ER Visits Up Since Implementation of Affordable Care Act


Nearly half of emergency physicians responding to a poll are already seeing a rise in emergency visits since January 1, when expanded coverage under the Affordable Care Act (ACA) began to take effect.  In an online poll conducted by the American College of Emergency Physicians (ACEP), 86 percent expect emergency visits to increase over the next three years. More than three-fourths (77 percent) say their ERs are not adequately prepared for significant increases.

"Emergency visits will increase in large part because more people will have health insurance and therefore will be seeking medical care," said Alex Rosenau, DO, FACEP, president of ACEP.  "But America has severe primary care physician shortages, and many physicians do not accept Medicaid patients, because Medicaid pays so low.  When people can't get appointments with physicians, they will seek care in emergency departments. In addition, the population is aging, and older people are more likely to have chronic medical conditions that require emergency care."

The data suggest that states that expanded Medicaid are more likely to see increases in the volume of Medicaid emergency patients. Dr. Rosenau said that policymakers need to make sure there are adequate resources to care for growing numbers of emergency patients.

"Long-term solutions, such as increasing the supply of primary care physicians, will take years to develop and will not solve our immediate and short-term problems," said Dr. Rosenau. "Congress and President Obama must make it a national priority now to strengthen the emergency care system. ACEP is urging Congress to make a firm commitment to emergency patients by holding a hearing to examine whether additional strains are occurring in the emergency department safety net as a consequence of the Affordable Care Act."

An overwhelming 84 percent of emergency physicians report that psychiatric patients are being held—"boarded"—in their emergency department, with 91 percent saying that this practice has led to violent behavior by distressed psychiatric patients, distracted staff, or bed shortages, all of which may harm patients.

"People having a mental health crisis seek care in emergency departments because other parts of the health care system have failed them," said Dr. Rosenau. "Because of the critical shortage of mental health resources, some of these vulnerable patients wait for days in emergency departments. It is simply inhumane."

More than half of the physicians polled add that the amount of time and effort their emergency department expends to transfer psychiatric patients who need admission has increased since January.

The poll follows ACEP's 2014 State-by-State Report Card released in January, which gave the nation a dismal D+ grade for its lack of support of emergency patients. Forty percent of emergency physicians polled say their state policymakers are doing a poor job of addressing the issues raised in their state's recent Report Card, which looked at the issues of Access to Emergency Care, Quality and Patient Safety, Medical Liability Environment, Public Health, and Injury Prevention and Disaster Preparedness. (State and national grades are available at  

When asked about the most important policy solution to improve emergency care, the top response (32 percent) was "enacting liability reform."

"The lack of medical liability limits is directly linked to workforce shortages in medicine, especially among specialists called to see patients in the emergency department," said Dr. Rosenau. "Emergency patients tend to be more critically ill and have higher risks of bad outcomes, and some specialists are simply unwilling to take the risk of being sued."

ACEP supports passage of H.R. 36/S. 961—the "Health Care Safety Net Enhancement Act of 2013" that would provide liability protections to physicians (emergency and on-call)  who perform the services mandated by federal law. That law requires patients be screened, diagnosed, and treated regardless of their insurance status or ability to pay.

When asked about other issues related to the implementation of health care reforms:
>>More than two-thirds (69 percent) report challenges with the disposition of patients who require hospital admission but do not meet the Two-Midnight Rule for hospital admission—25 percent call it a "significant dilemma." (This rule requires patients to be in the hospital for two midnights before Medicare will reimburse for a hospital admission.)
>>Just over one-third (35 percent) of emergency physicians report seeing more Medicaid patients, and 27 percent are seeing fewer privately insured patients.
>>In regard to long-term impact, 34 percent believe the ACA will have a positive impact on access to emergency care.

Source: American College of Emergency Physicians,