Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion
We describe changes in emergency department (ED) visits and the proportion of patients with hospitalizations through the ED classified as Ambulatory Care Sensitive Hospitalization (ACSH) for the uninsured before (2011–2013) and after (2014–2015) Affordable Care Act (ACA) health insurance expansion in Illinois. Hospital administrative data from 201 non-federal Illinois hospitals for patients age 18–64 were used to analyze ED visits and hospitalizations through the ED. ACSH was defined using Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs). Logistic regression was used to test the effect of time period on the odds of an ACSH for uninsured Illinois residents, controlling for patient sociodemographic characteristics, weekend visits and state region. Total ED visits increased 5.6% in Illinois after ACA implementation, with virtually no change in hospital admissions. Uninsured ED visits declined from 22.9% of all visits pre-ACA to 12.5% in 2014–2015, reflecting a 43% decline in average monthly ED visits and 54% in ED hospitalizations. The proportion of uninsured ED hospitalizations classified as ACSH increased from 15.4 to 15.5%, a non-significant difference. Older uninsured female, minority and downstate Illinois patients remained significantly more likely to experience ACSH throughout the study period. ED visits for the uninsured declined dramatically after ACA implementation in Illinois but over 12% of ED visits are for the remaining uninsured. The proportion of visits resulting in ACSH remained stable. Providing universal insurance with care coordination focused on improved access to home and ambulatory care could be highly cost effective.
KeywordsAffordable Care Act Health insurance Emergency care Ambulatory Care Sensitive Hospitalization
This research was supported by Emergency Medicine Foundation funding for Scott M. Dresden, MD, MS. Aabha I. Sharma was supported by American Heart Association pre-doctoral fellowship 16PRE26400009.
Compliance with Ethical Standards
Conflict of interest
No authors have any potential conflicts of interest.
- 1.Patient Protection and Affordable Care Act; Requirements for Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule (6/28/2010) (database on the internet) 2010. Retrieved from http://webapps.dol.gov/federalregister/HtmlDisplay.aspx?DocId=23983&AgencyId=8&DocumentType=2. Accessed 4 June 2016.
- 2.Current status of state medicaid expansion decisions (database on the internet) 2016. Retrieved from http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/. Accessed 4 June 2016.
- 4.Schencker, L. (2016). Uninsured rate drops again in Illinois after Obamacare takes effect, Chicago Tribune. Accessed 13 Sept 2016.Google Scholar
- 5.Martinez, M. E., Cohen, R. A., & Zammitti, E. P. (2016). Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–September 2015.Google Scholar
- 7.Billings, J., Parikh, N., & Mijanovich, T. (2000). Emergency department use in New York City: A substitute for primary care?. Issue Brief (Commonw Fund), 433, 1–5.Google Scholar
- 8.Prevention quality indivators overview (database on the internet). Retrieved from http://www.qualityindicators.ahrq.gov/modules/pqi_resources.aspx. Accessed 29 August 2016.
- 9.Patient safety indicators overview (database on the internet) 2016. Retrieved from http://www.qualityindicators.ahrq.gov/modules/psi_overview.aspx. Accessed 6 June 2016.
- 11.Zibulewsky, J. (2001). The Emergency Medical Treatment and Active Labor Act (EMTALA): What it is and what it means for physicians. Proceedings (Baylor University Medical Center), 14(4), 339–346.Google Scholar
- 12.National hospital ambulatory medical care survey factsheet (database on the internet) 2011. Retrieved from: https://www.cdc.gov/nchs/data/ahcd/nhamcs_2011_ed_factsheet.pdf. Accessed 5 June 2016.
- 18.Nguyen, K. H., & Sommers, B. D. (2016). Access and quality of care by insurance type for low-income adults before the affordable care act. American Journal of Public Health, e1–e7. doi: 10.2105/AJPH.2016.303156.
- 19.Paradise, J., & Garfield, R. (2013). What is Medicaid’s impact on access to care, health outcomes, and quality of care? Setting the record straight on the evidence. Menlo Park, CA: The Henry J. Kaiser Family Foundation 2013.Google Scholar
- 24.Blumberg, L. J., Karpman, M., Buettgens, M., & Solleveld, P. (2016). Who are the remaining uninsured, and what do their characteristics tell us about how to reach them?. Urban Institute and Robert Wood Johnson Foundation.Google Scholar
- 25.Chapter 1: State unauthorized immigrant populations (database on the internet) 2014. Retrieved from: http://www.pewhispanic.org/2014/11/18/chapter-1-state-unauthorized-immigrant-populations/. Accessed 31 August 2016.
- 26.Profile of the unauthorized population: Illinois (database on the internet) 2014. Retrieved from: http://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/IL. Accessed 31 August 2016.
- 27.A look at early ACA implementation: State and National Medicaid Patterns for Adults in 2014 (database on the internet). Urban Institute, Robert Wood Johnson Foundation 2016. Accessed 18 Sept 2016.Google Scholar
- 28.System CCHH. cook county officials announce 70,000 County Care members. Declare Medicaid expansion in Cook County working 2014.Google Scholar