EXECUTIVE SUMMARY

A new study of patients in Illinois found that fewer uninsured people visited the ED after implementation of the Affordable Care Act.

  • Study found 42.4% reduction in ED visits by uninsured people.
  • Overall ED visits increased, largely because of lack of primary care providers and limited case management.
  • A repeal of the ACA could halt the progress of reducing uninsured visits to ED.

A new study of the effect of the ACA on ED visits in Illinois found that enrollment after the act’s first years resulted in an increase in Medicaid visits and privately insured visits, but a reduction of 42.4% in ED visits by people who do not have insurance.1

“It was dramatic and reflects the fact that in Illinois there was a significant decline in uninsured people, related to an expansion of Medicaid,” says Joseph Feinglass, PhD, research professor of medicine in the division of general internal medicine and geriatrics, Northwestern University Feinberg School of Medicine in Chicago.

Previous studies of the ACA showed that ED visits began to spike after more people became insured because the first people to enroll often are those with health problems, he says.

“There’s a history of insurance expansions leading to increased ED use,” Feinglass says. “In Illinois, uninsured visits went way down after ACA implementation, but visits for Medicaid and private insurance went up, so the net was an additional increase in ED use.”

For young people ages 19 to 25 who could go on their parents’ insurance plans, studies showed a reduction in ED use, he notes.

One of the issues with the ACA data is that it looks at a couple of the early implementation years before all of the primary care and population health infrastructures were implemented to handle the influx of newly insured patients.

So much of the increase in ED visits among the newly insured was related to the fact that primary care doctors were not equipped to handle a large increase in people with serious illnesses. “It’s very difficult for a private doctor seeing a patient for 15 to 20 minutes to handle that stuff, and the ED has all of the needed diagnostic equipment,” Feinglass says.

“Newly insured people confronting they have diabetes, hypertension, heart failure, kidney problems, and so forth have problems not easily dealt with in primary care practice,” he adds.

In Chicago, care transition and coordination programs are still in the early stages of finding medical homes for Medicaid and uninsured populations, he says.

Case management services can help people deal with their housing, homelessness, substance use, and mental health issues, but it takes time to set up systems to handle the challenges, and it takes money, which is what the ACA provides — at least for now. “Very few researchers know about the ACA’s funding, and most people don’t understand that the ACA’s source of funding is very progressive,” Feinglass says. “It’s a tax on wealthy people that funds all of these subsidies and expenditures.”

Without additional federal or state funding to supplement what providers receive from Medicaid, care coordination and case management services might not be initiated.

“Medicaid in Illinois is not a good example of care coordination,” Feinglass says. “That’s why there’s an increase in ED visits by the Medicaid population.”

If the ACA is reversed, it will slow down the population health and reduce funding for case management services, he says.

“What will happen to funding for care coordination for lower-income Americans who need that kind of care coordination the most, and who use the emergency room the most because they don’t have it?” he says.

“Emergency departments become the social safety net’s last stop,” Feinglass adds. “This is where the healthcare system needs to change.”