Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018

JAMA Netw Open. 2020 Nov 2;3(11):e2025586. doi: 10.1001/jamanetworkopen.2020.25586.


Importance: Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear.

Objective: This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies.

Design, setting, and participants: This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index.

Exposures: Implementation of ACA on January 1, 2014.

Main outcomes and measures: Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker.

Results: In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04).

Conclusions and relevance: Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Ambulances / statistics & numerical data*
  • Asthma*
  • Emergencies
  • Emergency Medical Dispatch / trends
  • Emergency Medical Services / trends*
  • Humans
  • Insurance, Health / trends*
  • Linear Models
  • Medically Uninsured / statistics & numerical data*
  • Multivariate Analysis
  • New York City
  • Patient Protection and Affordable Care Act*