Safety-Net Emergency Departments: A Look at Current Experiences and Challenges

Safety-net hospital emergency departments (EDs) are an important part of our health care system, especially, but not only, for the uninsured and others with low income. With multiple major changes unfolding in our system today, including the development of new health care delivery models, payment reforms, health insurance expansion, and increasing demand for primary care, safety-net EDs are a sort of crucible in which these shifts and transitions can be seen playing out. To understand more about safety-net EDs’ current experiences and challenges as the Affordable Care Act (ACA) begins to take hold, we conducted interviews in June and July 2014 with ED directors in a convenience sample of 15 of the 750 safety-net hospitals around the country, and asked them about selected aspects of their ED’s experience in January-June 2014 compared to the same period of 2013.

The hospitals in our sample come from all four Census regions and a mix of Medicaid expansion and non-expansion states. Our sample includes primarily large, urban teaching centers with an average of close to 100,000 ED visits per year. Ten of the 15 hospitals are public (non-federal) and five are private non-profits. All are trauma centers, including 11 Level 1 Regional Resource Trauma Centers, three Level 2 Community Trauma Centers, and one Level 3 Rural Trauma Hospital.

Several key themes emerged from our interviews:

• The ED directors we spoke with in hospitals in Medicaid expansion states reported reductions in the share of ED patients without insurance and corresponding increases in the share with Medicaid. However, uninsured rates remained high in all the safety-net EDs.
• The ED directors’ expectations regarding trends in ED visit volume over the next few years varied. Some anticipated increased visits, citing pressures on primary care access, remaining large uninsured populations, or expanded ED capacity. Others anticipated flat or declining ED visits due to expanded coverage and access and the impact of new models of health care delivery and payment.
• The ED directors we interviewed were not certain what the net impact of expanded coverage, large remaining uninsured populations, DSH cuts, delivery system reforms, and other ongoing changes will be on ED finances.
• The interviews underscored that EDs play multiple roles in our health care system, not only providing emergency care, but also acting as a primary and specialty care safety-net, a diagnostic and referral center, and a psychiatric treatment site.
• The interviews also spotlighted how EDs have become a critical site of psychiatric treatment due to major strains on access to inpatient psychiatric treatment. The ED directors reported that adult patients needing inpatient psychiatric treatment often have to wait in the ED for 10 hours or more for an inpatient bed, and waits for children are as long as 24 to 48 hours.
• We heard that broader changes in the health care system, such as the emergence of stand-alone EDs, the growing prevalence of high-deductible plans, and delivery system transformation, present safety-net EDs with new challenges and opportunities.