Health care reform increases emergency department use in Massachusetts

The implementation of health care reform in Massachusetts - principally the expansion of health insurance coverage to nearly everyone in the state - was associated with a small but consistent increase in emergency department use, according to the findings of a study to be published online today in Annals of Emergency Medicine ("Increased Use of the Emergency Department After Health Care Reform in Massachusetts").

"This obviously has implications about what we can expect to see nationally as the roll-out of the Affordable Care Act continues," said Peter Smulowitz, MD, FACEP, of Beth Israel Deaconess Medical Center in Boston, Mass. "We cannot say for sure why more people came to the ER - whether it's a lack of access to primary care or the result of pent-up demand - but we need to be ready. Other states should be prepared for equal or greater influxes of patients into the ER after reform is fully implemented."

Dr. Smulowitz and his colleagues found emergency department visits increased by as much as 1.2 percent between October 1, 2006 and September 30, 2007 after Massachusetts implemented its first-in-the-nation law to increase health care insurance coverage. That rose to a 2.2 percent increase in ER visits for the period that ended Sept. 30, 2009.

The data included all emergency department visits in Massachusetts submitted annually from 69 acute care hospitals, accounting for approximately 2 million outpatient emergency visits, 850,000 inpatient admissions and 150,000 observation stays.

Overall emergency visits by the uninsured under the age of 65 decreased from 9.5 percent of overall visits before health reform to 5.7 percent of the visits after health reform implementation. Emergency department visits from those 65 and older remained steady at about 1 percent.

"Our study should further weaken the long-held notion that high use of the emergency department is driven mainly by the uninsured," said Dr. Smulowitz. "Barriers to primary care are serious and persistent across the country. It appears that when people have health insurance, they will seek medical care wherever they can get it, which is sometimes only the ER."