The Patient Protection and Affordable Care Act (ACA) has brought about massive changes to the structure of the American health care financing system. As a consequence, an additional 20 million Americans have coverage, and for the first time ever, the uninsured rate dove below 10 percent.¹

For emergency physicians, the ACA has resulted in dramatic shifts in our payer mix, especially among the nonelderly adult population. While the ratios of emergency patients with Medicare have remained relatively stable over the past decade, there has been a slow but steady decline in private coverage. However, in 2013, when the ACA’s Medicaid expansion went into full effect, a dramatic shift in payer mix from uninsured to Medicaid became evident. This has been demonstrated in multiple studies of general emergency department patients, in states such as Illinois and Maryland, for young adults, and for trauma patients.^2–9

What does this portend for our specialty? A few years ago, Jon Mark Hirshon, MD, PhD, MPH, FACEP, the current Chair of the ACEP Board, co-authored a paper suggesting that this shift in payer mix from uninsured to Medicaid represented $3.97 additional revenue per RVU for the average emergency physician.¹⁰ The calculus for Medicaid expansion is crystal clear. The swath of preexisting data combined with a new paper, presented in this month’s EMRA+PolicyRx Health Policy Journal Club, builds upon what we should agree is an unimpeachable fact.

The ACA positively shifts payer mix for emergency care and ultimately leads to improved financial viability for our specialty. Emergency physicians in the 14 states that have yet to expand Medicaid should strongly consider advocating for the 2.5 million Americans who remain stuck in the Medicaid gap.^11,12

Dr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of PolicyRx.org.

References

1. Diamond D. Thanks, Obamacare: America’s uninsured rate is below 10% for first time ever. Forbes website. Aug. 12, 2015. Accessed Jan. 17, 2020.
2. Nikpay S, Freedman S, Levy H, et al. Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases. Ann Emerg Med. 2017;70(2):215-225.e6.
3. Orgel GS, Weston RA, Ziebell C, et al. Emergency department patient payer status after implementation of the Affordable Care Act: a nationwide analysis using NHAMCS data. Am J Emerg Med. 2019;37(9):1729-1733.
4. Garthwaite C, Gross T, Notowidigdo M, et al. Insurance expansion and hospital emergency department access: evidence from the Affordable Care Act. Ann Intern Med. 2017;166(3):172-179.
5. Pines JM, Zocchi M, Moghtaderi A, et al. Medicaid expansion in 2014 did not increase emergency department use but did change insurance payer mix. Health Aff (Millwood). 2016;35(8):1480-1486.
6. Feinglass J, Cooper AJ, Rydland K, et al. emergency department use across 88 small areas after Affordable Care Act implementation in Illinois. West J Emerg Med. 2017;18(5):811-820.
7. Klein EY, Levin S, Toerper MF, et al. The effect of Medicaid expansion on utilization in Maryland emergency departments. Ann Emerg Med. 2017;70(5):607-614.e1.
8. Bush H, Gerber LH, Stepanova M, et al. Impact of healthcare reform on the payer mix among young adult emergency department utilizers across the United States (2005-2015). Medicine (Baltimore). 2018;97(49):e13556.
9. Knowlton LM, Dehghan MS, Arnow K, et al. The impact of Medicaid expansion on trauma-related emergency department utilization: a national evaluation of policy implications. J Trauma Acute Care Surg. 2020;88(1):59-69.
10. Pimentel L, Anderson D, Golden B, et al. Impact of health policy changes on emergency medicine in Maryland stratified by socioeconomic status. West J Emerg Med. 2017;18(3):356-365.
11. Status of state Medicaid expansion decisions: interactive map. Kaiser Family Foundation website. Accessed Jan. 17, 2020.
12. Garfield R, Orgera K, Damico A. The coverage gap: uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation website. Accessed Jan. 17, 2020.