For all the promises the Affordable Care Act made, one has been a source of heartburn for its supporters and evangelists. The promise of fewer visits for non-emergency conditions in hospital emergency rooms.

It turns out, that there are actually more visits to the emergency rooms by people who became eligible for coverage through Medicaid expansion. The promise of fewer unnecessary visits to the emergency room has not materialized. This is according to the study: All Medicaid Expansions are not Created Equal: The Geography and Targeting of the Affordable Care Act. Why not?

The incentives for the newly covered do not promote the use of primary care physicians sufficiently over the use of hospital-based emergency rooms. Let’s use the simple example of a visit to a physician’s office to highlight the barriers to use compared to a visit to the emergency room.

  1. To visit a primary care physician it is often necessary to have an appointment. The emergency room does not require an appointment.
  2. To visit a primary care physician, in nearly all cases the patient will have to arrange for transportation to the physicians office in advance; this often costs the patient some inconvenience in time or money. To visit the emergency room, all that is required is a call to 9-1-1. Not only is the ride free, it is on-demand and gets you bumped to the front of the line in the emergency room.
  3. When visiting a primary care physician, oftentimes a prescription for medication or an order for lab work is made. In many cases, to fill the prescription or get the lab work done, it is necessary to make another trip (with all the difficulties in planning and execution that may involve) to a pharmacy or lab. A visit to the emergency room will often be to a hospital that can do the requested lab work or fill a prescription on site. The same is true for any necessary medical tests that need be done.

The ACA promised a more efficient use of health care spending through lower emergency room utilization; to date, that vision has not been realized. It hasn’t been realized because those who designed the ACA did not necessarily understand the social realities and economic incentives their target population have. However, more insured patients and fewer uninsured patients mean hospitals face fewer problems getting paid for the services initiated through emergency room visits.