Before the Affordable Care Act (ACA) became law, there were two schools of thought on how President Obama's signature health reforms would impact emergency rooms. Opponents predicted that it would drive up the number of ER visits and increase wait times, while supporters argued it would decrease ER visits because more people would visit primary-care doctors instead.
A few years into the law, not much has changed. The average wait time at a hospital in 2014 -- the first year that Americans were required to have health insurance -- was 24 minutes, down only four minutes from 2012. From 2008-2010, 31 minutes was the median time before someone was seen in the ER.
According to Matt Salo, director of the National Association of Medicaid Directors, the idea that more insured Americans would do anything to ER wait times was the wrong conversation to have.
“We really did ourselves a disservice by equating ER utilization with a healthy working population in the run up to the ACA implementation and Medicaid expansion," he said. "There are so many variables that go into it, such as the number of people working in a hospital. The ACA isn’t responsible for something like that."
In a poll that the American College of Emergency Physicians conducted this year, almost half of respondents said the volume of emergency patients had “increased slightly” since the Obamacare's implementation.
“There was a hope and maybe even a little bit of a fear that we would see a dramatic decrease in intake once more people started to get covered by the ACA,” said Todd Taylor, an emergency physician at Emory University hospital. “That simply isn’t the case. I’m as busy as ever.”
In 2014, state-by-state average ER wait times ranged from 16 minutes in Colorado and Utah to 46 minutes in Maryland and 55 minutes in the District of Columbia -- which in each case was barely a change from before Obamacare's individual mandate took effect in 2014. Both Colorado and Maryland also expanded Medicaid yet are at opposite ends of the spectrum.
Other states with more than 30-minute average wait times in 2012 and 2014 include Alabama, Delaware, Georgia, Massachusetts, North Carolina, New Jersey and Rhode Island -- a near even mix of states that chose to expand Medicaid and states that rejected it.
How Long People Wait in the ER
Gaining Medicaid doesn’t necessarily mean that recipients will suddenly have access to timely primary care -- and there are many reasons for that.
For one, Medicaid doctors are becoming harder to find. In 2013, the number of doctors who opted not to treat Medicaid patients tripled from previous years. Medicaid reimbursements typically aren't money makers for doctor's offices, and with an almost certain influx of new patients, many likely weren't incentived to accept more. A U.S. Department of Health and Human Services investigation found last year that many Medicaid doctors that were listed as being available either couldn't offer appointments to low-income patients at all or had months-long wait times. There are new rules to keep doctor directories up-to-date, but they don't take effect until next year.
Looking ahead, the Medicaid doctor shortage is only likely to worsen. That's because the ACA program that boosted pay for doctors who treat low-income patients expired at the end of 2014, effectively cutting Medicaid doctors' pay, and most states refused to cover it themselves.
Some states also disincentive Medicaid patients from using the emergency room by, for example, charging higher copays -- up to $30 -- for issues deemed a non-emergency. Florida also got itself into trouble last year for capping the number of times Medicaid patients can visit the ER each year. According to the American College of Emergency Physicians, such policies aren't a practical way to cut patient volume.
“States with punitive policies toward Medicaid patients in the ER may be discouraging low-income patients with serious medical conditions from seeking necessary care, which is dangerous and wrong,” said Orlee Panitch, an ER doctor at MEPHealth in Germantown, Md., in a statement.
There are also social determinants to consider, according to Salo.
“Newly insured Medicaid patients are more likely to have jobs that don’t give them sick leave,” he said. These populations are also more likely to not have a car, and hospitals are almost always on a public transit route -- but specialists aren't, according to Salo.
For American College of Emergency Physicians President Michael Gerard, the stagnant numbers show how vital emergency care is to our health-care system.
"It's the only place that's open 24/7, and we never turn anyone away," he said in a statement. "Rather than trying to put a moat around us to keep people out, it's time to recognize the incredible value of this model of medicine that people need."