Of course, no one can predict exactly how this scenario will play out. But the available data suggest we’d be wise to anticipate increased volumes. First, let’s look at patient numbers. In 2011, California had 7.1 million uninsured residents under 65 — the largest number of any state. It was the first state to enact legislation under the Affordable Care Act, which created its new health benefit exchange, Covered California, and expanded Medi-Cal, the state Medicaid program. When these laws take effect, experts predict that:
- 2.3 million people will enroll in a Covered California health plan by 2017
- 750,000 to 910,000 newly eligible Californians will enroll in Medi-Cal
- 240,000 to 510,000 people who are currently eligible for Medi-Cal will enroll to meet the ACA’s individual mandate
That’s roughly 3.5 million people who will access healthcare coverage for the first time. In the past, these people may not have sought care very often. If they came down with a case of the flu, they probably stayed home and toughed it out. But now that they’re insured, they can go to the doctor.
Except they may not be able to find one.
The national shortage of primary care physicians is expected to swell to 30,000 by 2015. The situation is especially dire for Medi-Cal patients. County and community clinics are already overwhelmed. As of July 2013, these organizations had received just $3 billion of the $11 billion promised by the ACA, even while sequestration slashed their funding by 5 percent.
When patients cannot easy access primary care, this leaves the local emergency department as de facto provider. We’re happy to serve in that role. It’s what we do as emergency medicine physicians — keep the safety net intact. But coupled with the start of flu season, this influx of patients could create challenges for emergency departments.
So how can we prepare? In recent months, "New Year’s Day" has been a topic of discussion among my medical directors. We’ve identified the following areas as priorities for action:
1. Space. Here in Los Angeles, where hospital emergency department bed space is limited, there’s a need to better utilize the space. Administrators under similar constraints can be working now with hospitals to identify potential areas for expansion.
2. Personnel. Come January, emergency departments will be delivering more care on a relatively similar budget. To meet the demand, hospitals need to consider increasing provider staff to cope with higher volumes. Advanced practitioners such as physician assistants and nurse practitioners can play an important role in filling this gap. And don’t forget nursing and ancillary staff — they’re essential to keep the department running smoothly.
3. Systems. Now is the time to focus on turnaround time and teamwork. Work out processes that get patients through the door, evaluated and on to the next level of care quickly and smoothly — before you have a crowd at the door.
Of course, there’s no way we can be completely prepared for all contingencies. The infrastructure of most EDs simply hasn’t kept pace with the realities of healthcare reform. But with five months remaining in 2013, there’s still time to make meaningful preparations. If we’re even modestly successful, our efforts will benefit our newly insured patients, who may have nowhere else to turn.
