Should reduced ER use be a measure of health reform?

In making the case for health care reform, inappropriate utilization of emergency rooms is frequently cited as an example of our inefficient system and an important factor behind the staggering cost of U.S. health care.

At first, the logic makes sense: emergency rooms have to treat people, so the uninsured often turn there for care, including primary care, which is very expensive to provide in an emergency room, and would be much better treated in a private doctor’s office. Give people access to affordable health insurance, and they will no longer have to head to an emergency room when they get sick, which will translate into less crowded ERs and a lower national health care tab. There’s just one problem: It doesn’t work that way.

Opponents of health reform who suggested during the rhetorical back and forth over its passage that universal coverage would lead to long waiting lines were somewhat correct. It isn’t likely that the change will be measurably noticeable at your physician’s office, but it is very likely in the ER waiting room.

The reason is simple: people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for its host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.

So, if we give people insurance, we might actually see an increase in ER visits, because one of the primary reasons people might have avoided going to the ER (cost) will have been largely removed. In fact, we can take a look at Massachusetts, where ER visit rates haven’t dropped despite near-universal coverage as evidence of this. Does that mean that we shouldn’t have bothered to increase insurance coverage? Absolutely not. Having insurance is an important component of reform–it’s just not the only thing that matters. The system needs to be reformed in other ways too. That means focusing on the non-insurance barriers to health care access–things like transportation, translation, on-site child care, after hours appointments, same day appointments, electronic medical records that follow the patient, and so forth. These types of “enabling services” are actually one of the things that the well-respected and high-performing community health centers provide that set them apart from other health care providers.

What we need are more intermediaries–places like urgent care centers, and community health centers that can “fill the gaps” between the emergency room and traditional private practices. And all of these people need to be able to talk to each other. Until these types of changes are made to the health care system, people will continue to go to the emergency room for non-emergent conditions–even if they have insurance. We should anticipate that, because if we fail to do so, there are many opponents of health reform who will suggest that the lack of improvement in this single measure is indicative of reform’s failure.

The truth is, reduced ER use isn’t always the best indicator of whether or not health reform is working. It can be. It can tell us how well people are able to navigate our system and how well the various parts work together. But it doesn’t reflect well the effects of increased insurance coverage.

Brad Wright is a health policy doctoral student who blogs at Wright on Health.

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  • Mylissa Foley

    “Does that mean that we shouldn’t have bothered to increase insurance coverage? Absolutely not. Having insurance is an important component of reform–it’s just not the only thing that matters.”
    Well said.
    If a person goes to the ER, they know they will be treated regardless of whether or not they have payment present. They know they can be billed. I think this is why we have so many uninsured people going to the ER versus a walk in clinic. The walk in clinics are often too expensive for people with no insurance.

  • J.T. Wenting

    To counter the increase in ER visits they’ve here created a law that requires people to have a permit from their GP to visit the ER (not joking).
    No permit, no treatment, unless maybe you pay up front.

    Emergency cases delivered by ambulance are excluded from that, but there you get the bill for the ambulance afterwards (which may or may not be covered by your mandatory insurance depending on the reason for the trip).

    • Ms. Beck

      Some people don’t have a GP. We didn’t have one for years because no one was accepting patients.
      It feels strange to be a healthcare provider who can’t obtain healthcare themselves.

    • jp

      where is “here????” the UK?

  • Marilyn Nichols @ Phlebotomy Training

    Now I’m wondering how many ERs in hospitals all over the country are always over-crowded. They couldn’t all be attended to at one time if they were that many. There should be more to insurance coverage so patients won’t have to pack up a place where they can’t all be attended to with the best care.

  • sharon.a.wander

    ER visits: last time I did ER duty in Pediatrics, Mothers came in with baby and children for RX: for tylenol. ($100.00 ER charged visit They used their gold care, Medicaid.).. Also church buses would drive up and out would come children from El Salvador to the ER at midnight for free health care and medications . illegal undocumented aliens. free of charge treatment . The could go to the clinic in the daytime but……….

  • Bill Tucker

    This health care coverage issue is very difficult. I don’t see any easy answer and I’ve thought about for a long time as a health care provider for the past 15 yrs. In TN we tried a noble experiment call TNCARE. It provided insurance to low income individuals (and many undeserving as well). It was an economic disaster and a political lighting rod…oddly enough sustained all thorough a 2 term Republican Gov. and cut to the bear bones by a Democrat Gov. in his first term. During the period of TNCARE–ER visits actually increased! I did a Lot of ER shifts in that time period and saw the gamete of folks coming in with sore throats and other non emergent issues (a lot of drug seekers took advantage as you can imagine)–despite having been assigned to a PCP This was a small case study Universal health care that should be studied by every State and certainly by the House and Senate.

    • Mylissa Foley

      That’s interesting, thank you for sharing. Perhaps we should have non-emergent care clinics approximated directly in the ER parking lot? My idea is that we should have a physician and nurse stationed at the ER door to direct non emergent cases to the above mentioned clinic? The nurse and doctor do nothing but see the patients immediately and direct them to the correct facility- either further in to the ER or across the parking lot to a clinic.
      Just an idea.
      Then you’d have an attorney’s office spring up next to the on site non emergent care clinic. Next to that, private medical investigator’s office… I could go on but i’ll refrain.

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