2014 ACA Provisions Linked to Fewer Uninsured ED, Hospital Visits

The implementation of Affordable Care Act (ACA) insurance provisions in 2014 seemed to have made an impact on emergency department (ED) care. A new study shows the rate of uninsured patients to visit or be discharged from the ED has dropped substantially since ACA provisions were applied to broaden Medicaid eligibility and better regulate companies’ employee insurance policies.

The cross-sectional study, from the Department of Emergency Medicine at Stony Brook University’s Renaissance School of Medicine, found that the annual rate of uninsured ED visits were nearly halved among US patients aged 18-64 years old from 2006-2013, to 2016.

Renaissance School of Medicine investigators Adam J. Singer, MD, and Henry C. Thode Jr., PhD—along with Jesse M. Pines, MD, of US Acute Care Solutions—believe the findings are consistent with evidenced increases in Medicaid-covered ED visits from the same time period.

The 2014 provisions to the ACA—or, as its been nicknamed, “Obamacare”—were designed to further expand the availability of healthcare insurance in the US. Specifically, it broadened Medicaid eligibility; created health insurance exchanges; provided that young adults may remain on their parent’s insurance coverage until age 26; regulated rates for patients with preexisting conditions; set requirements that most citizens have an insurance plan; and set penalties for employers not offering employee coverage.

The end-result of the provisions was an extension of coverage to 20 million previously uninsured citizens and a 21% increase in Medicaid enrollment, investigators noted.

The team sought to examine ED visit and hospitalization trends from 2006-2016. They also assessed visit rates in relation to patient insurance coverage changes, particularly in the years after 2013.

“Specifically, we aimed to answer the following question: was ACA expansion in 2014 associated with significant changes in the number of ED visits and hospitalizations in the US overall and by uninsured individuals in particular?” Singer and colleagues wrote.

They conducted a cross-sectional study of ED visitors and patients discharged from US hospitals using data from the National Hospital Ambulatory Care Survey and Healthcare Cost and Utilization Project, respectively, from the observed time periods.

Investigators found that approximately 1.4 billion ED visits and 405 million hospital discharges in the US from 2006-2016. While ED visits rose by about 2.3 million annually, hospitals started to similarly decrease after 2009—before plateauing after 2013.

From 2006-2013, uninsured ED visits were relatively consistent, decreasing by just 0.2 percentage point annually (95% CI: -.46 to -.01; P= .11). From 2014-2016, it decreased by 2.1 percentage point annually (95% CI: -4.3 to -1.8; P= .003). In 2016, uninsured visits accounted for 8% of all ED visits.

The uninsured ED visit rate decrease was markedly greater in patients aged 18-64 years old. They fell from 20% from 2006-2013, to just 11% in 2016, denoting a 3.1% annual decrease after 2013 (95% CI: -4.3 to -1.8; P= .003).

In hospital discharges, the uninsured patient rate stayed consistent at 6% from 2006-2013, before declining to 5% in 2014 then 4% in 2016.

Singer and colleagues noted that the accentuated changes in patients aged 18-64 years old is significant, as they are the greatest risk of insurance due to differing eligibilities for state-level coverage or Medicare. Though the findings were consistent with previous studies showing Medicaid expansion is associated with changes in insured rates at EDs and hospitals, more assessment is needed to understand how policies affect different patient populations and their actual health outcomes.

“Additional work is needed to examine how these trends have affected out-of-pocket costs for patients and overall costs of care,” they wrote. “Longer-term studies will also be helpful to determine the continued or delayed impact of insurance changes.”

The study, "US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act," was published online in JAMA Open.