Research suggests that an increase in insurance coverage is associated with increased use of health care services. This should make intuitive sense. Individuals who were previously unable to afford health care services would seek them out once affordability was no longer an issue. This was demonstrated in several situations, including the expansion of Medicaid in Oregon and the introduction of an individual mandate and expansion of heavily subsidized insurance in Massachusetts, both of which predated the Patient Protection and Affordable Care Act (ACA).1-3 These same instances also provided examples of increases in inappropriate health care use, defined as patients seeking nonurgent care in the emergency department.
Courtemanche et al4 present a unique example of increased use associated with the implementation of the ACA. In this case-control study, the authors reviewed ambulance dispatch reports in New York City (NYC), New York, comparing low-severity with high-severity dispatches as defined by the city’s emergency medical services (EMS) Incident Dispatch Data. For the period evaluated, the authors show that there was a relative increase of 37.2% in dispatches for nonsevere or minor injuries.4 The authors posit that this increase was the result of the ACA “insulating patients from having to pay full cost”4 and suggest that there might be “appropriate incentives”4 (we presume via cost sharing) to decrease use of unnecessary emergency services.
Although the authors provide interesting data points for discussion, we believe that only limited conclusions can be made based on the observed association. It must first be noted that during the study, there were more than 4.7 million EMS dispatches in NYC.4 Dispatches for minor injuries represented less than 1% of dispatches during that time. Although the relative increases Courtemanche et al4 found are certainly impressive, the absolute increase needs to be put into perspective. That being said, the increase in EMS use could indeed lead to more congestion, slower response times, and possible mortality, as the authors stated.4
Moreover, evidence exists that while cost sharing can be effective as a means of reducing health care costs, it does so at the expense of both necessary and unnecessary care. Patients can be cost conscious but often times at the expense of needed health care services. This has been borne out specifically in research looking at health care use by patients with high-deductible health insurance plans. A 2017 systematic review5 looked at the effect of high-deductible health insurance plans on health care use and found that most studies demonstrated a reduction in preventive care and office visits. Additionally, while the studies showed a decrease in low-severity emergency department visits, they also saw a decrease in high-severity emergency department visits.5
Intentionally or not, Courtemanche et al4 bring up another critical aspect to health care access—transportation (or the lack thereof). Evidence exists showing that transportation can be a barrier to health care access,6 and in NYC in particular, lower-income individuals feel an increased burden. Owning a car and having access to affordable parking is not feasible for most (including many physicians), and public transportation is limited. Some clinics are far from the nearest public transit stops. Subways and buses are often overcrowded and slow, and for patients with debility, these services can feel especially unwelcoming during a time of distress; any alternative to that would certainly seem more enticing. While the authors may be correct that reduced cost sharing encouraged increased use of ambulance services, this also highlights the need for improving transportation to clinics and urgent care centers.
As clinicians who take care of disadvantaged populations in NYC, we are acutely aware of the risks of shifting costs to patients (forcing them to put more skin in the game, as it were). Not only do we see the effects of patients delaying care because of cost or lack of health insurance, but we also see the effects of rationing care. Systems need to be optimized to better relieve EMS congestion and response times. We recommend alternatives that are less punitive on the individual while continuing to promote necessary care.
Published: June 28, 2019. doi:10.1001/jamanetworkopen.2019.6856
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Tsega S et al. JAMA Network Open.
Corresponding Author: Hyung J. Cho, MD, New York City Health and Hospitals, 125 Worth St, Room 507, New York, NY 10013 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Tsega S, Cho HJ. The Reality of Accessing Transportation for Health Care in New York City. JAMA Netw Open. 2019;2(6):e196856. doi:10.1001/jamanetworkopen.2019.6856
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