Emergency department visits have continued to rise even as more Americans gained health insurance after the Affordable Care Act came into play, according to a new study.
ED visits increased by 2.3 million a year between 2006 and 2016, with the proportion of uninsured ED visits relatively unchanged from 2006 to 2013, making up between 14% and 16% of visits, the study published Friday in JAMA Network Open found.
But uninsured ED visits dropped after the ACA's 2014 implementation, which included allowing states to expand Medicaid and requiring individuals to have health insurance. Uninsured ED visits made up 8% all ED visits by 2016.
Hospital discharges also declined. Uninsured patients made up 6% of discharges every year from 2006 to 2016 but then decreased to 5% in 2014 and 4% in 2016.
Study author Dr. Adam Singer, professor and vice chairman for research in the department of emergency medicine at Stony Brook University's Renaissance School of Medicine, said the findings point to a continued overreliance on hospital emergency departments as a primary site for healthcare services. That has continued despite increased insurance coverage and alternative provider options, such as urgent care centers and retail health clinics.
"When one in 10 patients ED visits and one in 20 hospital discharges are among patients with no insurance, it shows that there is still a lot of work that needs to be done to expand access to coverage," Singer said.
Previous studies have come to similar conclusions regarding the ACA's impact—or lack thereof—on ED use.
The latest analysis looked at the law's impact years after its implementation and found the only substantive change in ED use was in the proportion of patients now covered by some form of insurance.
More than 20 million Americans have gained health insurance coverage since the ACA was signed into law in 2010. Studies have shown a strong relationship between having health insurance coverage and having better health outcomes. A 2017 analysis in the Annals of Internal Medicine concluded the evidence supporting the idea that health insurance reduced mortality had only increased since the Institute of Medicine made the finding in its 2002 report.
The study's findings raise questions as to whether other factors beyond increasing insurance coverage are impeding the effort to direct patients away from the ED and toward other healthcare settings.
"I think at the end of the day my question would be, do you have access to care because of insurance, or are there still financial impediments to that process," said Dr. Rade Vukmir, spokesman for the American College of Emergency Physicians. "If you look around you'll find that there may be."
The findings suggest the rise in ED visits may be less preventable than hospitalizations, which have come down partly due as more patients obtain care in outpatient settings. More hospitals also put patients who come to the ED on observation status rather than admitting them.