A Fresh Take on Health Care

Does reform solve the ER problem?

It all sounded so simple in the years leading up to health reform. The politicians, from the president on down, railed against people—particularly the poor and the uninsured—clogging up the ERs. The solution: Give them insurance, and they wouldn’t go to the emergency room any more. A very nice and illuminating story by Carla Johnson of the AP now tells us that’s not so. Conventional wisdom is wrong. Under the new health law, emergency rooms might grow even more crowded, with longer waits. Writes Johnson:

That may come as a surprise to those who thought getting 32 million more people covered by health insurance would ease ER crowding. It would seem these patients would be able to get routine health care by visiting a doctor’s office, as most of the insured do. But it’s not that simple.

Dr. Arthur Kellerman, a researcher at Rand Corp. who earned his bonafides as an ER doctor at Atlanta’s Grady Hospital, told the AP that the new health law will increase emergency room use, because people will have coverage and won’t be afraid to use it at the ER when they’re sick. Besides, he says, there are no other places for them to go.

Johnson dug deeper and discovered that the problem was more complex than the usual answer about a shortage of primary care doctors. Money is at the crux, she reported. Medicaid patients will be especially troublesome. They’re often persona non grata at doctors’ offices because the docs say they are money losers; the government doesn’t pay enough to treat them. Sixteen million more Americans will eventually have Medicaid coverage under the new law, so it doesn’t take a rocket scientist to figure out what will happen.

Picture all those newly insured folks clamoring for a spot at a declining number of ERs across the country, and you’ve got an explosive mess in the making. Many hospitals closed their ERs in the 1990s—a ten percent decline in those services from 1991 to 2008, Johnson reported. On top of that, really sick patients admitted through the ER who need to be in the hospital must compete for beds with patients having elective surgeries. Guess who brings in the bigger bucks? “If you’ve got 10 ER patients and 10 elective surgeries, which are you going to give the beds to?” Kellerman asked.

The Boston Globe revisited Massachusetts’s ER conundrum last week, and reported pretty much what it did last year—that despite the state’s reform law, which mandated everyone have coverage beginning in July 2007, emergency room use is rising. Last year, the state’s Division of Health Care Finance and Policy cautioned that it was too early to draw any conclusions from the seven percent rise in ER visits between 2005 and 2007. Now the agency is saying that expanded coverage may be one reason for the 9 percent rise from 2004 to 2008. According to commissioner David Morales, many studies have shown that expanding coverage does not reduce emergency room visits. That’s because the uninsured “are not really responsible for significant ER use,” he told the Globe.

No kidding! That was clear during the run-up to reform, but the politicos weren’t about to move off their talking points. A study by the Actuarial Research Corporation and Kaiser Family Foundation in late 2007 showed that people without insurance were no more likely to use emergency rooms than those with insurance, and accounted for only about 14 percent of all ER visits and 12 percent of ER expenditures. So who’s using the emergency rooms? It turns out that it’s the elderly, the poor, and those with chronic illnesses. Researchers also found that high users, contrary to more conventional wisdom, may not be visiting ERs as a substitute for primary care, but instead are living with chronic conditions and may need more health services overall.

Too bad the media didn’t check all this out before. We need to call politicians out on their questionable assertions and incorrect facts before those errors morph into the rationale for public policy changes. Nope, we shouldn’t be surprised at all by the messages sent by the AP and the Globe.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.