The Public Eye

With Affordable Care Act, fewer uninsured in California emergency rooms – but ERs still packed


Fewer uninsured Californians are seeking treatment in the state’s emergency rooms, a decline that experts say is a direct result of the federal Affordable Care Act.

The trend represents welcome news for previously uninsured patients who had trouble affording a trip to the emergency room. But it has not brought down ER treatment costs for everyone else, health care experts said, nor has it slowed a years-long increase in overall emergency room traffic.

The Affordable Care Act required most Californians to obtain health insurance by April 15, 2014, or face a penalty. The new figures, reported by hospitals to the Office of Statewide Health Planning and Development, show that about 337,000 uninsured patients visited California emergency rooms between April and June, down by 90,000, or 20 percent, from the same quarter in 2013. Put another way, 12 percent of emergency room patients lacked insurance this year, down from 16 percent in 2013.

The same pattern played out in Sacramento. For the first time in years, less than 10 percent of the patients entering the region’s emergency rooms lacked insurance, the state figures show.

For those most likely to lack insurance before the Affordable Care Act – students, part-time workers, low-income families and people with pre-existing conditions – a trip to the emergency room could lead to insurmountable debt. Average patient charges for a visit to a Sacramento emergency room range from $900 to $3,100, depending on the hospital, according to an analysis of state data by researchers at the University of California, San Francisco. A $2,000 hospital bill is equivalent to two weeks’ pay for a Sacramento worker earning the full-time wage typical for the region.

“In this world, anything could happen to you,” said Ali Farhat, a Sacramento resident still working to get insurance and worried about landing in the hospital without the ability to pay.

While hospitals are seeing fewer patients who are uninsured, officials said that hasn’t translated into the kind of bottom-line revenue boost that would allow them to cut costs for emergency room services. The reasons are rooted in the types of insurance patients are getting and reductions the federal government has made in Medicare reimbursements.

Most of the newly insured in California signed up for Medi-Cal, the state’s insurance program for the poor. The number of Medi-Cal patients visiting emergency rooms between April and June rose from 790,000 last year to 1,050,000 this year, a 30 percent increase, according to state figures.

Medi-Cal generally reimburses hospitals at a lower rate than private insurance companies, hospital officials said, limiting the savings they can pass on to patients. In addition, the Affordable Care Act mandated reductions in some payments under Medicare, the federal insurance program primarily for the elderly.

Anne McLeod, senior vice president at the California Hospital Association, estimated that hospitals will take in an additional $1.6 billion in annual revenue stemming from patients enrolled in Medi-Cal. But she said they also face $2 billion in Medicare cuts in 2015.

“Some of the good consequence is that there are at least some payments,” McLeod said. “With the uninsured, it was free.”

The growth in new Medi-Cal patients outpaced the growth in new patients with private insurance, state figures show. And the 260,000 additional Medi-Cal visits dwarfed the statewide decline of 90,000 uninsured patients.

Anthony Wright, executive director of the consumer group Health Access California, said, “there is some truth to what (hospitals) are saying … and I’m 100 percent in support of raising (Medi-Cal) rates.”

Still, he said, hospitals may be overstating the financial impact of treating more Medi-Cal patients. “A paying patient is better than one who can’t afford to pay anything,” he said.

While it may be optimistic to think that a lower rate of uninsured patients will lower emergency room prices, he added, “it may have an effect on reducing the rate of (price) growth.”

One of the goals of Obamacare was to lower the demand for emergency room care. The state figures indicate that has not happened.

Lindsey Woodworth, an economist at UC Davis, said that’s because some newly insured patients aren’t getting access to preventive care, a result of the limited number of primary care doctors willing to accept Medi-Cal rates. Much like the uninsured, some of the newly insured are putting off treatment until they are forced to use emergency rooms.

“It is just blowing up the patient populations that are coming to the ER,” said Woodworth, who is conducting postdoctoral research on the economics of emergency care.

Even when preventive care is available, some newly insured patients continue to use the emergency room as first-line treatment, said Richard SooHoo, chief financial officer for Sutter Medical Center of Sacramento.

“Behaviors from the past are still carrying over,” he said. “The issue we want resolved is appropriate care at appropriate times.”

Sutter Health has created several programs to help ER patients find primary care. It also has invested in primary care clinics that help traditionally underserved patients. Sutter says it has helped 6,000 people get the proper care through those programs. But because of the shortage of doctors willing to take low-income patients, its ERs are still packed.

“There is not enough capacity,” said Holly Harper, community benefits manager for Sutter Health in the Sacramento-Sierra region. “Transportation is a huge problem.”

Despite the obstacles, many of the newly insured say they welcome the safety net.

“I’ll be able to see the doctor,” said Isabelle Aurora, a sophomore at Monterey Trail High School who signed up for Medi-Cal last week. “I’m very happy.”

Aurora, speaking through an interpreter, said she has suffered with intestinal problems her whole life. She lives with an aunt in Sacramento, but sought medical care only during family visits in Panama because she lacked insurance.

“In comparison to American bills, definitely Panama is cheaper, even with airfare,” said her aunt, Beatrice King.

In the United States, King said. “We were kind of afraid for (Isabelle) to see the doctor.”

Farhat, who still lacks insurance, came to America a year ago after helping the U.S. Army and Department of State in Afghanistan, a service for which he was rewarded with a permanent resident card. He plans to attend college in California.

He said he tried to sign up for health insurance last week and was told he qualified for a subsidized plan but needed to come back after paying taxes. He’s young and healthy, but said he will feel more secure once his coverage kicks in.

“You could get in an accident,” he said. “You could get sick.”

Among the region’s largest hospitals, the biggest changes occurred at Sutter General, Sutter Memorial, Mercy San Juan and Methodist. Collectively, those hospitals saw 3,000 fewer uninsured ER patients during the second quarter of 2014 – a 35 percent drop from the year before.

SooHoo, the Sutter chief financial officer, said the region should pay attention in coming months to whether emergency room visits overall start to taper. That would indicate that not only are patients getting affordable care, but that they are getting it at the right time, before an emergency.

“This is a good first step,” he said, “but it’s not the last step.”

Call The Bee’s Phillip Reese, (916) 321-1137.