The White House was quick to tout the 7.1 million Americans who enrolled in the Affordable Care Act’s (ACA) health care benefits last week, and this week’s cover of The New Yorker depicts President Barack Obama’s revenge on Republicans now that healthcare appears to be working. Despite this messaging, Washington, the media, nor the law itself can guarantee that health care will be accessed in the intended way.
Even with the surge to sign up, the fledgling ACA faces many challenges. Perhaps the greatest is the overwhelming number of people who seek care in the Emergency Department (ED), many of whom rely on it not for emergencies but for primary care. Understanding the psychology of why so many people seek care in the Emergency Department first is key to solving the problem. Otherwise, the devastating costs of overuse could sink the ACA all together. In a 2007 report supported by a grant from the Health Resources and Services Administration, Bureau of Primary Health Care found over $18 billion is wasted annually because of avoidable ED visits. To be sure, that cost is now much higher.
For minorities and patients from lower socio-economic groups, the ED is the great equalizer. It is the place where the rich and the poor converge under one roof and receive equal attention. While most visits to the ED are neither clearly non-urgent nor clearly emergent, for those with a long-standing pattern of visiting the ED for a variety of ailments from chest pain to a stubbed toe, change in behavior will be difficult to achieve.
Overuse of the ED is predicated on several factors. Many Americans live below the poverty line and are employed in low wage positions from which they cannot take time off. For the working poor, the ED is the most convenient way to receive healthcare with 24/7 access and no appointment necessary. According to a 2012 National Health Interview Survey, approximately 80 percent of adults who visited the ED over a 12-month period did so because of a lack of access to other healthcare providers.
Simply providing people with insurance cards will not decrease use of the ED because care there is convenient. Access is therefore not a question of insurance, but more so a question of comfort, ease and trust.
For many African-American patients, the root cause of their mistrust of the healthcare system goes back to Tuskegee — a controversial 40-year study of African-American men who thought they were receiving free government healthcare while their diseases went untreated. Many African-Americans still believe that they receive lower quality care in the out-patient clinics and are wary of physicians in those settings.
Furthermore, fear of being shunted to mid-level providers in outpatient clinics, such as physician assistants and nurse practitioners, albeit highly qualified ones, is real. Many in the African-American community perceive this conveyance as second-class medical care. In reality, unlike clinic physicians, ED physicians work so quickly that they lack the time to form fixed positive or negative impressions of the patients they see.
As a physician in an urban area, I am concerned that the primary care physician shortage I see may block access for thousands of patients, both old and young, despite the fact that they are now armed with health insurance cards. Some 8,000 additional physicians — a 3 percent increase in the current workforce — are required to absorb insurance expansion according to a 2012 study in the Annals of Family Medicine.
Certainly, a systematic infusion of new medical schools focused on primary care will lead to a growth in the primary care physician population — but that will be approximately eight years from now. Americans need primary care access right now. Thus, having a health insurance card and having health insurance coverage are antithetical concepts.
Furthermore, expanding the physician workforce can only work if that group is truly diverse and can provide culturally competent care addressing ethnic, age, and racial disparities that are embedded in the health care system. Forgiving the student loans of graduating physicians in exchange for their work in medically underserved urban and rural areas is a potential solution — though a futuristic one.
An 18-month study of thousands of low income Americans in Oregon with Medicaid-based health insurance (an ACA-like program) surprisingly showed a 40 percent increase in ED use, meaning that people with insurance coverage went to the ED even more than they did before they had insurance. Published in the journal Science, the study inspired politically motivated calls to “flee from the ACA.” For me, these results do not support abandonment of the ACA. Rather, they highlight the importance of understanding why so many patients turn to the ED first. Encouraging behavioral change has to be a priority if the ACA is to achieve one of its major goals of decreasing costs and providing true access to care.
To be sure, behavioral change will not be quick. The institution of tangible changes, including night clinics (akin to night courts), week-end clinics (including Sundays), Mini-EDs, incentives for using ambulatory care practices, navigators to aid patient choices, and primary ambulatory care clinics in intimate physical proximity to EDs are all needed. Two of the fundamental pillars of the ACA are better health at lower cost.
It will require years of re-education and an army of out-patient offices willing to build flexibility into their practices to see a significant shift from ED care to office based care. No one will argue that emergency visits should only reflect true emergencies, yet indiscriminate use of the ED continues unabated. Expanding the primary care enterprise is desperately needed, but it may take years before we see if the initiatives outlined herein are good medicine for what ails the ACA.
Dr. June M. McKoy is an Associate Professor of Medicine and Preventive Medicine at Northwestern University Feinberg School of Medicine and a Licensed Illinois Attorney. She is a 2013-2014 Public Voices Thought Leadership Fellow at Northwestern University.
