To investigate the association of the Affordable Care Act with nationwide eye-related emergency department utilization.

Retrospective cross-sectional study.

All patients who presented to the emergency department with an eye-related primary diagnosis were eligible for inclusion.

Nationally representative data from the US Nationwide Emergency Department Sample (NEDS) were used to analyze eye-related ED visits before (2010-2013) and after (2014-2017) the ACA was mandated. All ED visits were categorized as emergent, non-emergent or could not be determined.

The primary outcome was to compare the nationwide and regional incidence of eye-related ED visits per 100,000 US population before (2010-2013) and after (2014-2017) the ACA was mandated. Secondary outcome measures included change in payor status, proportion of urgent versus non-urgent visits, proportion of visits at teaching versus non-teaching hospitals, associated charges and discharge disposition.

A total of 16,808,343 eye-related ED visits occurred in the United States during the study period from 2010-2017. Of these, 8,088,203 ED visits occurred before the ACA was mandated (2010-2013) and 8,720,766 ED visits occurred after the ACA was mandated (2014-2017). After the ACA was mandated in 2014, there was an initial decline in incidence of eye-related ED visits from 652.4 per 100,000 population in 2013 to 593.0 per 100,000 population in 2014, followed by a rapid increase in incidence to 658.5 per 100,000 population in 2015, with a further increase to 746.6 per 100,000 population in 2016. The percentage of uninsured patients decreased from 19.0% to 14.3% and those with Medicaid coverage increased from 29.4% to 36.0%. The increase in ED utilization was greatest for individuals belonging to the lowest income quartile (895.1 per 100,000 population in 2013 to 964.0 per 100,000 in 2017). Overall, 44.8% of ED visits during the study period were due to non-emergent eye conditions.

Although the ACA increased insurance coverage for Americans, theoretically increasing access to outpatient ophthalmic care; this did not decrease ED reliance for management of ophthalmic conditions. Additional measures beyond expanding insurance coverage may be necessary to provide high quality, efficient and equitable outpatient ophthalmic care to all Americans.