Frequent Emergency Department Users: A Statewide Comparison Before And After Affordable Care Act Implementation

Abstract

Frequent emergency department (ED) use often serves as a marker for poor access to non-ED ambulatory care. Policy makers and providers hoped that by expanding coverage, the Affordable Care Act (ACA) would curtail frequent ED use. We used data from California's Office of Statewide Health Planning and Development to compare the characteristics of frequent ED users among nonelderly adults in California before and after implementation of several major coverage expansion provisions in the ACA. Frequent users-patients with four or more annual ED visits-accounted for 7.9 percent of ED patients before and 8.5 percent after those provisions were implemented, and they were responsible for 30.7 percent of all visits before and 31.6 percent after. However, after controlling for patient-level characteristics, we found that the odds of being a frequent ED user were significantly lower post ACA for Medicaid-insured patients. Uninsured patients were also less likely to be frequent users post ACA, while privately insured patients experienced little change. The largest predictors of frequent ED use included having a diagnosis of a mental health condition or a substance use disorder. Interventions to address frequent ED use must involve Medicaid managed care plans, given that more than two-thirds of frequent ED users post ACA have Medicaid as their primary coverage source.

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review

“…Despite the increase of overall ED use during the study period, recent work indicates a decrease in the likelihood of the uninsured being FEDU after the PPACA implementation . This might suggest that some of the FEDU with complex medical conditions who could not get the needed coverage because of pre‐existing conditions now have coverage.…”

“…We limited our search to studies in English language published after 2010, given the important changes in the US health care system since 2010 with the PPACA implementation. The PPACA included numerous health care interventions, which seem to have also affected FEDU . Thus, we limited our search term period to update past reviews of FEDU …”

“…A recent study of FEDU focusing on the Medicaid expansion implemented in 2014 as part of the Patient Protection and Affordable Care Act (PPACA) reported that the odds of being a FEDU were lower in the post‐ACA period compared with the pre‐ACA period, particularly among the uninsured . The payer mix of FEDU also changed, with the Medicaid share of FEDU increasing post‐ACA, which was attributed to expanded Medicaid enrollment among the previously uninsured . However, a previous review on FEDU was not able to account for the impact of other major health care policy changes in the US health care system associated with the implementation of PPACA in 2010 …”

Association of Primary Language and Hospitalization for Ambulatory Care Sensitive Conditions

“…28,29 Our study, which controlled for insurance status, would likely reflect the immediate impact of increased access to health insurance. The expansion has also been associated with increased utilization of outpatient services 27 and decreased ED utilization, 30,31 however, we are not aware of any studies which specifically examined the impact of the Affordable Care Act on use of EDs for ACSCs.…”

Office Visits Preventing Emergency Room Visits: Evidence from the Flint Water Switch

“…This informational shock induces parents to take children for lead tests and provides them with potential alternate places of service to the ED. Previous work has focused on the partial Medicaid expansion to study the effects of gaining insurance coverage on low-income individuals' ED and primary care usage (e.g., DeLeire et al, 2013;Sharma et al, 2017;Sommers et al, 2016;Gingold et al, 2017;Jacobs, Kenney, and Selden, 2017;Klein et al, 2017;McConville et al, 2018;Ladhania et al, 2019;Pickens et al, 2019), or how the availability of retail clinics affects both primary care and ED utilization (e.g., Ashwood et al 2016;Alexander, Currie, and Schnell, 2019). Our paper differs from these studies in multiple ways.…”