Study: Uninsured Aren’t Responsible for Emergency Room Overcrowding

Published March 1, 2009

Health care analysts are reacting positively to an important report countering the assumption, frequently presented in medical papers and the media, that the uninsured are responsible for emergency room overcrowding.

A study published in the Journal of the American Medical Association in October finds such crowding is evidence of other problems plaguing the health care system.

The study, “Uninsured Adults Presenting to U.S. Emergency Departments: Assumptions vs. Data,” found most emergency department overcrowding occurs because more patients from across the spectrum, not just the uninsured, are visiting emergency rooms than ever before and are being kept in the emergency room when they should be receiving treatment in the hospital itself or in a doctor’s office.

‘Canary in Coal Mine’

Although heavy concentrations of uninsured patients can bog down emergency rooms in some areas, such as inner cities, overcrowding happens across the country because of myriad flaws in the U.S. health care system.

Those flaws play out immediately in the emergency department, said Carla Keirns, a contributor to the study and a clinical instructor at the University of Michigan.

“This is a larger problem, and the emergency room is the canary in the coal mine,” Keirns said.

The study also explored biases in scholarly writing about the uninsured.

After examining 127 medical research papers and several news reports, the study concluded one in five papers simply assumed the uninsured are the cause of the overcrowding, even absent evidence for it. Likewise, 20 percent of the papers assumed the uninsured use the emergency department by default for basic care even when a hospital or family doctor would suffice.

Situation ‘Unlikely to Change’

The past decade has seen more emergency room patients than ever before. Americans are living longer, leading to more chronically ill elderly, but there are fewer primary care physicians available to serve them and other patients. So patients turn to the emergency room when in the past they would have gone elsewhere, said Keirns.

“It’s not the uninsured who burden America’s emergency rooms so much as it is people who are carrying government insurance policies,” said Devon Herrick, Ph.D., a senior fellow at the National Center for Policy Analysis. “The low reimbursement rates offered doctors by government programs means very few will accept taxpayer-funded insurance any more, leaving those on government plans to visit ERs for care instead of primary care physicians.

“People carrying taxpayer-funded insurance are far more responsible for flagrant emergency room overuse than the uninsured,” said Herrick. “Emergency rooms have replaced primary care physicians for many Americans, in part because programs like SCHIP and Medicaid pay doctors so little that few will accept patients carrying those insurance policies. As a result, those patients have become accustomed to going to the ER.”

National Safety Concern

Nick Jouriles, president of the American College of Emergency Physicians, said financial incentives, limited resources, and other factors mean “emergency departments find themselves boarding patients for several hours, patients who could be treated outside of the emergency department.

“It’s hard to take people coming in the front door when nobody’s leaving out the back door,” Jouriles said.

Jouriles warned the unnecessary boarding of patients could create a national safety problem if an emergency happened and a large number of people needed emergency treatment, as too few beds would be free for incoming patients.

“What it will really take is a national interest in making this better,” Jouriles said. “This is also an issue of national safety.”

Policy Changes Suggested

Keirns said the study highlights the need for state and federal policy changes. She suggested lawmakers should think more strategically about elder care and reimbursement.

Herrick suggests policymakers should encourage people to receive private care instead of taxpayer-funded care.

“Reducing or eliminating mandates and other barriers to private insurance would allow patients to rely on primary physicians rather than emergency rooms for day-to-day medical care,” Herrick said.

Jillian Melchior ([email protected]) writes from Michigan.

 For more information …

“Uninsured Adults Presenting to U.S. Emergency Departments: Assumptions vs. Data,” Journal of the American Medical Association: