The problem: The uninsured need medical attention. They have nowhere to go, so they come into the emergency department (ED). This creates overcrowding, strains medical resources, and costs much more than a visit to a primary medical doctor’s (PMD) office. Since these expensive bills go largely ignored and unpaid, hospitals pass the expenses to those health-care consumers who do have insurance, which drives up costs (or so the argument goes).

The ideal: The Affordable Care Act (ACA or Obamacare) provides health coverage to millions who currently lack it. Now, this same cohort will go to their new PMDs, instead of the ED, saving tons of money and reducing crowding.

The reality: Obamacare expands coverage to those most in need through Medicaid, a program originally intended to serve those with the lowest incomes. Of the 25 million uninsured Americans, about half are expected to gain coverage through this program. Accordingly, Medicaid recipients tend to visit the ED more frequently than the uninsured, essentially adding to the problem instead of mitigating it. Hence, I have labeled this new paradigm the Obamacare emergency room.

Why is this? Because the uninsured are responsible to pay the full cost of an ED visit, whereas those on Medicaid pay very little or next to nothing (it’s well recognized in the medical world that Medicaid has some of the lowest reimbursement rates, which is why so many physicians do not accept it).

Case in point: A recent study in the journal Science has demonstrated that adult Medicaid beneficiaries in Oregon rely on the ED for medical care 40 percent more than similar uninsured adults. In this analysis, adults in the Portland area were chosen through lottery to receive Medicaid benefits or not. During the first 18 months of coverage, the former group made exceedingly more trips to the ED, and the pattern remained constant across most demographic groups, times of day, and types of visit. In this study, in no circumstance was it shown that Medicaid caused a decrease in ED utilization.

In California, it has also been demonstrated that Medicaid increases ED usage.

In 2006, when Massachusetts started their own form of state-sanctioned insurance for all, similar trends in increased ED usage were seen across the state.

Another fact to consider is that despite all the attention given to the ED and how expensive it is, EDs accounted for less than 5 percent of the total health-care spending in 2010, according to the Medical Expenditure Panel Survey. Compare this to hospital care, where $882.3 billion, or 31.5 percent of total expenditures ($2.8 trillion), was allocated in 2012.

Emergency medical care is vastly more expensive than primary medical care. In a normal market transaction, demand will go down the more expensive a commodity is, so it should follow that when given the option of going to the ED or a PMD, a patient would choose the latter. This is, however, not the case as all patients with some form of insurance are shielded from the true costs of care by their insurance, so the normal rules of supply and demand do not apply. Consider also that the ACA will inject more than 10 million newly insured into the health-care system without a concomitant increase in physicians—this will inevitably lead to delays in accessing PMDs, increase the wait time in order to see a physician, and drive those who would rather not wait straight to the ED. Furthermore, if a Medicaid patient would be responsible for about the same amount in co-pays in going to either the hospital or a doctor’s office, what incentive would exist in not going to the ED, regardless of the chief complaint? After all, if you have a problem and want it fixed now, everything is at the hospital anyway.

In a 2013 JAMA article, Dr. Ateev Mehrotra described a “convenience revolution” for the treatment of low-acuity conditions. Essentially, the emergency department need not be viewed as a place to treat emergencies, but a place to just get treated for whatever. The rising popularity of other health-care outlets of convenience—such as urgent care centers or a kiosk in the mall—highlights that supply is meeting rising demand. He writes that 50 million times annually, patients visit physicians for low-acuity conditions; many prefer to visit their PMD for the said conditions, but delays often preclude such visits.

The Affordable Care Act will only make matters worse as millions of more patients gain coverage and seek out primary care doctors.

The architects of the ACA may have started with good intentions, but we also know where that road leads. From the standpoint of practicing better utilization, eliminating ED overcrowding, and cost cutting, Obamacare only adds to the problem. It appears that the only thing the program will do is provide a financial buffer for those who will use expensive services even more.

Dr. C.H.E. Sadaphal

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  1. RadioTech says:

    More patients in the ER means more work for me. Bring it on!

  2. Guest says:

    the er doesn’t cost “much more” but so much more that it defies comprehension (like my $3200 bill for an ankle sprain, cast, and an xray). if people had to pay the “real” fees the hospital was charging, no one would go to the er ever unless they truly were on the verge of dying.

  3. Neil says:

    Kiosks in the mall? Who wouldn’t want to spend hundreds of bucks on overpriced clothes for their kids and then drop a couple of grand just for a doctor to tell you that a stuffy nose is a virus, do nothing, and it will go away in a few days? Sounds like a real convenience to me!

  4. Mr. Strong says:

    As with everyone else out there with narrow-minded views, you have missed the real point. How can you equate 10 million+ people who will now have health insurance as being a bad thing? If physicians are too lazy to do their job and see all the people that walk into a ER, then they should look for another line of work and leave the gritty tasks to those responsible and diligent enough to do them. Doctoring is about service, not money.

    • CHE Sadaphal says:

      The conversation is not whether giving some groups insurance is a bad thing, it is whether the means to accomplish those feats are sustainable and cost-effective. The program fails on both accounts. It would also be nice if the powers that be gave every high school senior a free 4-year college education, but if that meant everyone paid 30% more in federal taxes, the initially admirable gesture now looks a bit different when viewed from another angle.

      • Baxter says:

        In my mind, this is a key point for the national conversation on entitlements, access, etc. Most people assume that when anyone speaks out against these things that the speaker is an elitist, out-of-touch, or simply indifferent to their fellow man. Although this holds true for many, there is also the group (like me) that favors assisting those in need but simply disagrees with the way we’re doing it, since if we do keep on doing what’s been done, we’ll burn out an already bankrupt system.

  5. CHE Sadaphal says:

    “Of course, even insured people need the emergency room in urgent situations. But visiting the ER instead of a primary care doctor makes sense on another level.”

    See what I mean? View the full article at:,0,6721543.story

  6. Lydia says:

    I once had to pay over two grand to get my broken leg fixed and casted in the ER (no insurance). The surgeon told me if I had insurance, I would need screws and pins, but since I didn’t I would stay in a cast for a few weeks. Now I’m fine and run everyday. Obamacare would have made this guy even more rich and given me a pricey in rehab. I’d take the two grand bill any day of the week.

  7. siri says:

    will the obamacare er write me for some more xanax? i’m having a seizure right now.

    • CHE Sadaphal says:

      yes I can tell. seizures are usually associated with typing coherent, fluent text on a keyboard that incidentally requires acute mental awareness and fine motor control of the fingers. yes, sarcasm is intended.

  8. Tailor says:

    I was referred to your site by a friend, and articles like this make me glad they did. Great info and keep the knowledge flowing!

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