Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments

Abstract

Importance: The Affordable Care Act (ACA) has expanded access to health insurance for millions of Americans, but the impact of Medicaid expansion on healthcare delivery and utilization remains uncertain.

Objective: To determine the early impact of the Medicaid expansion component of ACA on hospital and ED utilization in California, a state that implemented the Medicaid expansion component of ACA and Florida, a state that did not.

Design: Analyze all ED encounters and hospitalizations in California and Florida from 2009 to 2014 and evaluate trends by payer and diagnostic category. Data were collected from State Inpatient Databases, State Emergency Department Databases and the California Office of Statewide Health Planning and Development.

Setting: Hospital and ED encounters.

Participants: Population-based study of California and Florida state residents.

Exposure: Implementation of Medicaid expansion component of ACA in California in 2014.

Main outcomes or measures: Changes in ED visits and hospitalizations by payer, percentage of patients hospitalized after an ED encounter, top diagnostic categories for ED and hospital encounters.

Results: In California, Medicaid ED visits increased 33% after Medicaid expansion implementation and self-pay visits decreased by 25% compared with a 5.7% increase in the rate of Medicaid patient ED visits and a 5.1% decrease in rate of self-pay patient visits in Florida. In addition, California experienced a 15.4% increase in Medicaid inpatient stays and a 25% decrease in self pay stays. Trends in the percentage of patients admitted to the hospital from the ED were notable; a 5.4% decrease in hospital admissions originating from the ED in California, and a 2.1% decrease in Florida from 2013 to 2014.

Conclusions and relevance: We observed a significant shift in payer for ED visits and hospitalizations after Medicaid expansion in California without a significant change in top diagnoses or overall rate of these ED visits and hospitalizations. There appears to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization.

Fig 1. Emergency department utilization in California (A) and Florida (B) between 2009 and 2014 by payer, expressed as annual visits per 100 state residents. Hospital utilization in California (C) and Florida (D) between 2009 and 2014 by payer, expressed as annual hospitalizations per 100 state residents.

See S1 Table for corresponding data tables.

Fig 2

(A) Predicted vs. Actual Emergency Department visits in Medicaid enrollees in California (per 100 state residents). In 2014, the actual rate was 32.2% higher than predicted based on 2009–2013 data (p<0.0001). (B) Florida Medicaid ED visit rates did not differ from those predicted based on 2009–2013 data.

Fig 3. Rate of hospitalization California (A) and Florida (B) between 2009 and 2014 by payer, expressed hospitalizations per 100 emergency department visits.

See S2 Table for corresponding data tables.