Examination of How the Affordable Care Act Influenced Use of Lower-Acuity Emergency Department Services

CONTEXT: The Affordable Care Act (ACA) was implemented to make insurance accessible and reduce healthcare costs. The purpose of this study was to examine for changes in the use of lower-acuity types of Emergency Department (ED) services at two suburban Detroit facilities before, and after implementation of the ACA. METHODS: A retrospective chart review of patients presenting to the ED at a two-campus suburban hospital system was performed over two 18-month pre- and post-ACA periods. The authors completed a review of electronic health record data and used ICD-9 code and ED visit billing and collections data. Sample patients included those who had received lower-acuity ED care within the two designated time periods. A total of 16 lower-acuity ICD-9 codes were included to gauge pre and post changes in use of ED services. RESULTS: The authors identified 2,099 patients meeting study criteria during the pre-ACA period and 2,158 patients within the post-ACA period. A subgroup of 166,483 ED patients received care during the pre-ACA time period and 179,879 post-ACA. There was no statistically significant difference between the volume of lower-acuity ED visits during the two analytic periods (i.e., 1.26% seen pre-ACA implementation and 1.20% seen post-ACA). (p = 0.420) Neither did the absolute number of all ED visits significantly change. As could be anticipated, however, the proportion of self-pay patients pre-ACA significantly decreased from 506 (24.1%) to 191 (8.9%) post-ACA. (p < 0.001) Medicaid HMO payments also increased significantly from 824 visits pre-ACA to 1,086 visits post-ACA. (p < 0.001) In addition, Blue Cross coverage increased from 54 visits pre-ACA to 98 visits post-ACA. (p < 0.001) CONCLUSIONS: In summary, our results revealed no significant change in the absolute volume of all ED visits or proportions of lower-acuity ED visits between the pre- and post-ACA periods. As the authors had anticipated, pre and post changes in the number of self-pay patients and those with certain types of insurance coverage were dramatic. The authors conclude that changes in lower-acuity visits to the ED in these study settings had not decreased as envisioned by ACA developers. Future studies with larger longitudinal samples are warranted to more fully investigate the longer-term implications of the ACA on use of ED services.