ER Overload

The modern emergency room, as most people think of it, has an emergency of its own: It's packed, costly, noisy, and overrun by uninsured freeloaders who can't legally be turned away once they walk through the ER doors. If you've actually been in an ER in the past few years, you know the first three things are true—but how much do you know about the rest of the people in the waiting room? As it turns out, they're not disproportionately uninsured patients with nowhere else to turn. They're more likely to be people who do have insurance, and according to a new study in the Journal of the American Medical Association, the reasons they're backing up in ERs go much deeper than who's paying for their care. NEWSWEEK's Mary Carmichael asked Dr. Manya Newton, an emergency physician at the University of Michigan, Robert Wood Johnson Clinical Scholar, and the lead author of the new paper, to explain the problem. Excerpts:

NEWSWEEK: You looked at some common assumptions about why emergency rooms are so crowded. A lot of them turned out to be untrue. What were these myths, and how did people come to believe in them?
Manya Newton: First, there was a belief that the uninsured are all coming to the emergency department for non-urgent care. That's a tricky one to talk about, because there's no good definition of what "non-urgent care" is—if you have a big cut on your face, or if your baby has a fever and it's one in the morning, that is coded as "non-urgent" by doctors even though it's urgent to you. But when people talk about crowded ERs and the uninsured coming in for "non-urgent care," they're thinking about things like the sniffles, or the back pain these people have had for 11 years. And if you actually look at the uninsured, they're not coming in for sniffles or back pain, because they're the only group that bears the full cost of an ER visit. Yes, a $50 co-pay is painful, but a $5,000 bill is really painful.

So they actually come to the ER less often than people with insurance do? 
Yes. They're underrepresented in ERs compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they're really sick. So it's not the uninsured who are causing crowding. It's everybody.

Why do you think people came to believe the opposite—that the uninsured were responsible for crowded ERs? 
Before the 1990s, at least in the medical literature, it was widely understood that the uninsured were putting off care, showing up sicker [and] showing up less often. But then there were some big changes in the medical system. The Emergency Medical Treatment and Active Labor Act went into effect in 1986. This is the act that's often misquoted as "you can get free care in the emergency department," which is absolutely not right. The fact is that if you show up and you're sick, we do have to treat you—we can't look in your wallet first. But it's not free. You still get billed. Also, there were a bunch of changes at that time regarding managed care, and the result was that ERs found themselves strapped for money. A lot of emergency departments across the country closed, so all the remaining ERs were seeing more patients—and I think the uninsured became our scapegoat.

What people don't understand is that in general, the uninsured are people who are working two or three jobs trying to hold their families together, and none of their jobs offer insurance. There's this presumption that they're choosing not to have insurance—there's a feeling that these people are unworthy, that they'd have insurance if they just worked harder. And we can't make policy based on assumptions like that, because a lot of times what "everybody knows" turns out to be wrong.

So if the uninsured aren't to blame for overcrowding, who is? 
It's multi-factorial. The population is getting older and sicker, so more people are coming to the ER for real emergencies. Use-per-person has also gone up, and we're not sure why that's happening. Part of it is because there are fewer primary care doctors now, so it's hard to get appointments. If you call your doctor's office and you say, "I'm super-sick and coughing up green stuff," and they say, "we'll see you three weeks from Tuesday," you might think you need to go to the ER instead. And you might be right.

But you might be wrong, in which case you're in the ER unnecessarily.

You also write that the actual number of beds in ERs has gone down, at the same time the need has apparently gone up. Why?
That would be a whole other paper—but it has to do with changes in reimbursement and the nursing shortage.