With Obamacare, Emergency Rooms Still Packed

By  //  August 18, 2014

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ABOVE VIDEO: FOX News Network’s Medical Correspondent Dr. Marc Siegel reports on studies that suggest that healthcare coverage expansion under the Affordable Care Act will drive up volumes in already overcrowded U.S. emergency rooms.

EDITOR’S NOTE: Nearly half of emergency physicians responding to a May 2014 poll reported that they were already seeing a rise in emergency visits since January 1 when expanded coverage under the Affordable Care Act (ACA, aka Obamacare) began to take effect. So far, one of the projected benefits of Obamacare–a decrease of volume in crowded emergency rooms across the country due to new healthcare policy holders who would theoretically have access to primary care–has not come to fruition.  

In the online poll conducted by the American College of Emergency Physicians (ACEP), 86 percent of respondents expect emergency visits to increase over the next three years, and more than three-fourths said their emergency rooms are not adequately prepared for significant increases. 

“Emergency visits will increase in large part because more people will have health insurance and therefore will be seeking medical care,” said Alex Rosenau, DO, FACEP, president of the ACEP in a statement referencing the poll.  “But America has severe primary care physician shortages, and many physicians do not accept Medicaid patients, because Medicaid pays so low.  When people can’t get appointments with physicians, they will seek care in emergency departments.”  

This Kaiser Health News article focuses on the bottom line: coverage does not equal access. Continued crowding and even increased ER volumes underscores the challenges beyond expanded healthcare coverage under Obamacare, including improving access to primary care and changing the habits of patients accustomed to using the emergency room as a one-stop-shop for medical care.

“Long-term solutions, such as increasing the supply of primary care physicians, will take years to develop and will not solve our immediate and short-term problems,” said Dr. Rosenau. “Congress and President Obama must make it a national priority now to strengthen the emergency care system.  ACEP is urging Congress to make a firm commitment to emergency patients by holding a hearing to examine whether additional strains are occurring in the emergency department safety net as a consequence of the Affordable Care Act.”

—Dr. Jim Palermo, Editor-in-Chief

KAISER HEALTH NEWS — Experts thought if people bought health insurance through the Affordable Care Act, they would find a private doctor and stop using hospital emergency rooms for their primary care.

Well, more people have health insurance. But they are still crowding into emergency departments across the nation.

An online study by the American College of Emergency Room Physicians found that nearly half of its members have seen a rise in visits since Jan. 1 when ACA coverage began. A resounding 86 percent of the physicians said they expect that number to continue growing.

In Philadelphia, emergency room visits were 8 percent higher in June than in November 2013, according to the Delaware Valley Healthcare Council, which collects data from 70 percent of the region’s hospitals.

“We find that when people don’t have health care, there is a degree of pent-up demand,” said Alex Rosenau, the ER physicians’ group and an ER doctor in Allentown. “People finally feel like they can go get medical care once they have some insurance.”

The spike in emergency room visits isn’t totally surprising. Rosenau said when Massachusetts enacted its own health care reform in 2006, everyone predicted the newly insured would find a private doctor. Instead, emergency departments saw a 3 to 7 percent increase in volume.

“Insurance does not equal access,” said Rosenau, adding that his group believes everyone should have access to care. “They know when they go to the emergency department, they are going to be seen.”

Complicating the matter is the growing shortage of primary care physicians. People who have never had a private doctor may have trouble finding one. So they continue to rely on emergency rooms.

“We are seeing some folks who have new insurance but they just can’t get access to primary care,” said Theodore Christopher, Thomas Jefferson University Hospital’s chairman of emergency medicine. “If you can’t access a primary care doctor, then you are going to go to the emergency room.”

From July 2013 through January 2014, Jefferson’s emergency room visits fell 6 percent. But from February through June of this year, visits picked up, increasing 4 percent. Since July, the start of the hospital’s new academic year, business has been brisk.

“It’s back to the old days,” said Christopher, an avowed supporter of the ACA. “A lot of emergency department overcrowding, a lot of patients.”

At Einstein Medical Center in North Philadelphia, Jack Kelly, the ER’s associate chair, says it’s still too early to tell what impact the law has had on his department. But from conversations with his North Philadelphia patients, he knows many don’t have insurance.

“I find that there are still a lot of impoverished people here at Einstein who have not had access to the [ACA] website or who haven’t made the call to sign up,” said Kelly.

Those who have gone on healthcare.gov have told Kelly that the price of insurance is out of their reach.

“I’ve had numerous patients tell me that,” Kelly said. “I think another important question is what is affordable health care and what are people willing to budget for it?”

Many of the newly insured under expanded “affordable” Obamacare coverage may still not be able to afford the required high deductibles and copays, and will be forced to continue to seek healthcare services in the ER where care cannot be denied.

What people can afford is also a “big concern” for emergency medicine, Rosenau said. People who bought bronze plans because of the low premium payments didn’t always consider the other costs of their plan, such as high deductibles, large co-payments, and other costs.

“What we’ve done is we’ve made the bronze plan very low-cost and people bought them,” Rosenau said. “But these are the people who can’t afford the $6,200 deductible and may not have in their lifetime, in their economic status, ever heard of the concept of a deductible.”

And because many won’t pay their bills because they can’t, emergency departments, which treat 140 million patients a year, are bracing for the worst.

“We haven’t really seen this yet because it hasn’t played out,” Christopher said. “I think it’s going to be hard for us to collect those dollars.”

In Pennsylvania, the real X factor for emergency departments is what the state is going to do with Medicaid. Gov. Corbett’s Healthy Pennsylvania plan is still awaiting a decision on a waiver from the U.S. Department of Health and Human Services.

If the plan is approved or if Medicaid is expanded, it could introduce as many as 400,000 Pennsylvanians into the health system. Many of those newly insured people may be unable to find a primary care doctor and will likely turn to the hospital emergency department.

“The Medicaid issue is the real issue that might hit us,” Christopher said. “If expansion passes, we will see a lot more patients in the emergency department.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.