Universal Coverage Won't Cure All ED Woes

November 2009

Mass. EDs Still Crowded

By Terry Rudd
Elsevier Global Medical News

BOSTON -- In the wake of Massachusetts' ground-breaking move in 2006 to universal health coverage, nearly two-thirds of surveyed emergency physicians said more patients are seeking emergency care--and nearly two-thirds of surveyed state residents said waiting times in emergency departments have remained the same or risen.

The results are proof that "providing universal health care, while a great feat, is not going to solve the major problems facing emergency department patients, such as prolonged wait times, boarding, and overcrowding," cautioned Dr. Peter Smulowitz, an emergency physician at Beth Israel Deaconess Hospital in Boston and chair of the governmental affairs committee for Massachusetts ACEP.

At a press conference last month, Dr. Smulowitz presented the results of two polls commissioned by the American College of Emergency Physicians and released during its Scientific Assembly. Researchers surveyed 1,002 state residents and 138 emergency physicians in September 2009 to assess the impact of Massachusetts' requirement that residents must purchase health insurance.

Three years after the state's mandate took effect, almost 98% of Massachusetts residents now have health insurance coverage, Dr. Smulowitz said.

"The problem is that, contrary to popular belief and the policy makers and politicians, we've seen clearly that emergency department visits have not dropped," Dr. Smulowitz cautioned. "So, just providing access to health insurance is not going to result all of a sudden on a national level in a dramatic decrease in visits to our nation's emergency departments."

In the survey of state residents, nearly half of respondents (47%) said they had visited an ED in the past year, either for themselves or for a family member. Nearly three-quarters of respondents (72%) said their frequency of ED visits either had remained the same (68%) or increased (4%).

Twenty-three percent of residents said waiting times in the ED have increased since the reforms began, while 33% said they spent less time waiting, and 39% saw no difference. Thirty percent of patients said the EDs were more crowded than before 2006, while 33% said they were less crowded, and another 33% said crowding was unchanged.

The realization that the Massachusetts reform is no panacea for many of the challenges faced by emergency departments also was reflected in the survey of emergency physicians.

A total of 64% of emergency physicians said patient volume had either somewhat or significantly increased (see chart). More than half (53%) reported no change in patient acuity levels since the start of universal coverage, while 20% reported higher acuity levels, and 27% reported lower acuity levels.

Why didn't universal health coverage reduce emergency department visits? People show up in emergency departments for many reasons, Dr. Smulowitz noted.

"Overall, clearly we have a dysfunctional, disorganized health care system, so that the only safety net really is the emergency department," he explained. He also cited a lack of access to primary care, socioeconomic and cultural factors, and the convenience and efficiency of emergency departments that are open 24 hours a day and provide complete care.

Myths about emergency medicine are coloring the debate about emergency departments' role in health reform, noted Dr. Angela Gardner, ACEP president and an emergency physician at Parkland Hospital in Dallas.

The first myth is that EDs are crowded with people who don't need to be there, Dr. Gardner said. But only 12% of patients in emergency departments are nonurgent, she countered, according to data from the Centers for Disease Control and Prevention.

Other myths are that emergency care is expensive and inefficient, she noted. "I would contend that emergency care actually is very inexpensive," she said. "We actually are open five times longer than most doctors' offices."

ACEP supports the following steps to reform the nation's health care system:

  • Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance.

  • Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as "defensive medicine." Widespread adoption of electronic health records could substantially cut costs and improve patient care. 

  • Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an inpatient hospital bed. 


  • A national surge capacity plan must be developed and resources provided to prepare the nation's hospital emergency departments for public health crises.


"Every person in America needs affordable and appropriate health insurance coverage," Dr. Gardner said. "Universal health coverage is a vital first step in reforming our nation's health care system, but it will not solve the severe problems facing emergency department patients right now. There are more steps--and if we don't take them, there will be more severe consequences.

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