ACA Hasn’t Reduced Emergency Room Visits

April 18--When President Barack Obama was selling his signature health care overhaul before it was adopted in 2010, he said, "If everybody's got coverage, then they're not going to the emergency room for treatment."

But two years after the Affordable Care Act, commonly called Obamacare, was fully implemented, local hospitals have continued to see emergency room visits increase rather than decrease.

"That's a theory," Athens-Limestone Hospital President David Pryor said of Obama's statement. "He's not a clinician."

Under federal law, most emergency rooms must provide emergency care to patients even if they lack insurance or the ability to pay.

The hoped-for reduction in emergency room visits has not occurred nationally, either, according to a national survey. A February report by the Centers for Disease Control and Prevention found "few changes in ER use" from 2013 to 2014, which was the first year of full implementation of Obamacare. An additional 7.9 million Americans gained health insurance coverage in 2014.

"However, this nationwide analysis of adults' ER visits instead demonstrated little change in ER use during and immediately following ACA implementation," the centers' National Center for Health Statistics report said.

David Spillers, chief executive officer of Huntsville Hospital, said he didn't expect the Affordable Care Act would reduce the number of people who go to the emergency room.

"I never did," he said. "I don't know why you would. When people get insurance, they're still getting their health care where they had been getting it."

In other words, people who saw a family doctor still see their doctor, and people who went to the emergency room still go to the emergency room.

Huntsville Hospital, Huntsville Hospital for Women and Children and Madison Hospital saw a combined increase of 3.6 percent from 151,795 visits to the three emergency rooms in 2014 to 157,220 in 2015.

Spillers said it's difficult to compare the number of emergency room visits on a yearly basis. For instance, he said the area experienced a "terrible flu season" last year, but this year has not been as bad.

Spillers credits most of the growth in emergency room visits to the growing population of Limestone and Madison counties.

Emergency room visits at Decatur Morgan Hospital increased 1.9 percent from 62,941 in 2014 to 64,129 in 2015, according to Huntsville Hospital, which runs the hospitals in Decatur, Athens and Moulton.

Athens-Limestone Hospital saw a 5.5 percent increase from 34,433 to 36,318 from 2014 to 2015, and Lawrence Medical Center's visits increased 4.9 percent from 10,963 to 11,497 for the same period.

Enroll Alabama, which helps residents get health insurance through the federal marketplace, said 195,055 people obtained insurance through the exchange this year. That's a 14 percent increase from 2015.

Jim Carnes, policy director of Montgomery-based Arise Citizens' Policy Project, said the state has done an excellent job getting previously uninsured residents enrolled in insurance plans, but has not done as well teaching people how insurance works and how to best take advantage of it.

"It's hard to make that cultural change -- getting people accustomed to that new way of receiving health care," Carnes said. "It doesn't come with an instruction book on how you take care of things."

Arise plans to focus on helping the newly insured learn how to best use their coverage, he said.

Carnes said he also thinks emergency room visits have increased because of a pent-up demand for health care.

Obama and other supporters said before the Affordable Care Act was adopted in 2010 that people with insurance for the first time would seek care in a doctor's office. Catching a health issue early at a doctor's office could prevent a more costly emergency room visit later, they said.

The National Center for Health Statistics report found 77 percent of adults who visited an emergency room in 2014 cited seriousness of the medical problem for their emergency room visit. Their doctor's office not being open was cited by 12 percent of the respondents and 7 percent said they went to the emergency room because they didn't have access to another provider.

The percentages were similar to 2013's, the study said.

"Uninsured adults were more likely than adults with private coverage to have visited the ER because they lacked access to other providers," the report said.

The study said research in Massachusetts and Oregon indicated an increase in people with health insurance might increase emergency room use. But a recent study in California indicated the increase may be short-lived.

Expansion of Medicaid by the states was an important element of Obamacare. Expanding the health care program for the poor would provide insurance for the people who most frequent emergency rooms.

But 19 states, including Alabama, have declined to expand Medicaid under Obamacare. Gov. Robert Bentley said the state could not afford to add more people to the Medicaid rolls.

"I have seen very little impact of the Affordable Care Act because we in this state have done zero to participate in the expansion of Medicaid," Spillers said.

Some states that have expanded Medicaid coverage for low income and disabled residents have seen their uninsured population cut in half, Spillers said.

"Very few people have benefited because the state chose not to expand Medicaid," Spillers said.

Between 200,000 and 300,000 state residents would gain health care coverage if Alabama expanded Medicaid, Carnes said.

"That would be such a leap forward on a lot of these issues," Carnes said.

Pryor said Obama's assertion that emergency room visits would drop was predicated on the states expanding their Medicaid rolls. The Affordable Care Act required states to expand Medicaid or forfeit significant federal funding, but the U.S. Supreme Court in 2012 struck that provision.

"He was going under the assumption that every state would go to Medicaid and, therefore, more people would have access to a primary caregiver," Pryor said. "What he was selling wasn't completely bought into."

Although more Alabama residents now have health insurance, Spillers said, Huntsville Hospital has not experienced a reduction in charity care. He said the hospital had a small uptick in bad debts.

Many Alabama residents who have gotten insurance coverage through the federal marketplace have chosen plans with high co-pays and deductibles, Spillers said.

The average cost of an overnight stay in the hospital is $9,000, Spillers said. On average, insurance will pay $3,000 of that cost. Someone who once had a $500 insurance deductible is now choosing a plan with a $6,000 deductible, he said.

"We have to go try to collect that $6,000, and most people don't have it," Spillers said.

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