Change in Health Insurance Status and Use of the Emergency Department

The Patient Protection and Affordable Care Act (ACA) was designed to expand health insurance coverage, enhance access to primary care, and reduce potentially preventable visits to hospital emergency departments (EDs). However, according to researchers, “providing insurance to previously uninsured individuals may affect a paradoxical increase in healthcare use by creation of a ‘moral hazard’ or by increased use of services that had been previously deferred.” In addition, the recent economic recession and the accompanying increased rates of unemployment created a population of newly uninsured people with reduced access to acute and primary care.

These instabilities in the health insurance environment may result in increased numbers of individuals turning to EDs for medical services. Noting that “changes in ED use are an important indicator of healthcare system performance,” the researchers designed an analysis to compare ED use by newly insured versus continuously insured adults and by newly uninsured versus continuously uninsured adults. They reported the results of their analysis in Archives of Internal Medicine [2012;172(8):642-647].

The researchers defined newly insured as currently insured but lacked health insurance at some point during the prior 12 months, and newly uninsured as currently uninsured but had health insurance at some point during the prior 12 months. Data on 159,934 adult respondents to the 2004 through 2009 National Health Interview Survey were used to analyze the number of ED visits during the prior 12 months; the analysis utilized multivariable Poisson regression modeling.

Most of the respondents reported having health insurance at the time of the survey (83.1%); 16.9% were uninsured. Overall, 13.1% of respondents reported 1 ED visit, 5.4% reported 2 to 3 ED visits, and 2.0% reported ≥4 ED visits during the prior 12 months. The unadjusted proportion with at least 1 ED visit was similar for insured adults (20.7%) and uninsured adults (20.0%). The similarity remained after controlling for covariates.

Newly insured adults were more likely to be younger, represent racial/ethnic minority groups, and have lower income, and were less likely to have common chronic health conditions. After adjusting for insurance type and other covariates, newly insured adults had 31.7% higher ED use than continuously insured adults.

Of the newly insured adults, 29.5% reported at least 1 ED visit, compared with 20.2% of continuously insured adults. Similarly, 25.7% of newly insured adults reported at least 1 ED visit compared to 18.6% of continuously uninsured adults.

Following adjustments for demographics, socioeconomic status, and health status, a recent change in health insurance status was independently associated with greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% confidence interval [CI], 1.22-1.42 vs continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). This association was strongest for Medicaid beneficiaries among newly insured adults (IRR, 1.45; 95% CI, 1.27-1.64), but was attenuated for those with private insurance (IRR, 1.24; 95% CI, 1.11-1.38) (P<.001 for interaction).

In conclusion, the researchers said, “recent changes in health insurance status for newly insured adults and for newly uninsured adults were associated with greater ED use. As policy and economic forces create disruptions in health insurance states, new surges in ED use should be anticipated.”