One of the virtues of increasing access to insurance through the ACA was supposed to be lower emergency room use. Research has pretty much confirmed that this hasn’t happened. And a new paper finds that the trend of greater use of ERs has been ongoing in the United States from the period 1996 to 2010. (IJHS Article) How and where people receive health care can be an important factor in their health. ER use may reflect poor access to primary care, lack of funds to pay for care at other sites, or not understanding what care is appropriate to seek at an ER. Receiving lots of care at an ER may make it difficult to effectively coordinate services across providers. But a lot of care at ERs is probably necessary. In 2015 there were 44.5 ER visits per 100 persons and 12% of those visits ended up with the patient being hospitalized. Using survey data, the researchers sought to identify how much of health care in the US, particularly inpatient services, stem from ER use. During the study period, there were over 3.5 billion hospital-associated health care contacts–ER, outpatient and inpatient. ER visits accounted for 48% of these contacts and rose 44% over the study period. ER users were more likely to be young, African-American, live in the South and to be uninsured than those who used hospital outpatient or inpatient services.
There has been an uptick in ER visits by Medicare beneficiaries, but the most significant increase in use was among Medicaid recipients, rising from 19% to 27.5% as the source of payment for an ER visit. The combination of living in an urban area, being African-American and being covered by Medicaid was particularly associated with ER use increases, likely reflecting inadequate primary care resources in some neighborhoods, coupled with some cultural factors. The relatively high rate of use of ERs in the South may be age-related. The emerging picture is increasing use of ERs for relatively routine care, either for convenience or cost reasons. Since ER care is fairly expensive, this is not a good trend. To the extent it is driven by convenience, financial incentives should be in place to deter such use and ERs may need to be empowered to turn people away for clearly non-emergent care. For-profit companies are establishing more stand-alone urgent care and ER centers, but these tend not to be in the neighborhoods with the greatest health access needs. Alternatives to ERs need to be established in neighborhoods which have few primary care resources and people need to be educated about these alternatives, such as community health centers.