Heritage Foundation Leadership for America

America's emergency rooms are in crisis.

Emergency medicine encompasses the care of patients with traumatic injuries or serious signs and symptoms of disease. Quick evaluation and rapid treatment of these patients obviously cannot be done on an "elective" basis. These services are invariably provided under the auspices of a hospital and are available to patients 24 hours a day, seven days a week.

Moreover, hospital emergency departments (EDs) are the only part of the health care system that is required by federal law to provide care to all patients, regardless of ability to pay. Yet a sizable number of patients who visit the ED do not require the level of care that an emergency room provides. In Maryland, for example, patients with non-urgent medical problems account for over 40 percent of ED visits.

Jammed with increasing numbers of uninsured Americans and enrollees in public programs, emergency rooms find their overcrowding further aggravated by outdated federal and state policies. Worse, while many emergency rooms are already operating at peak capacity on a day-to-day basis, the emergency medical system is incapable of absorbing the massive surge in demand for emergency medical assistance that would follow a natural disaster or terrorist attack.

Recent trends highlight the challenge:

• The emergency medical system is stretched beyond capacity.
• In most states, the system could not absorb the surge in demand that would accompany a pandemic, natural disaster, or terrorist attack.
• Recent increases in ED demand are driven by patients seeking care for non-urgent problems.
• Current conditions degrade the quality of patient care.
• Current conditions contribute to the uncompensated care burden on physicians.

A Better Policy. Beyond correcting federal and state laws and regulations, policymakers need to help hospital officials realign the economic incentives for emergency care, clarify the roles of hospitals and emergency departments, and restore a federalist approach to the provision of emergency care that clearly distinguishes between what is a public responsibility and what is a private responsibility and between what is the proper role of the federal government and what priorities should remain with the states. The states should have the primary role in setting rules for first responders.

Specifically, policymakers should:

• Rapidly expand private health insurance coverage. Policymakers should move as many non-urgent patients as possible out of the emergency room to increase the capability to care for patients with true emergencies. Based on the data, private insurance coverage correlates with relatively low emergency room usage, and expanding public programs would only make conditions worse.
• Focus on public safety as a key component in the delivery of emergency medical services and promote alternatives for urgent care. In many respects, the delivery of emergency medicine should be viewed as a public safety function, particularly in the aftermath of a natural disaster or terrorist attack. State officials should plan accordingly. Beyond that, they should change any laws or regulations that hinder hospital specialization, the private expansion of free-standing emergency care centers, or urgent care options for individuals and families seeking treatment when primary care physicians are unavailable.
• Separate emergency medical planning from laws governing hospital planning and construction and allow hospitals to specialize in the conventional delivery of care. State officials should re-examine all state laws, including certificate of need (CON) laws, that may hinder the provision of emergency medical services. In a properly functioning system that distinguishes between emergency medical services and routine hospital functions, hospitals would specialize in the provision of conventional care, and robust competition would drive innovation, productivity, and improvements in quality of care.
• Clearly define federal and state responsibilities, streamline financing, and improve the capacity and efficiency of emergency services. While the Secretary of Health and Human Services should take the lead role in defining federal responsibilities, particularly in response to natural disasters and terrorist attacks, states should continue to exercise broad discretion over the provision of emergency medical services. States should also pursue medical liability reform.

Conclusion. America's emergency room crisis is complex. Simply throwing more taxpayer money at the problem will not solve this crisis. Reform of the emergency medical system will require fundamentally rethinking the role of the emergency department and its relation to the acute care hospital.

Generally, the failure to address the problem of emergency medical care degrades the quality of care for all Americans. Specifically, it jeopardizes critically ill citizens' access to timely, efficient, and highly competent emergency medical services while compromising the ability of the health care system to respond to disasters.

John S. O'Shea, M.D., is Health Policy Fellow in the Center for Health Policy Studies at The Heritage Foundation.