Emergency room use under the ACA

Is patient access to appropriate care settings improving?

In ongoing efforts for health care organizations to provide better care at a reduced cost, health systems, states, and health plans continue to seek strategies to manage emergency room (ER) use. Many organizations are investing in these areas, but has unnecessary ER use decreased and has patient access to alternative care settings improved?

Explore the drivers behind ER visits

ER utilization is one of the barometers to track progress towards achieving certain Affordable Care Act (ACA) goals: ER use should likely drop with better access to care and a more efficient health care system. ER use is driven by many factors; among them, perceived need for urgent care, the severity of the medical condition, availability and accessibility of ER and other ambulatory care, and physician referrals to the ER. However, studies suggest that uninsured individuals—who may lack access to alternative care settings—might also use ERs for non-emergency conditions.1, 2

ERs can be an expensive care setting for routine or preventative care, since they maintain 24-hour staff and have a wide range of capabilities, services, and equipment, including resource-intensive technologies. Most ERs are not set up for continuity of care, and are not a substitute for a primary care relationship, nor can they address the broader social determinants of health.

Under new value-based payment models, including those under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), health care payers (government and private health plans) and health systems are striving to find ways to lower total cost of care while maintaining high quality. This includes reducing costs through a more appropriate use of ERs.

Are stakeholders’ efforts working? Has inappropriate ER utilization decreased and has patient access to alternative care settings improved? Deloitte Center for Health Solutions’ analysis of recent trends in ER use finds:3

The growth in ER visit rates (ER visits per 100 population) has generally been slower in Medicaid expansion (ME) states than in non-expansion states, particularly over longer time horizons (two-to-three years following expansion):

  • Prior to 2014, the growth in ER visit rates was similar in Medicaid expansion and non-expansion states. However, between 2013 and 2014, the year when most Medicaid expansion programs started, the growth in ER visit rates was generally slower in ME states.
  • In the District of Columbia and many of the six states (California, Colorado, Connecticut, Minnesota, New Jersey, and Washington) that expanded Medicaid earlier than 2014, ER visit rates increased in the first year following the expansion but stabilized or even slightly decreased two-to-three years after their expansions.

Following the 2014 expansions, new Medicaid enrollees reported fewer issues in accessing alternative care settings, including primary care, compared to the uninsured.

  • Our analyses of the National Health Interview Survey show that in 2014, just four percent of the new Medicaid enrollees (compared to 30 percent of the uninsured) reported the ER as their usual care setting. In 2014, nine in ten of the newly Medicaid-insured visited a primary care physician compared to just 51 percent of the uninsured.
  • In 2015, people new to Medicaid were slightly more likely to cite lack of access to other care settings as the reason for an ER visit compared to those who enrolled in Medicaid in 2014 (though the percentage was much lower compared to pre-expansion years). In 2015, 33 percent of new Medicaid enrollees said they visited an ER because they had no other place to go (versus 24 percent in 2014 and 52 percent in 2013).

Markets with a higher concentration of urgent care centers (UCCs) have lower ER visit rates. UCCs are sparse in markets with higher ER visit rates, most of which have larger uninsured and Medicaid populations. However, more UCCs are accepting the new Medicaid enrollees and may be emerging as an alternative to ERs.

  • Between 2011 and 2014, median ER visit rates in the local markets (hospital referral regions or HRRs) with the highest concentration of UCCs per capita were generally lower than in areas with lower UCC concentration. In markets with moderate-to-low UCC concentration, many of which have a high concentration of Medicaid enrollees, we found high median ER visit rates.
  • Our analysis of survey data from the Urgent Care Association of America shows that UCCs are increasingly serving Medicaid patients. In 2014, for instance, the share of total UCC visits by Medicaid patients was 15 percent, compared to just five percent in 2013.

Implications for health care stakeholders

ER care is an important component of health care spending and is often a potential savings target for health systems, states, and health plans.

Health systems

The shift to value-based care and the strengthened incentives for it under MACRA will likely lead to health system executives’ renewed focus on identifying ways to reduce costs and maintain quality. As a result, executives may want to shape their strategies to include a potentially new role for ERs.

Expand access to lower-cost settings 

As more people gain coverage under various ACA provisions (e.g., Medicaid expansion, health exchanges), health systems may want to consider acquiring or creating joint ventures with UCCs to complement their ER offerings, reduce uncompensated care costs, and avoid putting undue strain on limited resources such as primary care physicians and nurses. Large health systems such as HCA and Tenet have acquired several UCCs in the past few years, and their investments might be starting to pay off. HCA had over one million UCC visits in 2015, a 500 percent increase compared to the previous year.4

Better direct patients to the right care setting

One of the frequent challenges faced by the newly insured is navigating the unfamiliar and often complex web of coverage features, benefits, and costs. As a result, some health systems are using technology to steer patients to the right care setting. For instance, in 2016, California-based Sutter Health and Alameda Health System started employing technology and analytics to identify frequent ER users, and steered them to more appropriate care settings through increased education and coordination activities.5 Health systems are also beginning to invest in “patient access call centers” with 24/7 guidance to appropriate care settings.6


State initiatives are a starting point to improve access and educate people about where to get good primary and urgent care. While it may be too early to quantify the impact of various state initiatives on ER use, recent studies have shown that the new Medicaid enrollees have better preventive and primary care options than were previously available.7

Health plans

As more uninsured individuals gain coverage, health plans’ knowledge of their members’ health care services use patterns should help steer these members to the most appropriate care settings. For instance, Molina Healthcare’s study of its new Medicaid enrollees from Michigan found that they used ERs at twice the rate of Molina’s traditional Medicaid members.8 Access to preventive services such as screenings, and timely access to primary care and alternative care settings such as UCCs, could improve early disease detection and management. This will likely help health plans better manage costs while preserving care access.

Health care executives may want to shape their strategies to include a new role for ERs.


1National Association of Community Health Centers, “The Role of Health Centers in Lowering Preventable Emergency Department Use,”, accessed September 15, 2016.

2Kimberly R. Enard, Deborah M. Ganelin, “Reducing Preventable Emergency Department Utilization and Costs by Using Community Health Workers as Patient Navigators,” PubMed Central, J Healthc Manag. 2013 Nov-Dec; 58(6): 412–428., pmc/articles/PMC4142498/, accessed September 15, 2016.

3Deloitte Center for Health Solutions analysis of ER visits based on data from American Hospital Association, and reasons for ER visits based on data from National Health Interview Survey.

4Bruce Japsen, “HCA's Urgent Care Buying Binge Pays Off,” Forbes, January 2016,, accessed August 24, 2016.

5Dave Barkholz, “Sutter Health and Alameda Health redirect ER hoppers with new software,” Modern Healthcare, June 2016, http://www., accessed August 24, 2016.

6Todd Krim, “Leading trends in Patient Access,” American Health Connection,, accessed August 24, 2016.

7US Department of Health and Human Services, “Impacts of the affordable care act’s medicaid expansion on insurance coverage and access to care,” June 20, 2016,, accessed August 24, 2016.

8Marianne Udow-Phillips, Kersten Burns Lausch, Erin Shigekawa, Richard Hirth, and John Ayanian, “The Medicaid Expansion Experience In Michigan,” HealthAffairs, August 2015,, accessed August 24, 2016.

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