ACA and the ED - Past, Present and Future Part III

Previously, in the second of a 3-part series centering around health policy and the ED, we discussed the ACA and its impact on the health care system and the ED in particular. For those who missed it, see here for Part 1 and the introduction.  Here, we remark upon the future with hopeful pragmatism. 


As we have previously mentioned, the ACA has left an indelible mark upon the healthcare system in the US.  Latest estimates suggest over 20 million fewer uninsured; continued increase in ED utilization rates; shifting payer mixes within the ED population; increasing percentage of federal and state health care spending; continuing increase in NHE per capita and as a percentage of GDP; improved access; and quality and payment reform strategies.    

As the executive leadership within the US transitions, many are left wondering about the future of the healthcare system.  Will the ACA continue? Will there be a repeal? What will the insurance marketplaces look like going forward? 

Recently, we have seen the passage of the 21st Century Cures Act,(1) which aims to devote funding and reform strategies to the NIH, FDA, and other organizations.  It remains to be seen what impact this law will have, but many are hopeful about the law’s central tenets of funding research, protecting health data, and reforming drug and device approval and development processes. In addition, it creates a new vehicle for financing health coverage on behalf of employers, that of a health reimbursement arrangement (HRA). 

Leaders within the new administration and Congress have also proposed additional health system reforms.  As part of A Better Way,(2) Republican leaders have proposed several elements as part of a vision towards a new healthcare system.  Removal of the individual mandate, age-adjusted refundable tax credits, health savings account expansions, interstate insurance markets, medical liability reform, maintaining protection against pre-existing conditions, protecting coverage for those under 26, block granting Medicaid programs, and increasing NIH funding are some of its central components.  Under Empowering Patients First Act,(3) we would see the repeal of the ACA and removal of the individual mandate, insurance exchanges, and income-related tax credits in favor of an age-adjusted fixed tax credit for the purchase of insurance. Coverage for pre-existing conditions would remain provided individuals maintain continuous coverage.  HSA expansion, state-based risk pools for insurance coverage, capping business-related tax credits, repealing existing Medicaid expansion, and deregulating the insurance market are remaining central components. Critics raise concerns regarding  insufficient consumer and patient protections as well as inadequate funding for Medicaid block grants and the high-risk pools. 

Further, it remains to be seen how the patient’s exposure to balance billing and out of network (OON) emergency care will develop. Unanticipated costs to patients will constrain the doctor-patient relationship within the ED, and may potentially lead to misguided healthcare access choices. 


Many questions remain regarding the future of the healthcare system in the US and its impact on us in the ED.  As a specialty, we have the unique pleasure of serving patients 24/7/365.  Yet, we can and should do better.  Several strategies have been proposed previously that can enable us to carry the healthcare system forward towards a brighter and healthier future.

Care delivery innovation is one broad area that we can continue to target.  We in the ED are resuscitationists, risk stratifiers, and care coordinators.(4) We can continue to use our unique skills and position as the hub of the system to optimize care coordination for our patients, particularly as the complexities of the healthcare system grow.  Accountable care organizations, patient centered medical homes, and community partnerships may enable us to streamline healthcare delivery through the entirety of the care continuum.  We will be required now more than ever to optimize efficiency Evidence based strategies to improve operational efficiency, such as surgical schedule smoothing, front-end operational strategies, and facilitating inpatient discharges will need to be implemented and optimized.  Perhaps most importantly, a never-ending focus on high quality care and patient-centered outcomes in the face of these complexities will be paramount.(5)

We look forward to the future of acute care delivery.   Innovative strategies are being implemented that can be expanded upon and optimized, particularly as ED’s leverage their capabilities in the face of payment reform.  Implementation and expansion of clinical decision unit capabilities to areas as of yet undiscovered, post ED discharge follow up clinics, hospitals at home, outpatient infusion services, telehealth, digital monitoring devices, the expansion of ancillary services, and coordinated care bundles – to name a few – are innovations that excite emergency physicians and propel us toward a bright and innovative future in healthcare.  

The evolution of the healthcare system in the US carries us toward an exciting future.  The ACA, in particular, has brought about a multitude of changes affecting healthcare cost, access, and quality.  It remains to be seen how the healthcare system will evolve in the next several years, but we in the ED are well positioned to leverage our skills and capabilities to deliver high quality and valued care in an integrated manner. 

Post by Dan Axelson, MD, Tim Loftus, MD and Seth Trueger, MD