Obamacare Goes to The Emergency Room

Intended to reduce visits to crowded ERs, the law may increase them

Stephanie Armour

Doctor shortages in thousands

(Data for 2010-2025 are projections) DATA: AAMC CENTER FOR WORKFORCE STUDIES/LEWIN GROUP

On any given Saturday night, all 36 beds at UC San Diego Medical Center’s Hillcrest emergency room are likely to be occupied, and incoming patients can often be found lying on gurneys in the corridor. A grimacing patient with a gaping knee wound holds the screen of his mobile phone over the gash for extra illumination one weekend this spring as a doctor stitches him up. “There’s nothing more appalling than being treated in a hallway,” says James Dunford, medical director of the city of San Diego’s Emergency Medical Services system, who also works at Hillcrest. “Soon,” he says, “it’s going to be worse.”

Dunford anticipates that the Affordable Care Act will bring a surge of patients to his ER and those around the country — the opposite of what’s supposed to happen. The law’s backers argued it would help alleviate stress on overcrowded emergency rooms. The 25 million people expected to receive insurance under Obamacare, they reasoned, would make appointments with a doctor instead of turning to ERs for care.

Yet a nationwide shortage of primary-care doctors, especially in poor and rural areas, will make it difficult for many of the newly insured to find a personal physician. ER managers say they’re bracing for previously uninsured patients who came to the hospital when they needed acute medical attention to begin showing up, insurance cards in hand, for routine medical care. The overcrowding “we see now is going to pale in comparison with what we’ll see” once the health-care overhaul takes full effect starting in 2014, says Ryan Stanton, director of emergency medicine at UK HealthCare Good Samaritan Hospital in Lexington, Ky.

When Massachusetts passed a health-care reform law in 2006 that provided coverage for nearly everyone, hospitals were surprised to find a 4 percent rise in ER visits, according to a 2011 study of 11 medical centers published in the Annals of Emergency Medicine. The Affordable Care Act likewise may not relieve pressure on ERs, says Peter Smulowitz, an instructor at Harvard Medical School and the lead author of the study. “Health planners and states should start preparing for an increase in ER visits,” he says. “There will be higher demand.”

Even in areas where there are enough doctors to go around, some people may have a hard time getting in to see them. The Congressional Budget Office projects that more than a third of those receiving insurance for the first time will be covered under Medicaid, the federal program for lower-income and disabled Americans, which Obamacare expands to reach more people. Because Medicaid reimburses doctors at lower rates than private insurers do, many physicians are turning away those covered under the program. A 2011 study in the journal Health Affairs found that nearly a third of doctors were unwilling to accept new Medicaid patients — leaving the ER as a first resort for those people.

The rising demand for emergency room care is complicated by another problem: The number of ERs is shrinking. Years of hospital closures have left the nation with 650 fewer emergency rooms than two decades ago, according to the American Hospital Association. More than half of those that remain report they regularly operate at or over capacity. ER doctors in busy hospitals say they can’t imagine trying to treat more patients than they do now. “We hang our heads as ambulances roll in and ask, ‘How are we going to manage this?’ ” says Edwin Leap, a physician at Oconee Medical Center in Seneca, S.C. At Hillcrest in San Diego, Dunford moves quickly from bed to bed, checking to see which patients are ready to be moved to make room for others. “We’re the path of least resistance,” he says. “ER physicians had better get used to it.”

The bottom line Hospital closures have left the U.S. with 650 fewer ERs, even as demand for them is expected to spike under Obamacare.


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