Is the Emergency Room the Backdoor to the Healthcare System?

Let's start with some common healthcare wisdom. Basically, insurance is required to enter the healthcare system. However, the uninsured need healthcare too. Since 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) has required emergency departments to treat everyone, regardless of whether they have insurance. Anecdotally, this resulted in overcrowding of EDs (no, not that ED), with one third of ED visits being for nonurgent care. So common wisdom in healthcare says that EDs are being used as a backdoor to the healthcare system for the uninsured.

This makes perfectly rational sense However, a recent study in Health Affairs prooves this backdoor to be a myth.

Insurance, demographic, socioeconomic, and health factors are strongly related to individuals’ ED use, although some of these results run contrary to popular perceptions. For example, in 2003, the uninsured had about sixteen fewer visits on average (per 100 people) compared to Medicaid enrollees, about twenty fewer visits compared toMedicare enrollees, and roughly similar levels of use compared to privately insured people. Noncitizens had much lower levels of ED use than citizens did (about 17 fewer visits per 100 people, on average), and the difference between poor citizens and noncitizens was almost twice as large. In terms of racial/ethnic differences, blacks had higher ED use levels than whites and Hispanics did in 2003. More in line with expectations was the higher ED use by poor people (less than 100 percent of poverty) compared to other income groups, and higher ED use by people in fair/poor health and with chronic medical conditions.

So much for conventional wisdom.

The largest indicator of nonurgent ED use? Regional variation. So it seems that utilization of EDs for nonurgent care has a lot more to do with social norms and patient preferences than particular failures of the healthcare system. Another signifcant factor was the availabilty of outpatient facilites.

It cannot be doubted that the uninsured are looking to EDs for nonurgent care, which is a clear failure of the healthcare system. However, the problem of ED overcrouding needs to be corrected with an commecial expansion of outpatient facilites and, most importantly, education into the complex workings of the healthcare system.