One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing emergency departments for their care… including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care” (Emerg Med. 2010;42[4]:5).
Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (https://www.sciencemag.org/ content/early/2014/01/02/science. 1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (https://www.nytimes.com /2014/01/03/health/access-to-healthcare- may-increase-er-visits-studysuggests. html?_r=0).
Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine as a health care provider of choice? Yes, and no.
Every new health care plan since managed care was first aggressively promoted in the 1980s, has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.
If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs, nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all, regardless of their ability to pay, urgent care centers can be selective in who they treat.
Why have so many health care plans miscalculated the continuing and expanding role of emergency medicine? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. As noted in the 2013 Rand report on the evolving role of EDs (https://www.rand.org/content/dam /rand/pubs/research_reports/RR200 /RR280/RAND_RR280.pdf), and our June 2013 EM editorial “The Evolution of Emergency Medicine: Value Added (Emerg Med. 2013;45[6]:1), primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers— including many urgent care centers— are available 24/7.
So why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them? To paraphrase a remark associated with Winston Churchill on democracy as a form of government, for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.