BOSTON - The expansion of health insurance in New York City under the Affordable Care Act (ACA) resulted in a significant reduction in the dispatch of ambulances for asthma emergencies, a study by Massachusetts General Hospital (MGH) has found. In a paper published in JAMA Network Open, researchers suggested that the likely reason for this decline is improved access to outpatient management of the chronic condition. The finding has major implications for the broader public health system as it seeks to control costs and better utilize fixed resources like emergency medical services (EMS).
"Our research suggests that giving access to affordable health insurance to people with asthma can rapidly reduce the frequency and severity of asthma exacerbations and lead to significantly fewer 911 calls," says Gregory Peters, MD, an investigator in the Department of Emergency Medicine at MGH and lead author of the study. "Our analysis of the effects of a major health policy change like the Affordable Care Act on a high-volume EMS system like the one in New York City provides valuable insights for public health officials."
Emergency medical services respond to millions of calls per year nationwide, despite constraints on ambulances and personnel. Additional pressure on these systems through increased utilization, as often occurs in cities and larger communities, can result in delayed care and even increased mortality, particularly in vulnerable neighborhoods. Asthma, because it is an "ambulatory care-sensitive" condition - meaning it can typically be controlled with the help of a primary care clinician and a treatment plan - has been the subject of prior studies on the impact of disease management on emergency services use under expanded insurance coverage. Those studies, however, yielded conflicting results.
MGH investigated more than 217,000 EMS dispatches for asthma-related emergencies in New York City, one of the nation's busiest EMS systems, between 2008 and 2018. The study showed that national implementation of the Affordable Care Act in January 2014 resulted in a significant decline in asthma-related EMS calls, from 261 dispatches per 100,000 people per year before enactment to 211 dispatches afterwards, a reduction of 20 percent.
"Expanded insurance has enormous potential to reduce 911 calls by providing individuals with chronic diseases, like asthma, with a way to better control their disease and thereby lower the risk of requiring emergency care," explains Alexander Ordoobadi, MD, a resident with the Department of Surgery at Brigham and Women's Hospital and co-lead author on the study. "Improved coverage gives patients access to long-term controller therapies to prevent exacerbations, and to rescue therapies to improve breathing. More than just medications, though, expanded insurance gives them access to clinicians who can counsel them on how to avoid asthma triggers and provide an asthma action plan."
The public health impact of expanded insurance for individuals who often go without any health coverage could extend well beyond asthma, the MGH research team indicated. "Epilepsy is another ambulatory care-sensitive condition where we might be able to significantly reduce seizures - and emergency calls - by ensuring that people have access to effective medicines and neurologists," stresses Peters. "Preventing 911 calls to already hard-pressed EMS systems through improved outpatient management of a host of conditions is a discussion that public policy makers need to revisit. The upcoming challenge to the Affordable Care Act before the U.S. Supreme Court makes this issue more timely than ever."
Peters is a resident in the Harvard Affiliated Emergency Medicine Residency and a former volunteer firefighter in the Bronx. Ordoobadi is a general surgery resident at Brigham and Women's Hospital and a former paramedic. Lead statistician Rebecca Cash, PhD, MPH, is an epidemiologist and biostatistician at MGH and a former paramedic. Senior author Carlos Camargo, Jr., MD, DrPH, is a professor of Emergency Medicine and Medicine at Harvard Medical School, and professor of Epidemiology at Harvard T.H. Chan School of Public Health. Other co-authors include Matthew Wong, MD, MPH, assistant professor of Emergency Medicine at Beth Israel Deaconess Medical Center, and Paul Avillach, MD, PhD, assistant professor of Biomedical Informatics at Harvard Medical School.
The study was supported by a grant to Peters from Amazon Web Services.
About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In August 2020, Mass General was named #6 in the U.S. News & World Report list of "America's Best Hospitals."