Thursday, March 27, 2014

My friend and colleague Peter Smulowitz and co-authors have documented what many of us noticed anecdotally at the time.  Looking at Massachusetts following the introduction of universal health insurance coverage, they found:

Compared with the 2-year period before reforms started to go into effect, emergency department visits increased by up to 1.2% during the 1-year implementation and by up to 2.2% during the 2-year period after reforms were fully in effect.

The study is in the Annals of Emergency Medicine.  News@JAMA summarizes key points:

The authors analyzed all emergency department visits in Massachusetts between October 1, 2004, and September 30, 2009. The data included records from 69 hospitals, accounting for some 2 million annual outpatient emergency visits, 850 000 inpatient admissions, and 150 000 observation stays. Reforms that expanded health care access in the state were implemented between October 1, 2006, and September 30, 2007.

Several factors drive these trends, the Annals authors wrote. They named transportation, ability to take time off from work or find child care, emergency departments’ 24-hour availability, limited availability of primary care services, distances between the emergency department and a primary care physician, and the perceived efficiency and expertise of emergency departments.

“Our study suggests that other states should be prepared for equal or greater influxes of patients into the [emergency department] after health care reform is fully implemented,” the authors wrote.

Kristin Gourlay, a columnist at Rhode Island NPR, notes:

Another study from Oregon found something similar. So we've got two studies now suggesting that health care reform - the Affordable Care Act, extending health insurance to more Americans - may not necessarily be moving the needle on something we thought it would: reducing the number of costly ER visits made by the uninsured who can't afford care elsewhere. The big hope was that the more people got health insurance, the fewer would need to come to the ER for routine care.

According to these studies, it turns out that it's not just the uninsured who use the ER for health problems that could be taken care of by a primary care doctor or in another outpatient clinic. People with insurance may be using the ER for those kinds of health problems, too. No one's suggesting that there aren't legitimate emergencies represented in this data. But it suggests that people may have been waiting to get some things taken care of, or that they haven't been able to find a regular doctor.

It's not clear to me who had that "big hope."  Many of us projected that the ACA was not likely to lead to bending the curve of health care costs.  Its main purpose was to provide health insurance.  That's good and important, in and of itself.


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