Research shows that people tend to go to the doctor more when they have insurance. But this appears not to be the case since the Patient Protection and Affordable Care Act (PPACA) came into force. The PPACA, or Obamacare, has helped 14 million Americans gain insurance coverage, expanding medical insurance faster than any new policy since Medicare and Medicaid in 1965. Contrary to expectations, however, the new enrollees haven't flooded primary care doctors' offices.
Recent findings from 16,000 healthcare providers across the country indicate that requests for new primary care appointments rose only very slightly, from 22.6% in 2013 to 22.9% in 2014.
So where are the newly-ensured patients going? The answer seems to be the emergency department. One of the goals of Obamacare was to reduce pressure on emergency departments by giving poor people better access to primary care. Instead, many hospitals across the nation are seeing a surge of newly insured patients in their emergency rooms.
In May 2014, the American College of Emergency Physicians (ACEP) conducted an online survey of 1,845 emergency physicians. Nearly half reported a rise in emergency visits since Obamacare began. The majority (86%) expected emergency visits to increase over the next 3 years, and more than three-fourths (77%) believed their emergency departments were not adequately prepared for significant increases.
ACEP President Alex Rosenau, DO, FACEP, said, "Emergency visits will increase in large part because more people will have health insurance and therefore will be seeking medical care. But America has severe primary care physician shortages.
"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."
Analysts believe the trend of rising emergency room visits will continue until the newly insured become more familiar with the process. Dr. Mitchell Morris, a provider consultant at Deloitte Consulting, says, "More people have insurance, but the cultural norm has been to wait until they're sick to seek care. As they get educated, emergency room use will go down over a period of years."
Perhaps the lack of a rise demand for primary care means people are taking better care of themselves? One of main aims of Obamacare was to prioritize prevention and wellness. It was designed to encourage this change by ensuring health plans covered all preventive screenings, immunizations, and well visits for women at no cost.
Estimates suggest an additional 76 million people now receive preventive care since Obamacare took effect in September 2010. To achieve maximum impact, the law also included these services among the Essential Health Benefits the minimum benefits required in order for health insurance plans to participate in the Obamacare exchanges. In addition, doctors are now financially supported to take a more proactive approach to patient care under new payment models. As such, patients are likely to experience more frequent interactions with members of the care team.
Furthermore, reliable evidence points to a clear benefit of Obamacare on the health of young people, who can remain on their parents' insurance until age 25. The proportion of 19- to 25-year-olds with health insurance has risen to 79%, up from 66% in 2010. Young college graduates are now far more likely to report excellent health, to have a primary care doctor, and to go to the doctor regularly than previously. For older people, there are fewer indicators for how effective Obamacare has been; however, the screening rate for colon cancer among those with private insurance has shown marked growth, from 48% in 2010 to 56% in 2012.
At the very least, the apparent rise in emergency department visits highlights a long-standing shortage of primary care doctors. Demand may remain ahead of supply for a while, as more doctors are trained and recruited. Primary care doctors could perhaps ease the problem through "care coordination" - helping high-risk patients to control their illness and navigate the healthcare system. This approach has been found to significantly cut emergency department visits, as does boosting the prescribing powers of nurse practitioners. Public education on the correct use of emergency departments may also help ease the pressure.
ACEP Poll: Emergency Visits Up Since Implementation of ACA. APRIL 2014
Department of Health and Human Services
ACAView: Tracking the Impact of Health Care Reform February 25, 2015
ASPE (Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation): Increased Coverage of Preventive Services with Zero Cost Sharing under the Affordable Care Act, June 27, 2014.
New York Times, October 26, 2014: Is the Affordable Care Act Working?