect of expanding Medicaid seems to have had no effect on emergency department utilization at an aggregate level.”

The researchers analyzed ED visits across Maryland for the 18-months before the Medicaid expansion took effect and an 18-month period afterward using data from the state’s Health Services Cost Review Commission. The first six months of 2014 were excluded in the analysis, researchers say, to control for the initial expansion of insurance that year when people were still being enrolled in Medicaid.

The study also found that Medicaid visits increased by almost 6%, while the number of uninsured patient visits decreased almost 6%. Of the uninsured patients who visited an ED before the ACA, 37% made at least one visit to the ED during the post-ACA study period. About 28% of those patients remained uninsured for all visits, while 31% were consistently enrolled in Medicaid.

“It was unrealistic to expect emergency department visits to decrease immediately after the ACA enactment,” Gabor Kelen, MD, director of the Johns Hopkins Department of Emergency Medicine, said in remarks accompanying the study. “The ACA did not really address incremental primary care access for the newly insured. Many new Medicaid-insured patients are still dealing with serious conditions that require emergency hospital care. Also, a population who could only previously receive care in the emergency department is not likely to immediately change this tendency.”

While the ACA did not reduce the burden on ED, Klein said “it does protect many patients from expenses of health care services and gives hospitals increased financial security.”

The findings are consistent with a 25-state study published last month, also in Annals of Emergency Medicine. Vanderbilt researchers determined that states that expanded Medicaid coverage under the ACA saw 2.5 ED visits more per 1,000 people after 2014, while the share of ED visits by the uninsured decreased by 5.3%.

“Medicaid expansion had a larger impact on the healthcare system in places where more people were expected to gain coverage,” study lead author Sayeh Nikpay, PhD, of Vanderbilt University, said. “The change in total visits was twice as large in a state like Kentucky, where most childless adults were ineligible for Medicaid at any income level before 2014, as in states like Hawaii, where childless adults were already eligible for Medicaid above the poverty line.”

Nikpay analyzed patient visits in 14 states that expanded Medicaid coverage and 11 that did not and found that the share of visits covered by private insurance remained constant for expansion states and increased by several percentage points for non-expansion states. Gains in insurance coverage in non-expansion states were almost entirely in the form of private coverage, not Medicaid.

Increases in ED visits were largest for injury-related visits. There was also a large change in payer mix for dental visits, because dental ED visits are most prevalent among low-income, non-elderly adults on Medicaid. Out-of-pocket dental costs were reported as one of the more unaffordable types of care among the target population for Medicaid expansion under the ACA.