In the wake of the Supreme Court's ruling on health care reform, hospitals and EDs still grapple with uncertainty, continued stress

State decisions regarding Medicaid expansion loom large for hospitals and EDs

While the U.S. Supreme Court has settled the issue of constitutionality, President Obama's signature health reform legislation, the Accountable Care Act (ACA), still faces significant political headwinds that could chip away at provisions in the landmark health care law. Further, by enabling states the ability to opt out of the law's Medicaid expansion provisions, the high court has left hospitals and EDs in a precarious position. If their states go along with the expansion, scheduled to go into effect in 2014, millions of federal dollars will flow into the states to pay for the care of newly insured Medicaid recipients. However, if states opt out of the Medicaid expansion provisions in the law, as a handful of states have already pledged to do, hospitals and EDs will still have to care for these patients. (See more on this aspect of the law in "Hospitals and EDs have a lot riding on state-level decisions to opt in or out of plans to expand Medicaid in 2014," below.)

Such uncertainties make it more difficult for hospital administrators to plan for the future, but many believe all signs point to continued stress on the nation's EDs. "If we think crowding is bad now, I suspect we haven't seen anything yet," observes Brent King, MD, chair of the Department of Emergency Medicine at the University of Texas Health Science Center in Houston, TX. "Many of the newly insured patients will have chronic illnesses that have not been appropriately evaluated or treated. While EDs are very good at managing acute exacerbations of chronic illnesses, they are not the best places for patients to receive ongoing care. Emergency department leaders will need to consider how they can meet this new challenge."

Look to the Massachusetts experience with reform

Vidor Friedman, MD, FACEP, president of the Florida College of Emergency Physicians, and vice president of governmental affairs for Florida Emergency Physicians in Maitland, FL, agrees that EDs will face challenges, but he does not anticipate the flood of newly insured patients that some are predicting. "In emergency medicine we don't pick our patients; we take care of everybody regardless of their ability to pay, so we are already taking care of these patients in the ED," he explains. "We may see a few more because some people may access care more frequently once they receive coverage, but right now they can come to the ED anywhere in the country and be seen. The issue of payment comes later."

However, another factor that may drive demand up a bit, says Friedman, is the change in insurance status that many patients will see. "One of the things that has been shown in a number of studies is that when an individual's insurance status changes — either they get new insurance or they lose insurance — that tends to be when they use health care more than normally for whatever reason," adds Friedman.

When Massachusetts passed its health reform law in 2006, there was an 8% increase in volume to the state's EDs, observes Friedman. However, Massachusetts had a very low percentage of uninsured citizens, so it is not necessarily a model for how things will play out in states like Texas where roughly 25% of the population is uninsured.

"When Massachusetts expanded coverage, the mismatch between the number of people who wanted care and the number of providers became apparent," adds King, explaining that when people tried and failed to find care in office settings, they came to the ED. "Even more concerning is the fact that Massachusetts has one of the largest supplies of physicians in the country. In states that have fewer physicians, the situation could become far worse, so I think hospitals should be prepared to see even more crowding in their EDs. Most of these patients will have some form of insurance, but that will not solve the problem of crowding."

While there was an initial surge in demand when health reform was enacted in Massachusetts, the Associated Press (AP) reports that ED visits have now decreased by 4%, and 98% of the state population has insurance coverage. However, the AP also notes that access is still a problem there, as less than half of the primary care physicians (PCPs) in the state are accepting new patients, and there are long waits for PCP visits.

Anticipate continued problems with primary care access

Douglas Hough, PhD, an associate professor at both the Carey Business School and the Department of Health Policy and Management in the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, MD, sees the health care law impacting EDs in two divergent ways. "More of the uninsured will have insurance, which means that they will at least have the ability to access primary care providers and not have to use the ED as their source of primary care. I would think that will then relieve some of the pressure off of EDs," says Hough.

However, Hough agrees with King, noting that newly insured patients may still have a tough time accessing PCPs because of supply pressures. "There are few PCPs that I speak with who are working at significantly below capacity. Many of them are not looking to expand their patient pool. In fact, you see many of them who are closing their practices to new patients," he explains. "So you may have, in a sense, a revolution of rising expectations where people who gain insurance may think they can get a PCP, but then when they call around, they find they are unable to find a PCP because there is a shortage, and so then they turn to the ED."

Further, there is no question that while states with large uninsured populations may have the most to gain financially from a federally-funded expansion of Medicaid, the transition in these states is going to be more difficult. "If, in fact, a state like Texas engages in this, and all of a sudden 25% of their population has insurance and, theoretically at least, has access to health care, the pressures on that health care delivery system are going to be enormous," says Hough, "because it is built on a model where only 75% of the population is insured."

Another complicating factor is the reluctance among some PCPs to accept Medicaid patients. "They are looking at the cost of running a practice, and if a particular payer is not paying anywhere close to enough to cover the cost of care, then it would be almost foolish for a physician to say he or she is going to accept a Medicaid patient instead of a private pay patient," says Hough.

This is precisely the situation in Florida where Medicaid reimbursements are among the lowest in the nation, notes Friedman. "Medicaid patients have a very difficult time finding primary care, let alone specialty access in Florida, so a lot of them use the ED as the de facto primary care place because they can't get into a physician's office," he says.

There are some provisions in the ACA designed to boost the supply of PCPs, notes Matthew McHugh, PhD, CRNP, MPH, JD, an assistant professor of nursing at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, PA. However, he stresses that states need to do more to leverage the expertise of nurse practitioners and physician assistants. Such measures could further expand access to primary care, and take pressure off of EDs, he says.

"Some states restrict the scope of practice [of these midlevel providers] which, in essence, limits their ability to be able to provide care," says McHugh. "It puts them under a physician's supervision and really doubles everyone's work. It doesn't make the most efficient use of everyone's time, and it is really not a rational use of human capital."

Get involved with shaping new models

Perhaps the biggest wild card in any discussion about health reform is what impact new models of care will have on outcomes and cost. "I have been analyzing the health care sector for 30 years, and it seems like every 10 years or so there is a promise of more integrated care — a new way of getting providers to think about the patient holistically, to treat them holistically, and to eliminate the fragmentation of care," says Hough, recalling the advent of HMOs, PHOs, and other models. "Maybe this will be the time, and Accountable Care Organizations (ACOs) will be the mechanism by which we collectively will be able to treat patients on a continuum as opposed to the fragmentation we now have. Obviously, emergency medicine would have to be included in that continuum."

While the politics of health reform get sorted out, McHugh advises ED administrators and clinicians to focus more on how they might contribute to ACOs, medical homes, and other emerging models. "Emergency department providers need to have a seat at the table to direct how they think they will fit in and direct pathways for patients so that they get the best care and the most appropriate care," says McHugh. "We want exceptionally trained providers and specialists using the highest end of their skills, not the lowest end of their skills. And we want to make sure that the patients with the highest need are going to the right places, and the patients with lower acuity needs are going to the right providers so that there is room in the ED for really emergent needs."


  • Vidor Friedman, MD, FACEP, President, Florida College of Emergency Physicians, and Vice President, Governmental Affairs, Florida Emergency Physicians, Maitland, FL. Phone: 407-281-7396.
  • Douglas Hough, PhD, Associate Professor, Carey Business School and the Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. E-mail:
  • Brent King, MD, Chair, Department of Emergency Medicine, University of Texas Health Science Center, Houston, TX. Phone: 713-704-4060.
  • Matthew McHugh, PhD, JD, MPH, RN, CRNP, Assistant Professor of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA. E-mail:

Hospitals and EDs have a lot riding on state-level decisions to opt in or out of plans to expand Medicaid in 2014

One of the key planks in the Accountable Care Act (ACA) is an expansion of Medicaid coverage to citizens who earn up to 133% of the federal poverty level, beginning in 2014. The Congressional Budget Office estimates this provision would provide coverage for 33 million people who currently lack insurance. However, in its ruling on the ACA in June, the Supreme Court indicated that states cannot be coerced into going along with the expansion, giving states the ability to opt out of this provision if they so choose.

At press time, the governors of at least seven states had already pledged that they intend to opt out of the ACA's Medicaid expansion provisions, but many expert observers believe that in the end, few if any states will ultimately refuse the billions of federal dollars that the government is making available to the states to cover these newly insured Medicaid patients. Under the law, the federal government will pick up the tab for 100% of the cost associated with covering the new Medicaid recipients until 2017, and at least 90% of the cost after that. What's more, all states will be subject to cuts programmed into the law that legislators intended to be offset by the Medicaid dollars.

The bottom line is that hospitals and EDs in states that opt out of the Medicaid expansion would be severely short-changed. "Each state is going to have to make a decision, and hopefully we can get the states to understand that this is at least a first step of appropriately funding public policy with public dollars," observes Vidor Friedman, MD, FACEP, president of the Florida College of Emergency Physicians. "If you don't expand the Medicaid rolls and you don't give these people some form of insurance, what you are doing is continuing to dump the total cost of caring for these people on the private sector, and while hospitals get some reimbursement from low-income pool dollars for taking care of indigent patients, physicians don't."

Already, powerful business and health care interests are pressuring states to go along with the Medicaid expansion, but many states appear to be awaiting the results of the presidential election in November before indicating how they intend to move forward.

Even if every state falls into line, however, Friedman emphasizes that the ACA is only a first step. "We don't know exactly what all the ramifications of the bill are going to be, but I do think we are going to continue to see efforts towards health reform because the fundamental problem we have in this country is that we spend an enormous amount of money on health care," he says. "There are going to be hard choices that need to be made as we go forward. This [legislation] was difficult enough, and it didn't really do anything about cost-containment."