insurance expansion associated with redu”>American Journal of Emergency Medicine 40 (2021) 220-221

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American Journal of Emergency Medicine

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Insurance expansion associated with reduced use of emergency psychiatric services

Keywords:

Affordable care act Insurance

Emergency psychiatry Adults

To the editor:

The introduction of the Affordable Care Act in 2010 allowed states to expand the availability of Public insurance to their citizens [1]. Thirty-five states ultimately adopted insurance expansion. It was widely anticipated that the law would alter utilization of medical ser- vices. One of the surprising changes has been an increase in the utiliza- tion of emergency department (ED) services for medical [2,3] and substance abuse services [4,5]. This increase occurred despite an in- crease in utilization of outpatient and preventative services, but not for non-substance-related mental health services [6]. Similarly, home- less patients with substance abuse are more likely to utilize ED services if they have public insurance [4]. However, the specific effect on general psychiatric ED utilization has not been investigated.

In Kentucky, health insurance expansion was adopted in 2013 and became effective in 2014. In Louisville, the largest city in Kentucky, the University of Louisville Hospital has a dedicated emergency psychiatric service (EPS). This allowed us to investigate the effect of insurance ex- pansion on EPS use.

1. Methods

State and city statistics were obtained from census data (census. gov), insured rates were obtained from Kentucky Health Issues Poll (https://www.healthy-ky.org), and the Kentucky Healthy Living Data- base (http://www.oasisdataarchive.org). EPS visits were obtained from internal University of Louisville Hospital statistics. The years 2010 through 2018 were investigated, which included 4 years prior to and 5 years after the insurance expansion. It is important to note that there were no changes in how patients were triaged or managed throughout this period, or major changes in the City’s emergency ser- vices. All insurance and EPS visit data were corrected for population size. Statistics utilized Spearman (nonparametric) correlation coeffi- cient (Prism 7.0a software, 2016), and a z-score test for significance of proportions [7].

1. Results

In Louisville, Kentucky, the University of Louisville Hospital’s emer- gency psychiatric service (EPS) is the only dedicated psychiatric emer- gency room with continuous psychiatric physician presence and is the major provider of emergency psychiatric evaluations. In 2018, 6706

were seen (approximately 0.8 patients/h, or about 1% of the city’s pop- ulation; note that this may have included repeat visits). Insurance ex- pansion was incorporated in Kentucky on 1 January 2014. The rates of city population-corrected EPS visits from 2010 through 2018 were: 1.16%; 1.32%; 1.40%; 1.32%; 1.24%; 1.17%; 1.13%; 1.10%; and 1.08%. The

population-corrected rates of uninsured Louisville residents from 2010 through 2018 were: 21.46%, 26.77%; 27.24%; 17.55%; 12.03%; 11.73%;

9.39%; 13.31%; and 9.40% (average of 23.26% prior to expansion and 11.17% after expansion). The population-corrected rates of uninsured Kentucky residents from 2010 through 2018 were: 26%; 32%; 28%; 25%; 12%; 13%; 12%; 15%; and 11% (average of 27.75% prior to expansion and 12.6% after expansion).

The fraction of uninsured Kentuckians in 2018 (11%) compared to 2010 (26%) was significantly lower at a percent difference of 81.1% (z = 18,518.5, P b 0.00001). This was also true in the city of Louisville (z = 88.03, P b 0.0001). As the fraction of uninsured went down, so did EPS visits; so that the population-corrected fraction of EPS visits was significantly lower in 2018 compared to 2010 (z = 4.35, P b 0.01). This relationship was significant over the entire time interval, and there was a strong correlation between insurance status and EPS visits (r² = 0.6; P = 0.014) (Fig. 1).

1. Discussion

The current study finds that in the largest city of a state that imple- mented insurance expansion under the ACA, reductions in EPS visits were directly correlated with reductions in uninsured individuals (Fig. 1). This did not appear to change after the supreme court nullified the “individual mandate” provision (Fig. 1).

The introduction of the ACA in 2010 was associated with multiple as- sumptions. Key among those would be an increase in people seeking medical services, that was feared would over-extend the healthcare provision infrastructure [8]. Subsequent legal challenges and changes ultimately resulted in reduced funding and increased utilization of health services overall [9,10] Nonetheless, it was anticipated that the ACA would improve access to mental health services [11], resulting in a reduction of EPS utilization.

Medical ED service utilization has generally increased after the intro- duction of the ACA [2-5]. In the 19 to 25 years-old group who were allowed to remain on their parents’ insurance, use of the ED was overall modestly lower [12]. Use of EPS also went down modestly by about 0.05-0.45 visits per 1000 subjects [12,13]. The effect in the general adult population has not been studied.

In our investigation a reduction in EPS visits of about 0.0008 visits/ 1000 residents was noted from 2010 to 2018; smaller than that ob- served in Young people who obtained coverage through their parents’ insurance [12,13].

Limitations include that this was an associational study, without clues as to cause. We studied one hospital in one city in the state, al- though we examined the busiest EPS in the largest city in the state. We only studied adults and have no data on children.

https://doi.org/10.1016/j.ajem.2020.05.074

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Insurance expansion associated with reduced use of emergency psychiatric services 221

r²=0.6; P=0.014

30

20

% Uninsured

10

0

1.0 1.1 1.2 1.3 1.4 1.5

EPS % Visits

Fig. 1. As the population-correction fraction of Uninsured patients increases, so does the utilization of EPS services (data from 2010 through 2018).

Nonetheless, the data demonstrate a clear relationship between in- surance expansion and reduced EPS service utilization. This is the first study to look at emergent psychiatric visits in the general population after ACA introduction. Additional work is needed to determine the re- producibility and significance of this observation.

Acknowledgement

This work was not supported by any extramural funds.

Declaration of competing interest

Dr. El-Mallakh had recent funding from Galen and Janssen. He is cur- rently a speaker for Allergan, Indivior, Janssen, Lundbeck, Otsuka, Sunovion, and Teva.

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Rif S. El-Mallakh MD Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, United States of America Corresponding author at: Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202, United States of America.

E-mail address: [email protected]

Brenda Goetz MSW

Seven Counties Services, Louisville, KY, United States of America

Mohammed Nuru MS Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, United States of America

Ryan Weegens BA Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, United States of America

Urooj Yazdani MD Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, United States of America

Christina Terrell MD Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, United States of America

21 April 2020