Affordable Care Act
- Health insurance coverage does not equal access to medical care — Emergency visits have increased at twice the rate of the U.S. population, and they will continue to increase, despite the ACA.
- Three-quarters of emergency physicians are already seeing an increase in patients in their emergency departments since the implementation of the ACA. [i]
- ACEP advocated for provisions in the ACA, such as inclusion of emergency services as an essential part of any health benefits package and the prudent layperson standard, which guarantees health plans base coverage on a patient’s symptoms, not final diagnosis.
- Rather than trying to keep people out of emergency departments, policymakers must recognize the value of this model of medicine that people want and clearly need.
Q. Does ACEP support the Affordable Care Act?
- ACEP did not take a formal position on the passage of the ACA but support the provisions in the law that benefit emergency patients, for example, a national prudent layperson standard, which requires health plans to cover emergency care based on symptoms, not final diagnosis. ACEP opposed other provisions that harm emergency patients, such as the Independent Payment Advisory Board (IPAB).
- ACEP has said that emergency visits would continue to increase despite the implementation of the ACA. Many policymakers promoted that ER visits would decrease due to the ACA. Visits are going up in part because of a severe primary care physician shortage, growing elderly population and millions of patients added to Medicaid rolls.
- The nation’s emergency physicians are dedicated to working to achieve the long-term benefits of true health care reform. ACEP is asking Congress and the president’s administration to recognize and fund the central role emergency medicine plays in the health care system.
Q. Why do policymakers/lawmakers need to focus on emergency care?
- Emergency visits are at a record high. (136 million patients in 2011 ). An overwhelming 96 percent of them were triaged as needing medical treatment within 2 hours, up from 92 percent in 2010.
- Emergency physicians are key decision-makers for nearly half of all hospital admissions, highlighting the critical role they can play in reducing health care costs, according to a report by the RAND Corporation[ii]. Hospital admissions from the ER increased by 17 percent over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009. Hospital inpatient care is a key driver of health care costs, accounting for 31 percent of the nation’s health care expenses.
- Four in five people who contacted a primary care physician or other medical provider before seeking emergency care were told to bypass their doctor’s office and go directly to the emergency room.[iii] The RAND team found evidence that primary care physicians are increasingly relying on ERs to evaluate and, if necessary, hospitalize their sickest and most complex patients.
- Efforts to reduce non-urgent and non-emergency use of emergency departments oversimplify a complex problem, and should instead focus on increasing access to affordable options outside the emergency room.
- Efforts to shift care into other facilities, such as retail clinics, have not always been successful because of the limitations of other facilities. For example, retail clinics lack diagnostic testing, are unable to admit patients to the hospital and won’t see uninsured patients who can’t pay cash.
- If emergency departments continue closing their doors — where are people supposed to go for emergency medical care?
- Hundreds of ERs have closed in the past decade (CDC 2011). The number of emergency departments has decreased in 10 years, but the demand for care is up to 136 million patients nationwide. In 2013, there were 4,440 emergency departments in the U.S. That is a significant decrease from nearly 5,000 in 1993.
- Emergency visit rates have increased at twice the rate of growth of the U.S. population from 1997 to 2007.
What are the challenges facing emergency patients?
- Emergency departments continue to close, yet they are essential to every community and must have adequate resources.
- Health insurance coverage does not guarantee access to medical care. Seventeen million more people are projected to be added to the Medicaid rolls, but many will seek care in emergency departments because Medicaid reimbursement rates are so low that physicians will not see them. Medicaid enrollment also will be greatly affected by the number of states that choose not to implement the expanded coverage provided for in the Accountable Care Act. [vi] Adults with Medicaid insurance (under age 65) use emergency departments at more than double the rate of adults with private insurance. The majority of Medicaid patients ages 21 to 64 who seek emergency care have the symptoms of urgent or more serious medical conditions.[vii]
- Patients who need care in 1 to 14 minutes are being seen in twice that timeframe[viii], a dangerous delay for the sickest patients. The crisis in emergency care is everyone’s problem.
- No one predicts or schedules medical emergencies.
- Only 4 percent of emergency patients have non-urgent medical conditions.[ix]
- Emergency departments have a federal mandate to treat everyone, regardless of ability to pay.
- Two-thirds of emergency visits occur after business hours, when your doctor’s office is closed.[x]
- America has a growing elderly population; most have chronic health problems and require emergency care.
Shouldn’t the nation’s focus be on preventing people from using “expensive and inefficient” emergency departments?
- Emergency departments are masters of efficiency and ingenuity and provide more uncompensated care than any other physicians. Expenditures for emergency care are between 2-4 percent of the nation’s $2.9 trillion [xi] in health care expenditures. We provide a tremendous amount of care for two cents out of every dollar.
- Many people mistakenly lump the physician and hospital costs together. Only a small portion of an emergency bill is for the emergency physician’s charges. The remaining portion of a patient’s bill is represented by hospital costs (overhead, nurses, etc.) and any other diagnostic tests or physician consultants.
- Emergency departments have a federal mandate (EMTALA) to care for all patients, regardless of their ability to pay. However, the mandate is unfunded. The hospital’s actual costs for providing care during a nonurgent visit are similar to the costs of a family physician visit. Given the standby costs (staffing and equipment) to treat all patients 24/7, the extra (or marginal) costs of seeing an additional patient for an urgent or nonurgent problem are much less than what it would cost to open a private physician’s office after hours or build an urgent care center.
- Emergency care is timely and highly efficient because emergency physicians command the resources of the entire hospital, such as diagnostic equipment and consultants. When other office- or clinic-based physicians have seriously ill or injured patients, they send them to emergency departments. These doctors know that patients in an ER will receive rapid diagnostic evaluations and immediate lifesaving treatment.
What is ACEP’s position on the “medical home”?
- Emergency physicians still support the basic tenets of the patient-centered medical home, although they prefer the term “medical neighborhood,” which more appropriately represents all the individuals and services that must be made available to the patient. However, key specifics must be addressed to avoid unintended negative consequences, such as:
- The medical neighborhood approach must be truly patient-centered. It must not function like the “gatekeeper” model of HMOs and access to emergency care must be protected.
- Shifting financial and other resources to support the medical neighborhood concept could have tremendous adverse effects on emergency patients, especially if health care funding is diverted from specialist care, which could exacerbate an already tenuous situation of specialist availability in the emergency department. Furthermore, the medical home concept does not address the millions of people who are uninsured or underinsured.
- The medical neighborhood concept must account for the fact that most physicians’ offices are closed on nights and weekends, and many people are unable to get timely appointments during regular working hours because their physicians’ schedules are booked.
For more information on this and other topics, visit http://newsroom.acep.org/fact_sheets.
[i] ACEP.org, “ER Visits Continue to Rise Since Implementation of Affordable Care Act, 2015, http://newsroom.acep.org/2015-05-04-ER-Visits-Continue-to-Rise-Since-Implementation-of-Affordable-Care-Act
[ii] RAND Corporation, 2013, “The Evolving Role of Emergency Departments in the United States,” http://www.rand.org/pubs/research_reports/RR280.html
[iii] RAND Corporation, 2013, “The Evolving Role of Emergency Departments in the United States,” http://www.rand.org/pubs/research_reports/RR280.html
[iv] Avalere Health analysis of American Hospital Association Annual Survey data, 2013, for community hospitals. US Census
Bureau: National and State Population Estimates, July 1, 2013.
[v] “Trends and Characteristics of U.S. Emergency Department Visits, 1997-2007,” JAMA, 304: 6, August 11, 2010
[vii] “Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms,” Center for Studying Health System Change, No. 23, July 2012 http://www.hschange.com/CONTENT/1302/1302.pdf
[ix] CDC, National Health Statistics Report 2014,
[x] CDC, “National Health Statistics Reports, National http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary,” August 2010, http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf
[xi] CMS, “National Health Expenditures 2013 Highlights,” http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf