Editor's note: This is the fifth in an occasional series on the 10 essential health benefits required by the Affordable Care Act.
As patients, doctors and health analysts look to see how the Affordable Care Act plays out, the emergency room is one of the closely watched stages.
Nationwide, emergency rooms have seen a jump in patients who are newly insured under the law, drawing speculation and debate about whether the law is working as it should.
But seven months after new health insurance options, Chattanooga-area hospital officials say they are still unable to gauge the law's impact on their emergency rooms.
They are all seeing an increase, but it's nothing out of the ordinary, they say.
More notable, they say, is the shifting role the emergency department is playing as an access point to more regular care - especially as emergency room care is one of the 10 essential health benefits required by new individual insurance plans under the law.
From this time last year, Erlanger Health System, the region's safety net hospital and Level 1 trauma center, has seen a "fairly standard" increase in volumes, Chief Financial Officer Britt Tabor said.
Comparing this May and June to last year, the emergency room saw only a 3 to 4 percent increase in patient volumes.
At Memorial Health Care System, the number of emergency department patients has risen just 2.8 percent over the last year, hospital spokesman Joshua Ball said.
For this quarter, Parkridge Health System has seen a 7.3 percent increase in visits to its main campus compared with last year, spokeswoman Alison Counts said.
She said the figure was "steady, with no particular trend to speak of."
In a nationwide survey of more than 1,800 emergency room doctors released in May, the American College of Emergency Physicians found that nearly half reported increases in ER patients since Jan. 1, when the new health law took effect.
Twenty-seven percent said the number hadn't changed and 23 percent had seen a decline.
The differences can be starker between states that have and have not expanded Medicaid. In Kentucky, which expanded Medicaid under the ACA, the number of people in ERs has spiked as much as 12 percent or more in some hospitals.
In Tennessee and Georgia, states that have not expanded Medicaid, the impact of people newly insured on private plans through health exchanges is harder to see.
Regardless, most doctors across the country - 86 percent - believe that emergency room usage only will go up over the next three years, the survey found.
"We only expect volumes to increase," said Sudave Mendiratta, president of the Tennessee College of Emergency Physicians and an emergency physician at Erlanger. "The emergency department will continue to be a safety net for all patients regardless of their insurance status, but we are also moving to become the hub of the medical wheel."
The survey findings have called into question one goal of the Affordable Care Act: Alleviate emergency room usage and costs.
The theory was that as more people became insured, they would seek out preventive care before health problems escalated into crises.
But the ACEP survey and other studies have shown that increasing the number of insured people only increases emergency room volumes.
Some health law critics have used the data to show that the ACA will not decrease the burden on emergency rooms or high costs associated with them.
Other health experts say that the reality is more complicated. Insurance coverage, they say, is just one step toward care.
The medical community has long warned of a national primary-care shortage, as fewer medical school students choose that profession and as the population ages.
Newly insured patients may have to wait months for a first-time primary care appointment.
There also are social reasons why people continue to use the ER after they get coverage, Mendiratta explained.
The emergency departments are often the only medical facility open 24/7, and the most appealing or comprehensive option for people with hectic schedules.
"People talk about needing a medical home," Mendiratta said. "Well, the [emergency department] is like the front porch of the medical home. We'll always leave the light on for you."
The new trend, Mendiratta said, is to use that role to better connect repeat ER users to more stable care.
Erlanger, like other hospitals, is beginning to use more navigators in its emergency departments to get the uninsured insurance and get the newly insured connected to primary care.
This week, BlueCross BlueShield of Tennessee announced that it was giving the hospital $1 million to help fund its Care Transition Team, which seeks to bring down the number of high-risk, elderly patients with no primary care doctors who frequently use the ER.
Members of the team will call such patients after they are released to make sure they are taking medications and will work to set up appointments with primary care doctors.
Such coordination, Mendiratta said, is changing the ER's role.
"We're not just the people who are going to give you CPR when you come in from a car wreck," he said. "We have a higher mission and social responsibility to make sure every person in our community gets access to care."
Contact staff writer Kate Harrison at firstname.lastname@example.org or 423-757-6673.