Original Contribution Access to care issues and the role of EDs in the wake of the Affordable Care Act ☆ , ☆☆ Alexander T. Janke, BS a, ⁎, Aaron M. Brody, MD a , Daniel L. Overbeek, BS a , Justin C. Bedford, BS a , Robert D. Welch, MD, MSc b , Phillip D. Levy, MD, MPH b, c a School of Medicine, Wayne State University, Detroit MI, USA b Department of Emergency Medicine, Wayne State University, Detroit MI, USA c Cardiovascular Research Institute, Wayne State University, Detroit MI, USA abstract article info Article history: Received 21 October 2014 Received in revised form 4 November 2014 Accepted 6 November 2014 Available online xxxx Context: Americans who received public insurance under the Affordable Care Act use the emergency department (ED) more frequently than before they were insured. If newly enrolled patients cannot access primary care and instead rely on the ED, they may not enjoy the full benefits of health care services. Objective: The objective of the study is to characterize reasons for ED utilization among American adults by insurance status and usual source of care. Design, setting, and participants: Cross-sectional analysis of adult sample respondents to the 2013 National Health Interview Survey reporting 1 or more ED visits in the preceding 12 months. Main outcomes and measures: Among American ED users that reported no usual source of care and who reported relying on the ED, 27.7% (95% confidence interval [CI], 23.6%-32.2%) and 35.1% (95% CI, 28.0%-43.0%) noted at least 1 issue of access and none of acuity as a reason for their last ED visit, as compared to 17.7% (95% CI, 16.3%-19.2%) among those with a stable usual source of care. Conclusions and relevance: Although past research has shown that those who lack a stable usual source of care use the ED more often, this is the first population-level study to demonstrate their propensity for lack of access-based utilization. In the wake of the Affordable Care Act, EDs will need to evolve into outlets that service a wider range of health care needs rather than function in their current capacity, which is largely to address acute issues in isolation. © 2014 Elsevier Inc. All rights reserved. 1. Introduction The Affordable Care Act has been responsible for a dramatic rise in health insurance enrollment [1]. Although the trend over the past 20 years toward increasing emergency department (ED) utilization by Medicare and Medicaid enrollees is well established [2], Americans newly qualified for public insurance use the ED more frequently than they did before [3]. Increasingly, Americans receive their acute care from EDs rather than a physician's office [4], and conceptual models have identified access to care in the broader health care system as a key component of ED utilization [5]. Empirical research has demon- strated that poor health and disruptions in access to regular primary care are key predictors of ED utilization [6]. As such, it is likely that reliance on ED services will increase as health insurance enrollment expands under the Affordable Care Act. Increasing reliance on the ED is troubling in light of past research showing the health benefits of a stable usual source of medical care. Establishing a stable usual source of care is critical for effective health care services utilization. Specifically, population-level studies have found that those with an established usual source of care are more likely to follow recommended preventative care measures [7,8]; have better rates or awareness, treatment, and control of chronic conditions such as hypertension and hyperlipidemia [9]; and experience reduced mortality rates post–myocardial infarction [10]. Furthermore, they are less likely to report having difficulty accessing care in general [11]. In addition to the potential negative effects on well-being, patients lacking a usual source of care, especially those on public insurance, use the ED differently than other patients. Historical results from the Medicare Expenditure Panel Surveys suggest that Medicaid patients reporting barriers to primary care visit the ED for nonurgent reasons [12,13], and those without a usual source of care receive a larger proportion of their ambulatory care from EDs [14]. A cross-sectional study in Canada found that issues of accessibility were more significant than perceptions of need in driving nonurgent use among ED users without a regular physician [15]. Americans newly enrolled in insurance under the Affordable Care Act may be induced to visit the ED more often by virtue of their new American Journal of Emergency Medicine xxx (2014) xxx–xxx ☆ Funding sources: This research study was carried out without funding. ☆☆ Presentations: Results from this study were presented at the 2014 American College of Emergency Physicians convention, October 27 to 30, 2014, Chicago, IL. ⁎ Corresponding author. Wayne State University School of Medicine, 540 E. Canfield St, Detroit, MI 48201. Tel.: +1 616 914 6116. E-mail address: atjanke@gmail.com (A.T. Janke). http://dx.doi.org/10.1016/j.ajem.2014.11.006 0735-6757/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Please cite this article as: Janke AT, et al, Access to care issues and the role of EDs in the wake of the Affordable Care Act, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.11.006