Change in health insurance status linked to greater emergency department use

Recent changes in health insurance status were linked to greater emergency department use by newly insured and newly uninsured adults, according to a study published Online First by Archives of Internal Medicine. The article is part of the journal's Health Care Reform series.

The hospital emergency department (ED) is an important bellwether for access to care. Newly insured and newly uninsured individuals can struggle for different reasons with access to outpatient care and may turn to hospital emergency departments to receive medical care, the authors write in their study background.

Adit A. Ginde, M.D., M.P.H., of the University of Colorado School of Medicine, Aurora, and colleagues analyzed 159,934 adult respondents to the 2004 through 2009 National Health Interview Study, a cross-sectional household interview of a sample that approximates the noninstitutionalized U.S. civilian population.

The authors found that overall, 20.7 percent of insured adults and 20 percent of uninsured adults had at least one ED visit during the previous 12 months. However, 29.5 percent of newly insured adults (currently insured but lacked health insurance at some point during the prior 12 months) compared with 20.2 percent of continuously insured adults had at least one ED visit. Similarly, 25.7 percent of newly uninsured adults (currently uninsured but had health insurance at some point during the previous 12 months) compared with 18.6 percent of continuously uninsured adults had at least one ED visit.

"In conclusion, although adjusted ED use rates were similar for insured adults and uninsured adults, those with recent changes in health insurance status had greater ED use," the authors comment. "Adults with new Medicaid coverage were disproportionately likely to use EDs, suggesting that their reduced out-of-pocket cost for care was not associated with increased access to primary care services."

The authors note that implementation of the 2010 Patient Protection and Affordable Care Act is expected to increase health insurance coverage up to 94 percent of the U.S. population by 2019, primarily with Medicaid or Medicaid-like insurance.

The study suggests that individuals who are currently uninsured but did have health insurance during the prior 12 months also had greater ED use because these newly uninsured individuals may experience a sudden decrease in their access to care.

"Because health policy changes and economic forces are expected to create disruptions in health insurance status, policy makers and health care administrators should anticipate new surges in ED use," the authors conclude. "Consistency in provision and health insurance type may improve access to primary care services and reduce patient reliance on ED services."

In an editorial, Mitchell H. Katz, M.D., of the Los Angeles County Department of Health Services, California, writes: "With EDs already overcrowded, it is of great concern what will happen when insurance coverage is expanded under the provisions of the Patient Protection and Affordable Care Act."

"Indeed, one reason why the uninsured now use the ED is that under the federal Emergency Medical Treatment and Labor Act patients who go to a hospital ED cannot be denied care because of inability to pay. No such obligation exists in physician offices or other outpatient settings, in which patients who cannot pay are routinely turned away," he comments.

"The ED should not be the default option because other places are not open or are open only to those with the right billfold. Before the insurance expansion occurs, we need to expand the capacity and capability of primary care, including extended hours and same-day appointments, so that EDs can do their job of triaging and caring for the acutely ill or injured," Katz concludes.