Feinglass Joe, Cooper Andrew J, Rydland Kelsey, Powell Emilie S, McHugh Megan, Kang Raymond, Dresden Scott M
Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, Illinois.
Northwestern University, Northwestern University Library, Evanston, Illinois.
West J Emerg Med. 2017 Aug;18(5):811-820. doi: 10.5811/westjem.2017.5.34007. Epub 2017 Jul 17.
This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois.
We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.
The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.
ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.
本研究分析了2014年伊利诺伊州《平价医疗法案》（ACA）保险扩张前后医院急诊科（ED）就诊率的变化。我们比较了伊利诺伊州88个社会经济多样化地区在ACA实施前24个月（2012 - 2013年）和实施后24个月（2014 - 2015年）期间人口保险状况变化与ED就诊率变化之间的关联。
我们使用2012 - 2015年美国社区调查的年度估计数据，获取伊利诺伊州88个公共使用微观区域（PUMAs）中未参保、私人保险、医疗补助和医疗保险（残疾）人群的保险状况变化，这些区域平均约有90,000名18 - 64岁居民。伊利诺伊州201家非联邦医院超过1200万次的ED就诊记录被用于计算每个PUMA居民的就诊率，使用基于人口的映射权重将邮政编码区域的就诊分配到PUMAs。然后，我们估计了88个关于人口保险状况变化与每1000名居民ED就诊率变化之间的相关性，比较了ACA实施前后的两年情况。
PUMA的基线未保险率在6.7%至41.1%之间，基线PUMA的ED就诊率有4.6倍的差异。PUMAs中处于前四分位数的地区未参保居民减少了超过21,000人；16个PUMAs医疗补助登记人数至少增加了15,000人。与2012 - 2013年相比，2014 - 2015年未参保者的平均每月ED就诊次数下降了42%，但医疗补助参保者增加了42%，私人保险参保者增加了10%。医疗补助登记人数增加最多的地区ED使用增长也最大；医疗补助登记人数的变化是总ED就诊次数地区变化的唯一显著相关因素，并解释了88个PUMAs中三分之一的差异。
伊利诺伊州实施ACA加速了医院ED护理使用增加的现有趋势。对于以前未参保的人提供更好的初级和预防保健服务是否会随着时间推移减少ED使用，或者ACA保险扩张是否是持续长期增长的一部分，仍有待观察。在地方层面监测ED使用情况对于新的基于家庭和社区的护理协调举措的成功至关重要。
