Impact of Affordable Care Act on Emergency Practice

HEALTHCARE HEALTHCARE 6 6 HEALTHCARE Briefing Memo Name of the Student Name of the University Author Note To: From: Date: 06 February, 2020 Subject: Impact of Affordable Care Act on emergency practice It has come to my attention that there has been a significant impact on the number of emergency department (ED) visits, following the implementation of the Affordable Care Act in recent times. In addition to the Health Care and Education Reconciliation Act of 2010 revision, this act characterizes the most important supervisory overhaul

Running head: HEALTHCARE
Briefing Memo
Name of the Student
Name of the University
Author Note

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To:
From:
Date: 06 February, 2020
Subject: Impact of Affordable Care Act on emergency practice
It has come to my attention that there has been a significant impact on the number of
emergency department (ED) visits, following the implementation of the Affordable Care Act
in recent times. The Patient Protection and Affordable Care Act (PPACA), commonly
referred to as Obamacare had been enforced in the United States on March 23, 2010 by the
then president Barrack Obama. In addition to the Health Care and Education Reconciliation
Act of 2010 revision, this act characterizes the most important supervisory overhaul and
development of coverage of the healthcare system in the US, since
the Medicare and Medicaid had been passed in 1965 (U.S. House of Representatives, 2010).
It is widely known that after being enforced in 2014, the proportion of uninsured population
was reduced by half, with the estimates varying from around 20-24 million extra individuals
being covered by the act (Center et al., 2017). Moreover, the act also resulted in the
development of a plethora of delivery system improvements that were solely envisioned to
limit healthcare costs and advance quality. Following its immediate effect, a decline was
observed in the general healthcare spending, together with the premiums for insurance plans
that were employer-based. One significant provision of this act was the expansion of access
to health insurance coverage to an estimated 32 million Americans who were uninsured,
brought about by the advancement of both public and private insurance. While the major
purpose of this provision was to provide health coverage to majority of citizens, it created a
significant impact on ED care and visits (McCarthy, 2017).
Endorsing worth and significance in the ED care necessitates to be a matter of utmost
concern for the policymakers, with the implementation of PPACA. Emergency departments
have been identified to play a crucial role in delivery of health care services to the critically
injured and ill, and always acts in the form of an accessible resource for unprepared
care. Taking into consideration the unplanned kind of patient admissions, the department is
expected to deliver initial treatment for a range of conditions that might be life-threatening,
thus operating for all 24 hours in a day (Widmer et al., 2018). Factually, the necessity for
EDs originated from the upsurges in vehicular trauma that was concomitant with the
development of the Interstate Highway System during the 60s. Nonetheless, EDs also rapidly
became the suppliers of low acuity unprepared care. EDs have gradually substituted the
physician’s office as the chief source for hospice admissions and deliver a security net for the
underinsured, uninsured, and medically disenfranchised. However, the Emergency Medical
Treatment and Active Labor Act passed by the United States Congress in 1986 established
EDs as the healthcare provider of last option for all patients, notwithstanding their capability
to pay for their care, their legal status or citizenship (Gressick & Jackson, 2019). However,
the insurance expansion element of the PPACA directly affects the demand amid patients for
ED care and the anticipations for its part in delivering coordinated care.
The element of the PPACA revised and increased the Medicaid entitlement beginning
in the year 2014. According to this element, all US legal residents and citizens having
earnings up to 133% of poverty line, together with grown-ups not having dependent children,
will be considered suitable for health coverage across all state that contributed in the
Medicaid program. The act made it mandatory for the federal government to pay 100% of the
augmented charge in the years 2014, 2015, and 2016 (U.S. House of Representatives, 2010).

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Moreover, the government also had to pay around 95%, 94%, 93%, and 90% of the increased
costs in the following years. The presence of a 5% "income disregard" have resulted in the
operative income entitlement maximum for the Medicaid to reach around 138% of poverty
level (French, Homer, Gumus & Hickling, 2016). Nonetheless, it has been ruled by
the Supreme Court in the NFIB v. Sebelius that this facility of PPACA was forced, and that
different states have the right to select to last at pre-PPACA admissibility levels. Apart from
the Medicaid expansion, other PPACA elements related to the provision for health insurance
ranged from (i) development of health insurance exchanges, (ii) imposing regulation on
healthcare plans that permitted young adults to use the insurance of their parents until they
reached 26 years of age, and rejected excluding or incriminating greater rates for patients
suffering from pre-existing conditions, (iii) forfeits to companies for not giving coverage for
workers, and (iv) necessities that most persons are in possession of health insurance (Frean,
Gruber & Sommers, 2017).
My association with the emergency practice has helped me identify that there has
been a gradual decline in the ED visits. This in turn can be accredited to the fact that through
the expansion of Medicaid, there are several individuals who hold the notion that more
patients would select to access the primary care providers as an alternative to the ED, owing
to the presence of definite health coverage. My experience at emergency practice helped me
realize that the justification for increasing insurance coverage was a predictable reduction in
ED patients who were expected to be treated in a more cost-effective manner in other
healthcare settings. Findings from a retrospective cross-sectional study conducted across the
EDs located in Maryland affirmed my opinion by stating that in recent years, there has been a
considerable increase in the number of patients who are covered by Medicaid, following the
enforcement of the PPACA (Klein et al., 2017). However, the frequent patients who had been
newly registered to the Medicaid facility got admitted to the ED more, when compared to
their uninsured counterparts. The number of ED visits in Maryland were found to decrease by
as much as 36,531 between the time prior to and after PPACA implementation. While the
visits increased from 23.3-28.9% for Medicaid-covered patients, those for uninsured patients
reduced from 16.3-10.4%.
On examining the trends in visits to ED and hospitalization over the decade,
beginning from 2006, together with the alterations in insurance coverage and visit rate, it was
found that the ED visit numbers increased established on preceding time inclinations of 2.3
million visits per year from 2013-16. The proportion of visits to ED by patients who had
Medicaid steadily increased during the same time, in contrast an abrupt 2.1% decrease in the
visits by people who did not have insurance coverage after the year 2013. In other words,
uninsured visits accounted for an estimated 8% of visits to ED in 2016. While ED visits
ranged from 26-34% for insured citizens, it reduced from 14-8% for the uninsured, thus
highlighting the negative impacts that insurance provisions created on emergency care.
It needs to be considered that in recent years, crowding in ED has deteriorated, which
in turn can be attributed to the fact that patients who are not able to access primary care in a
timely manner generally visit the ED for management of non-emergent conditions.
Inappropriate utilization of the ED services have been associated to processes, admissions,
and unnecessary testing, all of which generally contribute to an increase in healthcare
expenditures (Marcozzi et al., 2018). In order to determine the impact of PPACA on two EDs
at Illinois, researchers conducted a retrospective record review of around 357,764 ED visits
for the duration January 1, 2011–December 31, 2016. It was found that there had been an
increase in ED visits for patients who had governmental coverage and/or Medicaid during the
post-PPACA period, compared to the pre-PPACA period (Probst et al., 2019). Nonetheless,

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there was a statistically substantial reduction in ED visits for patients who were uninsured
during post-PPACA period (Pre: 12.1% vs Post: 6.4%, and Pre: 13.9% vs Post: 9.8%,
respectively) (Singer, Thode & Pines, 2019). These findings also highlight the fact despite the
noble intention of the PPACA for increasing health coverage, it prevents uninsured patients
from using emergency services, thereby compromising their health and safety.
The provisions for insurance expansions had been created based on the notion that by
augmenting the access of all citizens to primary care, the PPACA insurance developments
might decrease ambulatory care related hospital usage over time (Sommers et al., 2016).
Feinglass et al. (2017) also analyzed the changes that occurred in visit rates to the hospital
EDs after insurance expansion and found that PPACA implementation augmented existing
tendencies towards larger usage of hospital ED care in Illinois. When compared to 2012–
2013 and 2014–2015, the mean monthly visits to the ED by the uninsured citizens plummeted
42%, nonetheless amplified 42% for those having Medicaid and 10% for citizens who were
privately insured. In addition to the baseline uninsurance rate of PUMA from 6.7-41.1%, a
4.6 fold difference was also noticed in the PUMA visits to the ED.
It is a widely accepted fact that expansion of insurance, in theory, generally offers
enhanced access to healthcare amenities, thereby decreasing the dependence on emergency
care. Findings from the aforementioned studies elaborated that people who have been
recently insured, after implementation of the act generally upsurge the rate of utilization of
emergency care services owing to the fact that they become familiarized to the new primary
care professionals and the newly retrieved health coverage also decreases the expenditure
barriers to ED care. However, the expansion of insurance created a negative impact on those
people who are not able to meet the eligibility criteria for Medicaid, and this remain without
any insurance. It has also been found that despite the 5.6% in ED visits following PPACA
implementation, there were no virtual differences in hospital admission rates (Feinglass et al.,
2017). The rate of uninsured ED visits significantly decreased from 22.9% to 12.5% during
2014-15 among Illinois residents, thus reflecting a 43% drop in mean monthly ED visits, in
addition to a 54% decline in ED related hospitalization. The total number of cases involving
uninsured hospitalization to ED, categorized as ACSH however demonstrated a non-
significant increase from 15.4-15.5%.
With the aim of exploring the impacts of PPACA on the individual patients who seek
emergency care, another nationwide analysis had been conducted, based on NHAMCS data.
It was found that despite the lack of significant change in proportion of ED patients having an
insurance, the total number of adult patients of the working age, with at least one insurance
plan significantly increased from 66-71.8% (OR 1.31, CI: 1.13–1.52). The alteration in
insurance coverage in this population was larger when compared to the adults who were
Medicaid eligible (AOR 1.70, CI: 1.29–2.23) (Orgel et al., 2019). Thus, it can also be stated
that during the initial two years after complete implementation of the PPACA, there had been
a substantial upsurge in the percentage of adult working-age ED patients having at least one
type of health insurance. The aforementioned increase seemed primarily connected with the
expansion of Medicaid program.
Similarly, results from another study conducted by Danagoulian, Janke and Levy
(2018) across six states, of which four expanded the Medicaid suggested that Medicaid
expansion brought about an approximate 2.7-4% increase in the number of processes per
patient visit to the ED. In addition, there was a decline in the number of diagnosis by an
estimated 0.098 per ED visit (95% CI, -0.22 – 0.03) in the year 2014, compared to the non-
expanding states. However, Nikpay et al. (2017) argued that contrary to the studies discussed

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above, expansion of Medicaid has increased usage of ED visits. Findings from their
longitudinal study suggested that the total ED users per 1,000 population demonstrated an
increase by as much as 2.5 times in states that have Medicaid expansion, compared to those
with non-expansion. Majority of ED visits after expansion of the insurance were associated to
injury and the share of ED visits was amplified by around 8.8 percentage points.
My practice has helped me realize that expansion of health insurance coverage, in
addition to an increase in the access to healthcare facilities creates an effect on the revenue of
medical providers. Though the forecasts of medical spending comprise of augmented
utilization of services that are attributable to enhanced and better-quality access, they fail to
take account of vicissitudes in the billing and provider practice misestimating the expenditure
of the insurance expansion. As thought-provoking the data might be, we are confident that
necessary steps shall be taken to increase the utilization of emergency care services for the
uninsured American citizens as well.
Thank you for your cooperation.
Yours sincerely,
___________________

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References
Center, H., Woods, C. A., Manchikanti, L., & Purdue Pharma, L. P. (2017). A critical
analysis of Obamacare: Affordable care or insurance for many and coverage for
few. Pain Physician, 20, 111-138.
Danagoulian, S., Janke, A., & Levy, P. (2018). Medicaid Expansion After the ACA: Intensity
of Treatment and Billing in Emergency Departments. Available at SSRN 3261600.
Feinglass, J., Cooper, A. J., Rydland, K., Powell, E. S., McHugh, M., Kang, R., & Dresden,
S. M. (2017). Emergency department use across 88 small areas after Affordable Care
Act Implementation in Illinois. Western Journal of Emergency Medicine, 18(5), 811.
Frean, M., Gruber, J., & Sommers, B. D. (2017). Premium subsidies, the mandate, and
Medicaid expansion: Coverage effects of the Affordable Care Act. Journal of Health
Economics, 53, 72-86.
French, M. T., Homer, J., Gumus, G., & Hickling, L. (2016). Key provisions of the Patient
Protection and Affordable Care Act (ACA): a systematic review and presentation of
early research findings. Health services research, 51(5), 1735-1771.
Garthwaite, C., Gross, T., Notowidigdo, M., & Graves, J. A. (2017). Insurance expansion and
hospital emergency department access: evidence from the Affordable Care
Act. Annals of internal medicine, 166(3), 172-179.
Gressick, K., & Jackson, J. S. (2019). The Emergency Medical Treatment and Active Labor
Act (EMTALA): Assisting physicians to honor medical oaths. The American journal
of emergency medicine, 37(7), 1391-1392.
Klein, E. Y., Levin, S., Toerper, M. F., Makowsky, M. D., Xu, T., Cole, G., & Kelen, G. D.
(2017). The effect of Medicaid expansion on utilization in Maryland emergency
departments. Annals of emergency medicine, 70(5), 607-614.
Marcozzi, D., Carr, B., Liferidge, A., Baehr, N., & Browne, B. (2018). Trends in the
contribution of emergency departments to the provision of hospital-associated health
care in the USA. International Journal of Health Services, 48(2), 267-288.
McCarthy, M. (2017). Obamacare repeal could leave 32 million uninsured and double
premiums, report finds.
Nikpay, S., Freedman, S., Levy, H., & Buchmueller, T. (2017). Effect of the Affordable Care
Act Medicaid expansion on emergency department visits: evidence from state-level
emergency department databases. Annals of emergency medicine, 70(2), 215-225.
Orgel, G. S., Weston, R. A., Ziebell, C., & Brown, L. H. (2019). Emergency department
patient payer status after implementation of the Affordable Care Act: A nationwide
analysis using NHAMCS data. The American journal of emergency medicine, 37(9),
1729-1733.
Probst, B. D., Walls, L., Cirone, M., & Markossian, T. (2019). Examining the Effect of the
Affordable Care Act on Two Illinois Emergency Departments. Western Journal of
Emergency Medicine, 20(5), 710.
Singer, A. J., Thode, H. C., & Pines, J. M. (2019). US emergency department visits and
hospital discharges among uninsured patients before and after implementation of the
Affordable Care Act. JAMA network open, 2(4), e192662-e192662.

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Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2016). Changes in utilization
and health among low-income adults after Medicaid expansion or expanded private
insurance. JAMA internal medicine, 176(10), 1501-1509.
U.S. House of Representatives. (2010). COMPILATION OF PATIENT PROTECTION AND
AFFORDABLE CARE ACT. Retrieved from
http://housedocs.house.gov/energycommerce/ppacacon.pdf.
Widmer, M. A., Swanson, R. C., Zink, B. J., & Pines, J. M. (2018). Complex systems
thinking in emergency medicine: a novel paradigm for a rapidly changing and
interconnected health care landscape. Journal of evaluation in clinical practice, 24(3),
629-634.