The Affordable Care Act (ACA), often called Obamacare, has come under sharp criticism. Now, with the nomination of Rep. Tom Price (R-Ga.) for secretary of health and human services, there are concerns about whether it will be repealed or changed. Price, a physician, has been a long-time critic of the law and has devised proposals of his own to replace it.
While Price may have alternative proposals that may be easier to pass in Congress, it is important to understand that the challenges associated with health care reforms are more than just a political battle. The ACA has been blamed for rising deductibles for people who do not receive subsidies and narrow networks. Critics want to blame the law for every flaw in our health care system. This is an inaccurate way to view the law, which has provided coverage for nearly 20 million people.
Most recently, critics of the law have cited an increase in visits to emergency rooms over the last three years as an example of a failure of the law. Insuring people and providing them care in a doctor’s office was supposed to cut down on visits, and therefore costs, or so the thinking went. Critics cite the increase as proof that the law has failed.
We are not political scientists and have no comments on the policy changes that are almost certain in the near future. However, as researchers studying health care delivery and emergency department (ED) care, we think it is important to draw attention to some of the findings that may need a holistic approach to solving health care issues.
As our nation grapples with how best to provide health care, it is also important to keep in mind that our health care system has problems beyond Obamacare. A shortage of primary care doctors and nurses is just one of the serious issues that need attention.
Based on our experiences, we also believe it is important for policymakers to know the facts and not rely on emotions and preconceived notions about ACA, and we will explain why.
The supply-and-demand side of health care systems
The Washington Post recently reported the surge in ED volumes across several states. The article also noted that the supporters of the ACA are disappointed that the spike, which was first reported two years ago, is not temporary.
While the spike may be real, there could be other factors driving the increases in ED volumes for an extended period (we refer to this as the demand side of the health care equation). Our concern is that conclusions derived from just looking at the increased usage of ED may not be thorough unless we understand the supply and quality side of the health care equation.
Our overall message is simple: Policy changes on the ACA based on volume spikes (demand side) may not solve the root cause of the health care access problem in the United States. The solution to health care problems, on the contrary, involves high-quality access through other forms of health delivery systems and improving the supply side of health care.
We will better explain the results from recent studies that found increased ED visits after ACA.
Basic science: Correlation is not causation
For instance, Dresden and colleagues’ study in the Annals of Emergency Medicine find that the average monthly ED visit in state of Illinois increased by 5.7 percent after ACA implementation. The same study finds that the total number of uninsured visits decreased, but this number is relatively small compared to the increases in ED use by Medicaid and private insured beneficiaries.
Another study, based on Oregon’s Medicaid expansion program, found that ED visits increased by 40 percent in the first 15 months of the program. While the surges in volumes are well-documented, increases in ED volumes are not a measure of ED operations quality or the efficiency of health care delivered.
In fact, the most common operations and quality metrics to measure ED efficiencies used by Centers for Medicare and Medicaid (CMS) across hospitals are:
- Median time from ED arrival to ED discharge
- Admit decision times to ED departure times
- ED-patient left without being seen
- Patient satisfaction
- Door to diagnostic evaluation time
- ED mortality rates
As the above two studies conclude, it is quite possible that with the advent of the ACA, patients who did not have medical coverage in the past may have visited the ED due to the lack of access to primary care. As a result, one plausible theory is that though the ED volumes may have increased post-ACA, the severity of patient’s illness visiting ED may have decreased. As a result, some of these metrics may have improved post-ACA.
A second study suggested this, in showing that the number of hospitalizations did not change, despite increases in ED volumes.
On the other hand, it is also quite possible that the patients who never sought medical care pre-ACA are seeking care through EDs, which could adversely impact the above metrics. It is also equally possible that the newly insured ACA patients may see ED as a step-up in quality from urgent care clinics and hence are crowding the system.
A deeper issue: Shortage of primary care doctors
Finally, it is also important to account for any changes to the delivery of care in the ED itself that are not currently considered in these publications.
For instance, a recent study in the New England Journal of Medicine suggests a 76 percent increase in free-standing emergency departments (FSEDs) between 2008-2015 that did not exist earlier. So, an increase in patient ED visits could also be due to the increase in access of new EDs that did not exist in the past.
Essentially, merely looking at demand side (just the ED volumes) and concluding that the ACA has increased health care costs may not be valid. It is important to get into these micro details before evaluating the benefits.
Evaluating the benefits from ACA requires us to also look at the supply side (i.e., resources available for patients) as well as the quality of the care provided. One of the founding principles of ACA is that this surge in demand is handled through preventive care access in the form of family medicine or primary care appointments, and other wellness appointments.
When looking at the supply side of the health care delivery equation, we find that there is minimal change to this part of the equation, which may be the root cause of the problem. A study by the Association of American Medical Colleges finds severe physician shortages in the near future. The report suggests that “demand for physicians continues to grow faster than supply, leading to a projected shortfall between 46,100 and 90,400 physicians by 2025.”
For years, a similar shortage of nurses has been reported, according to a study by Buerhaus and colleagues from Vanderbilt University.
As the new administration decides what to do to tweak or repeal the ACA, it needs to keep in mind that a growing insured population without adequate health care delivery options will exacerbate ED crowding. It also will reduce ED efficiency, quality of care and the overall quality of life of the patient. We believe that fixing the supply side of the delivery equation by creating more opportunities to provide care would be a meaningful approach to fixing this health care crisis instead of denying insurance.
Clearly ED volumes (demand side) continue to rise despite or because of the ACA so that EDs remain an important safety net. The challenge is improving the supply side regarding unscheduled or unplanned care in a way that improves both access and quality.