Since the first open enrollment period for the Affordable Care Act, the waiting room at PeaceHealth St. Joseph Medical Center is a little more crowded and more equipment lines the hallways in the emergency department. The hospital, Whatcom County’s largest private employer and only inpatient hospital, is handling 10 percent more patients than it was two years ago.

The number of people the emergency department staff treats each day grew from about 155 to 180 in the last year and a half, said Margie Campbell, emergency department manager. To deal with the surge, PeaceHealth is teaching patients how to use health care more effectively.

Whatcom County had a lot of success in getting people signed up for coverage through the Affordable Care Act. The percentage of people without health insurance in Whatcom County went from 14.3 percent in 2013 to 4 percent by April 2014. That’s 20,909 Whatcom County residents who are newly insured.

Whatcom Alliance for Healthcare Advancement (WAHA), a nonprofit, was one organization chosen by the state to help enroll people in Apple Health, the state’s Medicaid program. WAHA executive director Larry Thompson said the group was more successful than he expected.

“We thought we could get the percentage of uninsured down to about 6 percent,” he said. “We know about 2.5 percent of the population is not going to be eligible for health insurance. They are undocumented aliens or people who, for a wide variety of reasons, just don’t qualify. So you do the math and there’s only about 1.5 percent left to find.”

PeaceHealth has seen a jump in patients on Medicaid and a corresponding decrease in charity care patients, who get treatment at no cost or a reduced cost, said Chris Phillips, community affairs director. Last year, PeaceHealth provided $13 million in charity care, he said.

“More people are getting care and even with reduced reimbursement rates our bottom line is holding steady,” Phillips said. “While Medicaid rates are low, they are more than charity care.”

Phillips said the Affordable Care Act is basically working, because more people have health insurance and more people are getting care. But it’s a problem that so many of the newly insured are using coverage by going to the emergency department, which is the most expensive and least comprehensive way to use health insurance, he said. More patients are using the emergency department for what the hospital calls “avoidable visits” — visits for ailments that could be treated by a primary care physician.

“That suggests an access issue,” Phillips said. “Part of what this suggests is we need increased primary care capacity and we need to help people who are new to the system learn how to use it more effectively.”

PeaceHealth is recruiting more doctors, which is difficult because of a nationwide shortage, Phillips said.

To combat the problem of patients using the emergency department for avoidable visits, PeaceHealth and WAHA are working to increase “healthcare literacy.”

In a joint effort, PeaceHealth and the WAHA created a new position called a community connector. The community connector helps emergency department patients access care outside the emergency department.

“A simple example would be someone going to the ER with dental pain,” Thompson said. “There are no dental experts in the ER. They can give you something to staunch the pain and send you on the way, but the connector might be able to show you how you can afford to visit the dentist, which dentist you could go to that would accept the kind of insurance you have and help make the arrangements to get you connected with the dental practice.”

Ingrid Robinson, the hospital’s community connector, started working in PeaceHealth at the beginning of 2015.

When she arrives for work in the hospital’s social services department, she scans her computer to see who is in the emergency department. If she identifies a patient who is using the emergency department more than they need to, she approaches them to discuss other ways they can get health care. In a normal day, Robinson reaches out to eight to 15 patients.

“Mainly it’s just education about what the ER provides, and if they’re coming in for something that a primary care physician could better assist them with then we try and connect them with a primary care physician,” Robinson said.

Robinson also helps patients who are using the emergency department correctly by setting up follow-up appointments with doctors.

Robinson is the first community connector at PeaceHealth, but Phillips said the hospital will be hiring others.

“Our aim is to have a team of bicultural, bilingual community connectors who are based in the hospital but working for their home organizations,” he said.

Making healthcare more effective and reducing avoidable emergency department visits will help PeaceHealth with another change created by the Affordable Care Act. Upcoming changes to Medicaid and Medicare reimbursements will penalize hospitals if a patient is unnecessarily readmitted to the hospital within 30 days, Phillips said.

“In the past the hospitals made money even if they provided miserable care,” he said. “That change will reinforce a healthcare system that looks toward health promotion and disease prevention as opposed to just sick care.”