E.R. Crowding

Are the uninsured to blame?


According to the conventional wisdom, as enunciated by an editorial in the October 31 Raleigh News & Observer, "We all pay for the uninsured already: those patients without access to a 'medical home' simply clog our emergency rooms with nonurgent matters." As is often the case, the conventional wisdom turns out to be wrong.

For a study reported in the October 22, 2008 Journal of the American Medical Association (JAMA), researchers at the University of Michigan evaluated 127 peer-reviewed articles that made claims about the impact of uninsured patients on emergency room crowding. They concluded that "available data do not support assumptions that uninsured patients are a primary cause of overcrowding, present with less acute conditions than insured patients, or seek [emergency room] care primarily for convenience."

The JAMA study also found that patients with public insurance, such as Medicaid and Medicare, are more likely to crowd into emergency rooms for minor complaints than are the uninsured. Only about 17 percent of E.R. visits in the United States in the last year studied were by uninsured patients, about the same as their share of the population.

That isn't the only way people with subsidized insurance add more burdens to the system than people with no insurance at all. A 2007 study in the Annals of Emergency Medicine looked at charges and payments for 43,128 emergency department visits between 1996 and 2004. "What surprised us was that uninsured patients actually pay a higher proportion of their emergency department charges than Medicaid does," reported co-author Reneé Hsia, a specialist in emergency medicine at the University of California at San Francisco. "In fact, 35 percent of charges for uninsured visits were paid in 2004, compared with 33 percent for Medicaid visits."

So why are emergency rooms so crowded? The JAMA study blames a rising population, a falling number of emergency departments, and understaffing that prevents stabilized patients from being admitted to other parts of the hospital.