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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