Massachusetts Health Reform & ED Volume

This post also appears on Policy Prescriptions

Open enrollment for the ACA exchanges starts on October 1. As more Americans get health insurance, what will happen to ED visits? What happened when Massachusetts enacted similar reform?

Like many Republicans in Congress, orthopedic surgeon and Wyoming Senator John Barrasso is an outspoken critic of the Affordable Care Act. I’ve seen him speak twice – first when he was an invited speaker at the 2012 ACEP Leadership and Advocacy Conference, and again this winter when we brought our residents to Congress on our annual Capitol Hill Day. Both times, he predicted that ObamaCare would increase ED visits; after all, ED visits increased in Massachusetts after the state enacted health reform in 2006

Senator Barrasso is not the only one who makes this connection. It’s a claim repeated by Avik Roy, one of Mitt Romney’s key health care advisors,¹ as well as John Goodman, who the Wall Street Journal calls “the father of HSAs”² (not the actor). Journalists repeat the same argument: “In the wake of the Bay State’s 2006 health care overhaul, which provided the model for ObamaCare, emergency room visits soared”³ and “emergency department visits will rise with health reform, just as they did in Massachusetts after the state enacted a health reform law in 2006.”⁴

Prominent emergency physicians have recognized the trend as well. Referring to a 2011 poll of emergency physicians, then-ACEP president Sandra Schneider, stated: “This poll confirms what we are witnessing in Massachusetts — that visits to emergency rooms are going to increase across the country, despite health care reform, and that health insurance coverage does not guarantee access to medical care.”⁵

The argument makes some intuitive sense. As some people gain health insurance coverage, they will have one less barrier to going to the ED, driving up visits. And similar to the Affordable Care Act, Massachusetts' reform focused on covering the uninsured but did little to increase primary care, so of course they will come to us.

It's true. After implementing health reform from 2006-2007, ED visits in Massachusetts increased, rising between 6.7% from 2006-2009.^6,7

Many attribute this increase to health reform. But ED visits have been increasing everywhere. According to numbers from the CDC's National Center for Health Statistics, there were 119 million ED visits in 2006⁸ and 136 million in 2009,⁹ an increase of 14% nationwide. While total ED visits went up in Massachusetts, they increased less than they did across the country. In fact, when looking not at total ED volume but the per capita ED visit rate, after holding steady for a few years, by 2010 individuals in Massachusetts were actually less likely to go to an ED.¹⁰

A New England Journal of Medicine study compared ED visit rates across the same time period between Massachusetts and two neighboring states, neither of which implemented any state-level health reform.⁶ New Hampshire and Vermont saw nearly identical increases in ED visits over the same time period, too. Looking just at ED visits that led to admissions, the numbers look the same, implying the acuity levels were comparable in Massachusetts and its non-reform neighbors. Other studies have found that the “increase” in Massachusetts ED volumes after reform was not from low acuity or non-emergency visits.^11,12

Of course there are differences between Massachusetts and the country as a whole. The health care environment in Massachusetts is different than in the US, both before and after reform. For starters, state health reform decreased Massachusetts’s uninsured rate from only 10.9% in 2006 to 6.3% by 2009, compared to the >17% national uninsurance.¹³ And the ACA is not identical to Massachusetts’ reform.

The ACA is by no means perfect. Neither was health reform in Massachusetts. But despite the pessimistic views of some, health reform in Massachusetts did not flood EDs with patients. It’s no secret that EDs across the country are busy. But the increase in ED visits in Massachusetts doesn’t mean that ObamaCare will flood our EDs.

1.         Roy A. Emergency Room Visits Increase in Massachusetts. Critical Condition, National Review Online, and The Apothecary. July 7, 2010. http://www.avikroy.org/2010/07/emergency-room-visits-increase-in.html

2.         Goodman J. What Will Happen To Emergency Room Traffic? Health Affairs Blog. July 12th, 2010.

http://healthaffairs.org/blog/2010/07/12/what-will-happen-to-emergency-room-traffic/

3.         Suderman P. Like Long Medical Wait Times, Crowded Emergency Rooms? You’ll Love ObamaCare. Reason Hit & Run Blog. May. 4, 2011.

http://reason.com/blog/2011/05/04/like-long-medical-wait-times-c

4.         Becker AL. Health care reform likely to increase pressure on emergency rooms. The CT Mirror. August 18, 2010. http://www.ctmirror.org/story/health-care-reform-likely-increase-pressure-emergency-rooms

5.         Emergency Visits Are Increasing, New Poll Finds; Many Patients Referred by Primary Care Doctors. April 28, 2011. http://www.acep.org/Content.aspx?id=78646

6.         Chen C, Scheffler G, Chandra A. Massachusetts' health care reform and emergency department utilization. The New England Journal of Medicine. Sep 22 2011;365(12):e25.

7.         Massachusetts Emergency Department Visit Volume, FY2005-FY2009. Massachusetts Division of Health Care Finance and Policy.

            http://www.mass.gov/chia/docs/r/ed/ed-volume-fy05.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-fy06.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-2008.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-2009.pdf

8.         Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Health Statistics Reports. Aug 6 2008(7):1-38.

9.         National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables. National Center for Health Statistics.  http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf

10.       Long SK, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance    remains low, self-reported health status improves as state prepares to tackle      costs. Health Affairs. Feb 2012;31(2):444-451.

11.       Miller S. The Effect of Insurance on Emergency Room Visits: An Analysis of    the 2006 Massachusetts Health Reform. 2012;           http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1711502.

12.       Smulowitz PB, Lipton R, Wharam JF, et al. Emergency department utilization after the implementation of Massachusetts health reform. Annals of Emergency Medicine. Sep 2011;58(3):225-234 e221.

13.       Massachusetts Health Care Reform: Six Years Later. Kaiser Family Foundation. May 2012.  http://www.kff.org/healthreform/upload/8311.pdf