Robert Samuelson December 11, 2013

In America’s health-care dialogue, emergency rooms have come to symbolize the system’s economic and medical defects. To critics, typical ERs are swamped by the uninsured, who — lacking a regular doctor or source of care — go where they will be treated. Performing routine medicine at high prices, ERs are crowded and costly. If the uninsured had insurance, these problems would recede. Better medicine at less cost.

Who could oppose that? Well, nobody. It was a selling point for the Affordable Care Act. The trouble is that the story is mostly make-believe.

Just look at the figures: People with insurance accounted for roughly 80 percent of the 120 million emergency department visits in 2006, according to the Department of Health and Human Services. Even if all the uninsured abandoned ERs — an implausible assumption — there would still be almost 100 million visits. Actually, there would be more because by 2010 the number of visits had increasedto about 130 million.

ERs are the black boxes of the U.S. health-care system. From TV hospital dramas, we see them as citadels of chaotic caring. Otherwise, we’re mostly ignorant. The December issue of Health Affairs — the preeminent journal of health policy — focuses on ERs and shatters some myths.

“As recently as the 1950s, the ‘emergency room’ was often just that — a hospital room reserved for emergency cases,” writes Arthur Kellermann of the federal Uniformed Services University of the Health Sciences, with his co-authors. “The room was staffed by either inexperienced interns or rotating members of the hospital’s medical staff — regardless of their training, expertise, or interest.” The first residency program in emergency medicine didn’t start until 1970.

We’ve come a long way from these modest roots. There are now about 5,000 ERs. Large and sophisticated trauma centers handle 50,000 or more patient visits annually. Partly, ERs’ heavy use reflects hospitals’ legal obligation to accept most comers. Reacting to stories of “patient dumping” — hospitals rejecting uninsured people with acute symptoms — Congress in 1986 enacted the Emergency Medical Treatment and Active Labor Act, which requires most hospitals to provide care “in potential medical emergencies,” writes Sara Rosenbaum of George Washington University’s School of Public Health and Health Services.

But it’s mostly the way medicine is practiced that has expanded the role of ERs. Patients find them a convenient way to get care without making an appointment or skipping work. Doctors, too, increasingly turn to ERs. Kellermann reports that the 4 percent of doctors who run ERs handle 28 percent of acute care cases — patients with sudden heart, lung and brain problems or serious physical injuries. With appointment-filled days, he writes, few doctors “can afford to disrupt their routine to see an unscheduled walk-in patient with an urgent problem. It’s much easier … to direct the patient to a nearby [ER].”

As a result, ERs serve as gatekeepers, deciding who is admitted to hospitals. Although only 16 percent of their patients are hospitalized — a share that’s been stable for decades — they account for half of all hospital admissions. These very sick patients are costly. Other contributors to spending seem smaller. Drug abusers and people with mental illness are often said to overuse ERs and drive up spending. But one study disputes this, finding that these groups represented less than 8 percent of ER visits in New York City.

Obamacare notwithstanding, it’s doubtful that overhauling ERs would achieve huge cost savings. To be sure, the system could be run more efficiently and effectively; several studie
s indicate that. The trouble is that ER costs are relatively modest compared to all U.S. health spending. There are no uniform cost figures, but estimates are in the range of 5 percent. In 2011, this would have been $135 billion out of $2.7 trillion. Shaving 10 percent from that (a generous assumption) would represent one-half of one percent of total spending.

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