Hospital emergency departments (EDs) are an important part of California’s health care system. They are sometimes called the safety net of the safety net because they provide care to all comers. Policymakers, health plans, and health providers have long focused on ED use, partly because it serves as a proxy for lack of access to other, less costly forms of health care. So how has the expansion of insurance coverage under the Affordable Care Act (ACA) affected ED use in California? At an event last week in Sacramento, PPIC researcher Shannon McConville outlined a new PPIC report that addresses this question, and a panel of experts offered their perspectives on recent ED trends.

While many predicted that coverage expansion would reduce ED use by providing access to other kinds of medical care, such as primary care physicians, some worried that because insurance coverage typically reduces patients’ out-of-pocket costs, the ACA would increase ED use. The good news is that the PPIC report estimates that ED use rates would be higher in the absence of the ACA. But ED use statewide has been increasing for the past decade. To get a sense of how recent trends in ED use are being experienced and addressed around the state, PPIC convened a panel of experts.

All of the panelists highlighted the importance of finding out why people are using EDs. Some frequent ED users may not know about other ways to get medical care, while others may have behavioral or mental health issues that could be addressed more effectively by other kinds of care—from housing assistance to substance abuse programs. As Sara Kate Levin, medical director for Contra Costa Health Services, put it, “What are the unmet social needs that are driving a lot of this high utilization?”

But filling information gaps and addressing behavioral and mental health issues does not solve all ED use problems. In many areas, there is a scarcity of primary care doctors and urgent care clinics, and many patients cannot take time off to go to medical appointments during the workday. Moreover, primary care doctors sometimes refer their privately insured patients to EDs, in part so they won’t have to wait for tests.

This range of issues points to what Renee Hsia, an ED physician at Zuckerberg San Francisco General Hospital and a professor of emergency medicine and health policy, called “the elephant in the room”: because the United States has “a very market-based approach to health care,” there are two very different stories about ED use. On the one hand, EDs in affluent areas broadcast their availability and convenience. On the other hand, there are long waits for treatment at EDs serving low-income areas. “In some areas, your ER is a revenue center . . . and in some places, where you don’t have paying patients, your ER is a cost center.”

Jennifer Rasmussen, vice president of health care services at Molina Healthcare of California, highlighted the geographical differences across the state that make it difficult to find “one size fits all” solutions. She pointed out that Molina serves Imperial and San Bernardino Counties, “a vast geography” with fewer social services than a dense urban area has to offer. In other words, “a solution for Imperial County is not going to be the same as a solution for San Francisco.”