title: Availability of insurance linkage programs in U.S. Emergency departments.
abstract: BACKGROUND
  As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs.
  
  
  METHODS
  This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program.
  
  
  RESULTS
  After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 - 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37-2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12-2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding.
  
  
  CONCLUSIONS
  Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.
authors.affiliation: Stanford University School of Medicine, Stanford, California.
authors.forename: Mia
authors.initials: M
authors.lastname: Kanak
authors.affiliation: Department of Emergency Medicine and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: M Kit
authors.initials: MK
authors.lastname: Delgado
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
authors.affiliation: Division of Emergency Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: N Ewen
authors.initials: NE
authors.lastname: Wang
mesh_terms: D004636:Emergency Service, Hospital / Q000191:economics* / Q000331:legislation & jurisprudence; D005260:Female; D006801:Humans; D007348:Insurance, Health / Q000191:economics* / Q000331:legislation & jurisprudence; D008297:Male; D058991:Patient Protection and Affordable Care Act; D011314:Preventive Health Services / Q000191:economics; D011795:Surveys and Questionnaires; D014481:United States