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overcrowding further aggravated by outdated federal and state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
- 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
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
John S. O'Shea, M.D., is Health
Policy Fellow in the Center for Health Policy Studies at The