The emergency-room gap.

How to fix health policy.
April 14 2010 6:18 PM

The Emergency-Room Gap

Putting to rest a cherished myth about the uninsured.

Click here for a guide to following the health care reform story online.

Kathleen Sebelius. Click image to expand.
Health and Human Services Secretary Kathleen Sebelius 

On April 8, I lamented ("Unchanged Minds") that a majority of Americans seemed still to believe that the uninsured were able to get the health care they need. Even discounting the poor wording of the survey question I cited, nearly one-quarter of respondents maintained it was "not too" or "not at all" difficult for the uninsured to get adequate treatment, while nearly one-third claimed that the quality of health care available to the uninsured was "as good" as that available to the insured.

Where does this misconception come from? President George W. Bush didn't help when, in 2007, he said, "[P]eople have access to health care in America. After all, you just go to an emergency room." In fairness to Bush, his larger point seemed to be that treating the uninsured in emergency rooms was less efficient economically than treating them in doctors' offices—which, practically speaking, can't be done without health insurance. That's a point many liberals have made, too, including myself. Calculations of the cost of "uncompensated care" range from $56 billion to $73 billion annually. You and I pick up the tab through higher taxes and health insurance premiums.


The "hidden health tax" is a good argument for extending health insurance to the uninsured. But those who make it risk creating the false impression that a lack of health insurance is only a cost issue—that when it comes to health care quality there's no difference between the insured and the uninsured because, well, "you just go to an emergency room." A new study by the Health and Human Services Department's Agency for Healthcare Research and Quality should help set everybody straight on that point. The uninsured, it turns out, have slightly less access to emergency rooms than everyone else does.

HHS examined data about emergency-room visits between 2000 and 2007. (See Figure 4.3.) The median waiting period was about half an hour. Nearly everyone who showed up got to see a doctor, but about 2 percent left without seeing one. Some of these folks were on Medicare. These were the least likely to leave without seeing a doctor; fewer than 1 percent of them did. Some had private health insurance. About 1 percent to 1.5 percent of these people left unseen. Some were on Medicaid. About 2 percent of them left unseen. Then there were the uninsured. About 3 percent left unseen.

Why would the uninsured—the group least likely to receive treatment anywhere else—be more likely than anyone else to leave an emergency room without seeing a doctor? I e-mailed one of the study's authors to ask whether this disparity had been observed in the past. He said it had. What explained it? He cited four potential reasons:

1.) The uninsured are more likely to live in poor neighborhoods where hospitals and ERs are understaffed and where everyone has to wait a long time.
2.) ERs may recognize the uninsured as money losers and make them wait longer.
3.) The uninsured may be more likely to go to [ERs] for routine care because private doctors will not see them for free. Because their care is not emergent, more urgent cases are seen before them.
4.) Patients with mental health and substance abuse disorders may be more likely to be uninsured. Such patients are also more likely to leave without being seen.

Many uninsured people don't go to the emergency room at all, which often means they don't get any health care at all. A July 2009 study by the Robert Wood Johnson Foundation found that while it's true the uninsured are more likely than those with private health insurance to go to the emergency room, when you adjust for income level, health status, and emergency-room capacity, the disparity disappears. (Zachary F. Meisel and Jesse M. Pines made a similar point in a September 2008 Slate piece.) The real predictor for emergency-room use isn't whether you lack health insurance; it's whether you're poor and in lousy health (two conditions that frequently go hand in hand). Poor people on Medicaid account for about one-quarter of all emergency-room costs, possibly because it can be difficult to find a primary-care doctor who'll accept Medicaid's low fees, which are about 66 percent below Medicare fees. The new health care reform law brings Medicaid's primary-care fees up to Medicare's, which should ease that problem (though Maggie Mertens of Kaiser Health News recently noticed that the fee increase may lapse after two years). On the other hand, health reform will expand greatly the Medicaid rolls, which could easily wipe out any reductions in emergency-room visits by Medicaid patients' and the newly insured's increased access to primary care doctors. The Robert Wood Johnson study concluded that health reform will likely increase the crowding problem, not ease it. This finding was cited triumphantly by Robert Samuelson of Newsweek, who's been arguing for months that health reform will be a financial catastrophe. "[C]overing the uninsured is not the health-care system's major problem," he wrote. "The big problem is uncontrolled spending, which prices people out of the market and burdens government budgets."

Lack of health insurance may not be his problem, but I don't see how Samuelson can argue it isn't the health care system's major problem. The data on comparative health outcomes for the insured and the uninsured may be somewhat imprecise, but most studies show a significantly higher mortality rate for the uninsured. One point the new HHS study is clear on is that the uninsured get less of the care they need.

According to the report, if you have health insurance and you're age 40 to 64, you are 36 percent more likely to have received a mammogram during the past two years than someone who lacks health insurance. (The U.S. Preventive Services Task Force last fall recommended against routine mammograms for women in their 40s, but it still wants you to get them if you're over 50.) If you have health insurance and you're age 40 to 64 and you have diabetes, you are 19 percent more likely to have received a hemoglobin A1c (i.e., blood sugar) measurement during the past calendar year. (People diagnosed with diabetes are supposed to get this test every three to six months.) If you have health insurance and you're a child age 2 to 17, you are 32 percent more likely to have seen a dentist during the past year. (If you think dental health is a trivial concern, then please stop whatever you're doing and read my Slate colleague June Thomas' series "The American Way of Dentistry.")

At the risk of overstating the obvious: It really stinks not to have health insurance, as almost anyone who doesn't have it will tell you.

E-mail Timothy Noah at

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