237 Impact of the Affordable Care Act on the Health Care Coverage of Patients Seen in the Emergency Department: Initial First Quarter Findings

Abstract

The Affordable Care Act (ACA) was implemented by the United States government as a way to improve health care insurance coverage and quality. More Americans would have health insurance by being eligible to purchase more affordable coverage through insurance exchanges and through the expansion of public insurance programs (depending on the state). The ACA-associated insurance exchange opened for enrollment in 2013 and coverage began on January 1, 2014 for those who enrolled in the program. Although there has been much speculation on how the ACA may impact health insurance coverage, the true impact is unknown and will likely vary by region. The objective of this study was to assess the impact of the ACA on health care coverage among patients seen in the emergency department (ED). This was a multi-center retrospective study using ED utilization and billing data from two hospitals from July 1, 2013 to March 31, 2014 (pre-period July 2013 to December 2013 and post-period January 2014 to March 2014). Both hospitals were located in a state region that had created its own State-wide health insurance exchange, as well as had opted in for the expansion of Medicaid. One hospital is an urban academic teaching hospital with an ED census of about 42,000 and the other is a suburban community hospital with an ED census of about 24,000. Data were queried from the electronic medical record (EPIC) and included date of visit and primary payer. Primary payer was categorized into Medicare, Medicaid, County Medical Services (CoMS), which is a program to cover indigent patients, Uninsured (none or self-pay) and other. Other was predominately private coverage. Data are described using means and percentages. Comparisons of the average monthly proportions of health insurance between the two periods were performed using chi-square tests and differences (Diff) and 95% confidence intervals (CIs) are presented. The combined patient census remained consistent throughout the study period (mean 5580 in pre period and 5765 in post period). There was a significant change in the mean distribution of insurance coverage between the two periods (P<.001). The mean proportion of Medicaid coverage increased from 19.1% to 28.6% (Diff =9.5%, 95% CI=8.0-11.1%) while the CoMS indigent coverage decreased from 10.8% to 0.4% (Diff = 10.4%, 95% CI=9.5-11.2%). There was no similar changes in the proportion or number of patients seen in the ED from any other payer group, including Uninsured patients. Although there were significant changes between periods, there was little variation in primary payer groups within each of the study periods indicating the changes seen were associated with the early implementation of ACA coverage programs. In this multicenter study assessing the impact of the ACA on insurance coverage for ED patients, County-sponsored indigent care coverage decreased, while Medicaid coverage increased significantly. There was no change in the proportion of ED patients who were uninsured. These findings are very early on in the implementation of the ACA and require larger studies both geographically and temporally.