Uninsured not only cause of crowding in emergency rooms

While many people may believe it's the 47 million Americans lacking health insurance who cause crowding in emergency rooms or departments a new study debunks that myth.

The causes of ER overcrowding are much more complicated, U-M researchers say in a study published in the Journal of the American Medical Association. And some widely repeated perceptions about the uninsured and emergency care may be rooted more in assumptions than in solid fact.

In truth the uninsured do not make up a disproportionate share of emergency patients because they are the only group that faces the full cost of care, the study shows. It also demonstrates that people who have insurance are more likely to contribute to ER overcrowding and to use it for minor complaints or in place of a primary care doctor's visit, because primary care offices are overcrowded.

The study is based on an exhaustive review of 127 medical research papers, and on detective work to find out whether often-repeated statements about the uninsured and emergency care were actually based in fact. Most of the papers were published in the last decade, when both the plight of the uninsured and the state of the nation's emergency departments captured the national spotlight.

Although it challenges some of the most-repeated mantras about the uninsured and ER care, the study does confirm that solid evidence exists for many of the things that Americans have come to believe about the uninsured and emergency care.

For instance, the study shows, the number of people without insurance visiting American EDs is rising — but less quickly than the numbers of uninsured are rising. Meanwhile, patients with insurance are going to the ER more frequently.

"What we found is that there is a perception that — because one of the roles of the emergency room is a safety net for the uninsured — it is the uninsured who must be causing all the problems in emergency department care," says first author and emergency physician Dr. Manya Newton, a Robert Wood Johnson Clinical Scholar at the Medical School.

"The crisis in emergency medicine and the problems of the growing uninsured population have been conflated," she adds. "While there's excellent research out there on both issues, the myths about how the uninsured use the emergency department threaten to interfere with the policy-making process. The rise in ER use has much more to do with the aging of the population, the increase in chronic diseases, and the decrease in available primary care than with the uninsured. Policies based on false assumptions risk diverting energy and money from confronting the true drivers of emergency department crowding."

Newton holds positions in internal medicine and emergency medicine at the Medical School and at the School of Public Health. The study was funded by the RWJ Clinical Scholars Program.

At the least, Newton and her co-authors conclude from their review, ER policy solutions will need to address the lack of timely access to primary care by the uninsured and insured alike.

In addition to Newton, the authors of the paper are Dr. Carla Keirns, Dr. Rebecca Cunningham, Dr. Rodney Hayward and Dr. Rachel Stanley.