Insurance Expansion Reduced Asthma Emergencies in New York City

Insurance expansion reduced use of emergency medical services (EMS) for patients with asthma possibly due to improved outpatient disease management, according to a study published in JAMA Network Open.

Previous research has shown that lack of insurance can be a risk factor for asthma exacerbations that require emergency care, and the researchers sought to understand how an expansion of insurance due to the Affordable Care Act (ACA) impacted utilization of EMS. In particular, they analyzed ambulance dispatches for asthma emergencies in New York City between 2008 and 2018 to get a picture of both before and after implementation of the ACA.

“Most EMS systems have fixed resources, including a limited number of personnel and ambulances,” the authors wrote. “A strain on these systems because of increased utilization or other factors can result in delayed care and even increased mortality for patients with serious emergencies.”

They used New York City’s publicly available database that captures every 911 call to identify every call that resulted in an ambulance dispatch. The system differentiates asthma from other respiratory conditions as a distinct call type.

Of the more than 14.8 million EMS calls during the study period, 217,303 (1.5%) were for asthma-related emergencies. The mean total EMS dispatches per 100,000 population per year increased from the period before the ACA was implemented in 2014 (15,471) to the period after the ACA (17,143) was implemented. However, the asthma EMS dispatch rate decreased significantly from 261 per 100,000 population per year to 211 (P = .47).

During the study period the uninsured rate dropped from 14.2% before the ACA to 11.0% after the ACA (−3.2%; 95% CI, −5.1% to −1.4%; P = .003). The researchers also noted median income increased, while the percentage of the population under the age of 18 years and who were non-Hispanic White slightly decreased. During the study period, there was no significant change in the city’s air pollution.

Before the ACA, asthma EMS dispatch calls were increasing at a rate of 11.8 calls per 100,000 population per year (95% CI, 6.1-17.4), but the rate decreased annually by 28.5 calls per 100,000 population per year (95%CI, −37.6 to −19.3) after the ACA was implemented in 2014.

“The decrease in the asthma EMS dispatch rate was significantly associated with annual citywide decreases in the uninsured rate, which were most pronounced in the years following implementation of the ACA,” the authors wrote. In comparison, the dispatch rate for stabbings was unchanged, they added.

They speculated that increased access to primary care as a result of insurance expansion improved outpatient disease management and reduced asthma exacerbations. Access to insurance allows patients with asthma to reduce their utilization of emergency services through improved control therapy, improved rescue therapy, and increased access to counseling for their disease.

“For policymakers, the study supports the growing body of evidence that insurance expansion improves the control of ambulatory care–sensitive conditions such as asthma, as shown by significant decreases in the utilization of emergency services for these conditions,” the authors concluded. They added, “Ambulatory care–sensitive conditions should be targeted by policy makers hoping to reduce EMS utilization through insurance expansion.”

Reference

Peters GA, Ordoobadi AJ, Cash RE, Wong WL, Avillach P, Camargo CA Jr. Association of Affordable Care Act implementation with ambulance utilization for asthma emergencies in New York City, 2008-2018. JAMA Netw Open. 2020;3(11):e2025586. doi:10.1001/jamanetworkopen.2020.25586