If you listen to politicians, the Affordable Care Act has made Americans healthier and decreased health costs. Obamacare, on the other hand, has not made Americans healthier and is placing an unfair burden on taxpayers.

The problem is that these are the same law. Although data about the effects of the law have begun to trickle in, we're still not sure what the longterm effects will be, despite the many conflicting warnings or projections, depending your side of the aisle.

The Affordable Care Act, and the subsequent Medicaid expansions provided under it, mean fewer people are uninsured. The percentage of uninsured Americans took a deep dive after the April deadline for enrollment. Previously, the percentage of uninsured Americans had increased throughout the recession. That's about all we can say for certain right now though. The jury is still out on if Obamacare has improved health outcomes or slowed health spending.



Courtesy KFF

Twenty-seven states and the District of Columbia chose to expand Medicaid. Recent scholarship has tried to discover the effect of the expansion on emergency room visits. Emergency department use was a hot topic in the debates around the health care reform law. Despite a decrease in the number of emergency departments in the United States, visits to the ER have boomed in the last decade. Experts agree the trend doesn't bode well for health or costs. Often visits can be treated in other settings, such by a primary care physician, where they would impose much lower costs. The emergency room is an expensive and inefficient place to manage chronic conditions, such as asthma. Yet, uninsured and publicly insured individuals are likely to seek care in this setting.

Courtesy HCUP

An argument frequently employed by the left goes, if the Affordable Care Act expands insurance coverage, more people will seek preventative services and have regular doctors, which will make them healthier and decrease costly and unnecessary visits to the emergency room. This argument rested on results from previous studies saying, not surprisingly, that many people who visited the emergency room without real need didn't have another place to go for care, especially those without health insurance.

Courtesy CDC

Courtesy CDC

Recent research says that argument may not hold water, especially in the short term. Two studies looked at emergency room usage for Medicaid enrollees, one for children and one for adults. Neither found a decrease in emergency department utilization in the short term.

The first article, published in Science Magazine, used Oregon's limited expansion of Medicaid in the form of a lottery to create a randomized trial to compare uninsured, low-income adults who entered the lottery but didn't win insurance coverage to those that entered and had their names drawn. Researchers studied health habits of 25,000 lottery participants for about 18 months. The group found Medicaid increased health care use. New enrollees went to the doctor more, got more prescription drugs and went to the emergency department more – a 40 percent average increase compared to the control group. Even worse, the visits responsible for the increase were outpatient visits, where the patient wasn't admitted to the hospital, meaning visits that could have likely been treated in another setting.

They attribute the increase to simple economics: if the cost of something is lower, you are more likely to do it. The high cost associated with medical visits before the enrollees had health insurance deterred them from using health resources. When the barrier was lowered, they used more health resources.

“I think it would be an easier policy decision if the program were either all good or all bad," says Katherine Baicker, a professor of health economics at Harvard and an author of the study. "People advocating for expansion would like it to be the case that increasing insurance saves money and saves lives and people advocating against expansion would have an easier case to make if expansion costs a bunch of money and didn’t help people very much, but of course the reality is the more complicated situation."





Medicaid expansion definitely helps beneficiaries. They report more use of primary care and preventative care. They report better access to and quality of care, and a normal place to go that is not the emergency department (one of the goals of the expansion). They are less likely to have bills sent to collection or skip paying bills because of medical expenses. A drastic 30 percent drop in reported rates of depression among enrollees was another unexpected benefit to coverage. Still, the promised improvement in rates of physical health was not statistically significant.

It could be that actual improvements on the health of Americans will play out over longer periods of time. The data is still out on improvements to health.





Courtesy JAMA

“People always assume that if you have private insurance, that means you have access to a primary care doctor and you won’t need the emergency department as much as people who don’t have good access," says Dr. Renee Hsia, a professor at the University of California San Francisco and attending physician at San Francisco General Hospital. “There's this underlying assumption that if we give patients – children or adults – coverage that their use of the emergency department will decrease, but there’s mixed results on that.” Hsia thinks the changing role of the emergency department and the differences between treatment of adults and children may be responsible for different patterns in the two studies. Increasingly, the emergency department is a place for those who need complex treatment or quick imagining. As primary care physicians are busier and the field relies more on technology and imaging that primary care physicians may not have in their office or be able to order quickly, more patients are being sent to the emergency department by their doctors. These reasons could be compounded with the treatment of children. Another study published last week from the UCLA Center for Health Policy Research found increased costs could be temporary. "Newly eligible Medicaid enrollees are expected to have a significant level of unmet need (pent-up demand) and disproportionally higher rates of costly emergency room visits and hospitalizations," the study says. After the first year of enrollment when pent-up demand is met though, the new enrollees begin to look more like people who previously had comprehensive coverage, which is a good thing because it means decreased costs.



Courtesy UCLA

Rates of outpatient visits stayed mostly constant.







Courtesy UCLA

The differences in state populations could also be a factor. Although for now most of the numbers available are state numbers, the states and regions making up the United States have vastly different populations and norms that could impact differences in these numbers. It's hard to predict national influence without national numbers.

Apart from study design, research in this area is also difficult because of lack of good data, which is often incomplete and rarely standardized (if you can get it at all). Still, both researchers pointed to the need for more scholarship in the field.

Little is known about the effect of different ways of managing health for high demand, low income patients, or the results of other models that may do more to steer patients toward the best place for care.

Hsia has also done research on the cost of health care, finding that higher cost is not associated with higher quality health care and that the variation in cost is both unpredictable and unexplainable. She says more research is also needed about alternatives to the emergency department and specifically how to increase access to those alternatives. Although the Affordable Care Act increases the proportion of people who have insurance, that doesn't necessarily lead to increased access to good health care.