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Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data

Published:December 18, 2018DOI:https://doi.org/10.1016/j.ajem.2018.12.031

      Abstract

      Objective

      To evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA).

      Methods

      We evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012–2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage—overall and within the older (≥65), working-age (18–64) and pediatric (<18) subpopulations—using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends.

      Results

      Overall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014–2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13–1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29–2.23). The increase was almost entirely attributable to increased Medicaid coverage.

      Conclusion

      In the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.

      Keywords

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      References

        • Patient Protection and Affordable Care Act
        42 U.S.C. § 18001 et seq..
        2010
        • Jost T.S.
        First steps of repeal, replace and repair.
        Health Aff. (Milwood). 2017; 36: 398-399
        • UCSF/UC Hasting Consortium on Law, Science and Health Policy
        ACA Repeal and Replace Efforts Timeline.
        http://www.healthreformtracker.org/ahca-timeline
        Date: 2017
        Date accessed: June 28, 2018
        • Medford-Davis L.N.
        • Eswaran V.
        • Shah R.M.
        • Dark C.
        The patient protection and affordable care Act's effect on emergency medicine: a synthesis of the data.
        Ann. Emerg. Med. 2015; 66: 496-506
        • Klein E.Y.
        • Levin S.
        • Toerper M.F.
        • Makawsky M.D.
        • Xu T.
        • Cole G.
        • et al.
        The effect of Medicaid expansion on utilization in Maryland emergency departments.
        Ann. Emerg. Med. 2017; 70: 607-614
        • Dresden S.M.
        • Powell E.S.
        • Kang R.
        • McHugh M.
        • Cooper A.J.
        • Feinglass J.
        Increased emergency department use in Illinois after implementation of the Patient Protection and Affordable Care ct.
        Ann. Emerg. Med. 2017; 69: 172-180
        • Nikpay S.
        • Freedman S.
        • Levy H.
        • Buchmueller T.
        Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases.
        Ann. Emerg. Med. 2017; 70: 215-225
        • Garthwaite C.
        • Gross T.
        • Notowidigdo M.
        • Graves J.A.
        Insurance expansion and hospital emergency department access: evidence from the Affordable Care Act.
        Ann. Intern. Med. 2017; 166: 172-179
        • Dimick J.B.
        • Ryan A.M.
        Methods for evaluating changes in health care policy: the difference-in-differences approach.
        JAMA. 2014; 312: 2401-2402
        • Centers for Disease Control and Prevention
        NHAMCS Micro-Data File Documentation.
        (Accessed June 28, 2018)
        • American College of Emergency Physicians
        ACEP Poll Affordable Care Act Research Results.
        Marketing General Incorporated, Alexandria, VA2015: 2015
        • Findlay S.
        Health Costs Bear Down on Families Who Don't Qualify for ACA Subsidies. Shots (Health News from National Public Radio), December 14, 2018.
        • Scott Z.
        • Morton F.S.
        Out-of-network emergency-physician bills—an unwelcome surprise.
        New Engl. J. Med. 2016; 375: 1915-1918
        • Brown L.H.
        • Weston R.A.
        • Gough J.E.
        The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals.
        Am. J. Emerg. Med. 2017; 35: 1228-1233
        • Ai C.
        • Norton E.C.
        Interaction terms in logit and probit models.
        Econ. Lett. 2003; 80: 123-129