ER utilization shouldn’t be a measuring stick for health care reform

Mitt Romney’s “let them eat cake” comments on 60 Minutes serves to illustrate how badly both sides of a political debate can confuse an issue. In 2010 he criticized emergency room care as a potential  loophole used by people to get “entirely free care” while avoiding having to pay for health insurance and in his book No Apology, the Governor outlined the idea behind Massachusetts health care reform as “redirecting” the costs of expensive hospital care towards helping the uninsured pay for health insurance.

But in the 60 Minutes interview Gov. Romney appears to have reversed himself by emphasizing the fact that emergency rooms provide care regardless of a patient’s ability to pay while appearing to back off on the idea of universal coverage.

In my state, we found a solution that worked for my state. But I wouldn’t take what we did in Massachusetts and say to Texas, “You’ve got to take the Massachusetts model.”

Why? Texas has the the highest rate of people without health insurance coverage in the country. Are the uninsured in Texas somehow different from the uninsured in Massachusetts? No. But, Texas also has far more conservative and Republican voters than Massachusetts and the uninsured largely vote Democratic so screw them. Ergo, universal health care is fine for Massachusetts. Everyone else gets miniature American flags. At least Mr. Romney is consistent in abandoning or reversing his positions to pander for votes.

Still, using emergency room utilization as a measuring stick for health care reform appears to be dubious at best. The liberal mythology is that the uninsured flood emergency rooms for all aspects of their care but this is simply not supported by the evidence. The reality is that the uninsured make up only about 15% of all ER visits. The vast majority of patients who visit an ER have government insurance coverage and Medicaid beneficiaries under the age of 65 utilize the ER far more than those under 65 who have private insurance.

The reason for the relatively low ER utilization by the uninsured is that an ER visit is not “entirely free” as Mitt Romney says and most of  the uninsured are not immune to the financial impact of very expensive ER care. They tend to avoid the ER unless and until absolutely necessary, i.e. a true emergency.

The other side of this coin and the other part of this mythology is that increasing the number of insured patients will reduce overall ER utilization. Actually, health care reform has the seemingly paradoxical potential to increase ER utilization. There are several reasons for this and much that depends on demographics. While many of these newly covered patients tend to be poorer, have more health problems, and more unhealthy lifestyles, they also tend to live in areas that have poorly designed primary care infrastructures. They live in areas where primary care providers are few and overwhelmed with patients and where there are few if any urgent care or after-hours clinics. The net result is that this population is chronically undeserved, has decreased access to primary care, and where often the only viable option for timely care is the emergency room. If you remove the financial disincentive to visit the ER then this newly insured population can and will visit the ER more often.

There is already some data from Massachusetts that suggests that this is the case with health care reform. Researchers from Harvard found that the total number of ER visits at 11 Massachusetts hospitals increased 4% after the state required all individuals to be covered by health insurance in 2008. Liberals tried to spin this by pointing out that there was a decrease of 2.6% (4% in a Blue Cross Blue Shield study)  in the number of previously uninsured patients using the ER for “low severity” problems.  But given that 400,000 newly insured patients entered the system during this time these numbers seem oddly small. The reason for such small changes in ER utilization may be that any decreases in ER visits by newly insured patients who obtained their care in the community were offset by increased visits by newly insured patients for whom the ER is the most viable source of care.

ER utilization is more likely to be impacted by the quality of the local community’s assess to primary care than its percentage of uninsured patients. Unfortunately, neither ObamaCare nor RomneyCare legislation has addressed this issue. Medicare and Medicaid routinely reimburse far more for an ER visit than an office visit even for something as basic as an ingrown toe nail or a minor injury. The financial intensive is skewed towards pricey ER care (follow the money) while outpatient primary care offices concentrate on high volumes of lower complexity patients (medication refills) and anything more urgent or complicated is referred to the ER.

The ER is not the appropriate battleground nor measuring stick for the need for or success of health care reform. Not unless both sides are willing to admit that their financing and reimbursement schemes are deeply flawed and part of the problem rather then the solution.

Chris Rangel is an internal medicine physician who blogs at

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