OPINION
Increased Health Insurance Coverage Under the Affordable Care Act: Implications for Emergency Department Imaging Volume in the US Rakesh A. Shah, MD Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high-quality, affordable care they need. —US Department of Health and Human Services secretary Kathleen Sebelius, July 2009
A major goal of the Patient Protection and Affordable Care Act (PPACA), enacted in March 2010 and now being implemented throughout the United States, was to expand health insurance coverage in the United States. In 2012, 48 million Americans, or more than 15% of the American population, lacked any form of health insurance [1]. The lack of health insurance by such a large segment of the population, unique in the industrialized world, was found to be associated with approximately 45,000 excess preventable deaths per year [2]. Multiple organizations have demonstrated that the PPACA has been successful in the increasing the percentage of the US population with health insurance, dropping to 13.4% in the second quarter of 2014, down from a high of 18% in 2013 [3]. Twenty million Americans have either gained coverage or enrolled in new plans since October 2013, including 6 million new Medicaid
and Children’s Health Insurance Program enrollees [4]. Will this increased coverage translate to a reduced volume of patients in our nation’s emergency departments, as the need for them to serve as the de facto safety net for the uninsured is reduced? Prior experience with expansion of health care coverage suggests that the opposite may in fact be the case. In 2006, Massachusetts enacted a major health care reform bill that in many ways served as the basis for PPACA. The implementation of health care reform in Massachusetts successfully expanded coverage and was associated with a small but consistent increase in the use of emergency departments across the state from 2004 to 2009 [5]. Similarly, in 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults. Increasing Medicaid coverage was found to significantly increase overall emergency department use by 40%, including increases in visits for conditions readily treatable in primary care settings [6]. These findings are consistent with several additional recent studies demonstrating increased relative utilization of emergency departments by the Medicaid population and increased utilization of emergency departments by newly insured individuals relative to continuously insured adults [7,8].
ª 2015 American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.08.009
A major factor driving emergency department utilization by the newly insured may be the severe shortage of primary care physicians in the years to come, with a shortfall of 45,000 by 2020 [9]. Increased coverage will not translate into increased access to primary care services unless those physicians are available. The combination of increased insurance coverage and decreasing accessibility to primary care physicians may serve as a driver of the utilization of emergency departments, which are required to see patients at any time. Independent of the impact of increased health insurance coverage, escalating utilization of emergency departments in the future may also be driven by our aging population. The nation’s population aged 65 years is projected to reach 83.7 million in 2050, almost double in size from the 2012 level of 43.1 million [10]. In 2012, emergency department utilization by those 65 years of age was 16% higher than by those aged 18 to 64 years, and adults 75 years of age had the highest rates of emergency department utilization [11]. After a period of fairly rapid growth from 1995 to 2007, during which the utilization of CT in emergency departments grew by a compound annual growth rate of 13.9%, more recent data on the Medicare
907
population suggest there has been some slowing in this rate of growth [12,13]. In both studies, however, the rate of growth of CT utilization in emergency departments exceeded its rate of growth in other settings. In fact, from 2010 to 2012, emergency departments were the only setting that did not experience a downturn in CT utilization [13]. In recent years, there has been growing concern about the rapid rate of growth of CT imaging, particularly in the emergency department setting, with regards to both radiation exposure and appropriateness [14,15]. For overworked emergency physicians in increasingly busy emergency departments, however, the desire to avoid medical liability (an area largely unaddressed by PPACA) and rapidly triage patients may trump long-term concerns about cumulative radiation exposure and appropriateness of resource utilization. Even if there is further flattening or even a downturn in the growth curve utilization of CT in emergency departments in the years to come, an increase in the absolute number of patients driven by PPACA may potentially lead to a larger volume of emergency department imaging across all modalities of diagnostic radiology in the future. Increased access to health care under the PPACA may have significant benefits not only for the
previously uninsured but potentially for the public health of our nation as a whole. If disease can be detected and treated at an earlier stage, this may not only save lives but may potentially reduce overall health care costs. However, this expansion of coverage may not decompress patient volume in emergency departments, as many of its advocates had hoped, but in fact potentially increase emergency department utilization. Radiology departments should be prepared in the years to come for an increased volume of imaging from emergency departments and the manpower and equipment necessary to meet this potential surge.
7.
8.
9.
10.
11.
REFERENCES 1. US Census Bureau. Available at: https:// www.census.gov/hhes/www/hlthins/data/ incpovhlth/2012/figure08.pdf. 2. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US Adults. Am J Pub Health 2009;99:2289-95. 3. In U.S., uninsured rate sinks to 13.4% in second quarter. Available at: http://www. gallup.com/poll/172403/uninsured-rate-sinkssecond-quarter.aspx. Accessed August 28, 2014. 4. Blumenthal D, Collins SR. Health care coverage under the Affordable Care Act—a progress report. N Engl J Med 2014;371: 275-81. 5. Smulowitz PB, O’Malley J, Yang X, Landon BE. Increased use of the emergency department after health care reform in Massachusetts. Ann Emerg Med 2014;64:107-15. 6. Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid in-
12.
13.
14.
15.
creases emergency-department use: evidence from Oregon’s health insurance experiment. Science 2014;343:263-8. Gandhi SO, Grant LP, Sabik LM. Trends in nonemergent use of emergency departments by health insurance status. Med Care Res Rev 2014;71:496-521. Ginde AA, Lowe RA, Wiler JL. Health insurance status change and emergency department use among US adults. Arch Intern Med 2012;172:642-7. Health Resources and Services Administration Bureau of Health Professions National Center for Health Workforce Analysis: Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Available at: http://bhpr. hrsa.gov/healthworkforce/supplydemand/ usworkforce/primarycare/projectingprimary care.pdf. Accessed August 11, 2015. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. Available at: https://www. census.gov/prod/2014pubs/p25-1140.pdf. Accessed August 28, 2014. Centers for Disease Control and Prevention. Table 87. Emergency department visits within the past 12 months among adults aged 18 and over, by selected characteristics: United States, selected years 1997-2012. Available at: http://www. cdc.gov/nchs/hus/2013/087.pdf. Accessed August 28, 2014. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164-73. Levin DC, Rao VM, Parker L. The recent downturn in utilization of CT: the start of a new trend? J Am Coll Radiol 2012;9: 795-8. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009;169: 2078-86. Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. N Engl J Med 2010;363:4-6.
The author has no conflicts of interests to disclose. Rakesh A. Shah, MD: Department of Radiology, Winthrop-University Hospital, Mineola, NY 11501; e-mail: rshahmd@yahoo. com.
908
Journal of the American College of Radiology Volume 12 n Number 9 n September 2015
Increased Health Insurance Coverage Under the Affordable Care Act: Implications for Emergency Department Imaging Volume in the US Rakesh A. Shah, MD Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high-quality, affordable care they need. —US Department of Health and Human Services secretary Kathleen Sebelius, July 2009
A major goal of the Patient Protection and Affordable Care Act (PPACA), enacted in March 2010 and now being implemented throughout the United States, was to expand health insurance coverage in the United States. In 2012, 48 million Americans, or more than 15% of the American population, lacked any form of health insurance [1]. The lack of health insurance by such a large segment of the population, unique in the industrialized world, was found to be associated with approximately 45,000 excess preventable deaths per year [2]. Multiple organizations have demonstrated that the PPACA has been successful in the increasing the percentage of the US population with health insurance, dropping to 13.4% in the second quarter of 2014, down from a high of 18% in 2013 [3]. Twenty million Americans have either gained coverage or enrolled in new plans since October 2013, including 6 million new Medicaid
and Children’s Health Insurance Program enrollees [4]. Will this increased coverage translate to a reduced volume of patients in our nation’s emergency departments, as the need for them to serve as the de facto safety net for the uninsured is reduced? Prior experience with expansion of health care coverage suggests that the opposite may in fact be the case. In 2006, Massachusetts enacted a major health care reform bill that in many ways served as the basis for PPACA. The implementation of health care reform in Massachusetts successfully expanded coverage and was associated with a small but consistent increase in the use of emergency departments across the state from 2004 to 2009 [5]. Similarly, in 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults. Increasing Medicaid coverage was found to significantly increase overall emergency department use by 40%, including increases in visits for conditions readily treatable in primary care settings [6]. These findings are consistent with several additional recent studies demonstrating increased relative utilization of emergency departments by the Medicaid population and increased utilization of emergency departments by newly insured individuals relative to continuously insured adults [7,8].
ª 2015 American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.08.009
A major factor driving emergency department utilization by the newly insured may be the severe shortage of primary care physicians in the years to come, with a shortfall of 45,000 by 2020 [9]. Increased coverage will not translate into increased access to primary care services unless those physicians are available. The combination of increased insurance coverage and decreasing accessibility to primary care physicians may serve as a driver of the utilization of emergency departments, which are required to see patients at any time. Independent of the impact of increased health insurance coverage, escalating utilization of emergency departments in the future may also be driven by our aging population. The nation’s population aged 65 years is projected to reach 83.7 million in 2050, almost double in size from the 2012 level of 43.1 million [10]. In 2012, emergency department utilization by those 65 years of age was 16% higher than by those aged 18 to 64 years, and adults 75 years of age had the highest rates of emergency department utilization [11]. After a period of fairly rapid growth from 1995 to 2007, during which the utilization of CT in emergency departments grew by a compound annual growth rate of 13.9%, more recent data on the Medicare
907
population suggest there has been some slowing in this rate of growth [12,13]. In both studies, however, the rate of growth of CT utilization in emergency departments exceeded its rate of growth in other settings. In fact, from 2010 to 2012, emergency departments were the only setting that did not experience a downturn in CT utilization [13]. In recent years, there has been growing concern about the rapid rate of growth of CT imaging, particularly in the emergency department setting, with regards to both radiation exposure and appropriateness [14,15]. For overworked emergency physicians in increasingly busy emergency departments, however, the desire to avoid medical liability (an area largely unaddressed by PPACA) and rapidly triage patients may trump long-term concerns about cumulative radiation exposure and appropriateness of resource utilization. Even if there is further flattening or even a downturn in the growth curve utilization of CT in emergency departments in the years to come, an increase in the absolute number of patients driven by PPACA may potentially lead to a larger volume of emergency department imaging across all modalities of diagnostic radiology in the future. Increased access to health care under the PPACA may have significant benefits not only for the
previously uninsured but potentially for the public health of our nation as a whole. If disease can be detected and treated at an earlier stage, this may not only save lives but may potentially reduce overall health care costs. However, this expansion of coverage may not decompress patient volume in emergency departments, as many of its advocates had hoped, but in fact potentially increase emergency department utilization. Radiology departments should be prepared in the years to come for an increased volume of imaging from emergency departments and the manpower and equipment necessary to meet this potential surge.
7.
8.
9.
10.
11.
REFERENCES 1. US Census Bureau. Available at: https:// www.census.gov/hhes/www/hlthins/data/ incpovhlth/2012/figure08.pdf. 2. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US Adults. Am J Pub Health 2009;99:2289-95. 3. In U.S., uninsured rate sinks to 13.4% in second quarter. Available at: http://www. gallup.com/poll/172403/uninsured-rate-sinkssecond-quarter.aspx. Accessed August 28, 2014. 4. Blumenthal D, Collins SR. Health care coverage under the Affordable Care Act—a progress report. N Engl J Med 2014;371: 275-81. 5. Smulowitz PB, O’Malley J, Yang X, Landon BE. Increased use of the emergency department after health care reform in Massachusetts. Ann Emerg Med 2014;64:107-15. 6. Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid in-
12.
13.
14.
15.
creases emergency-department use: evidence from Oregon’s health insurance experiment. Science 2014;343:263-8. Gandhi SO, Grant LP, Sabik LM. Trends in nonemergent use of emergency departments by health insurance status. Med Care Res Rev 2014;71:496-521. Ginde AA, Lowe RA, Wiler JL. Health insurance status change and emergency department use among US adults. Arch Intern Med 2012;172:642-7. Health Resources and Services Administration Bureau of Health Professions National Center for Health Workforce Analysis: Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Available at: http://bhpr. hrsa.gov/healthworkforce/supplydemand/ usworkforce/primarycare/projectingprimary care.pdf. Accessed August 11, 2015. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. Available at: https://www. census.gov/prod/2014pubs/p25-1140.pdf. Accessed August 28, 2014. Centers for Disease Control and Prevention. Table 87. Emergency department visits within the past 12 months among adults aged 18 and over, by selected characteristics: United States, selected years 1997-2012. Available at: http://www. cdc.gov/nchs/hus/2013/087.pdf. Accessed August 28, 2014. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164-73. Levin DC, Rao VM, Parker L. The recent downturn in utilization of CT: the start of a new trend? J Am Coll Radiol 2012;9: 795-8. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009;169: 2078-86. Hillman BJ, Goldsmith JC. The uncritical use of high-tech medical imaging. N Engl J Med 2010;363:4-6.
The author has no conflicts of interests to disclose. Rakesh A. Shah, MD: Department of Radiology, Winthrop-University Hospital, Mineola, NY 11501; e-mail: rshahmd@yahoo. com.
908
Journal of the American College of Radiology Volume 12 n Number 9 n September 2015
